Encyclopedia of Couple and Family Therapy by Jay Lebow, Anthony Chambers, Douglas C. Breunlin

Jay L.
Lebow
Anthony L. Chambers
Douglas C. Breunlin
Editors
Encyclopedia
of Couple and
Family Therapy
Encyclopedia of Couple and Family
Therapy
Jay L. Lebow • Anthony L. Chambers
Douglas C. Breunlin
Editors
Encyclopedia of Couple
and Family Therapy
With 54 Figures and 14 Tables

Editors
Jay L. Lebow Anthony L. Chambers
The Family Institute at The Family Institute at
Northwestern University Northwestern University
Center for Applied Psychological and Center for Applied Psychological and
Family Studies Family Studies
Northwestern University Northwestern University
Evanston, IL, USA Evanston, IL, USA
Douglas C. Breunlin
The Family Institute at
Northwestern University
Center for Applied Psychological and
Family Studies
Northwestern University
Evanston, IL, USA
ISBN 978-3-319-49423-4 ISBN 978-3-319-49425-8 (eBook)

ISBN 978-3-319-49424-1 (print and electronic bundle)
https://doi.org/10.1007/978-3-319-49425-8
© Springer Nature Switzerland AG 2019

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Preface
Welcome to the Encyclopedia of Couple and Family Therapy, an evolving

comprehensive reference work. With strong leadership, our renowned editors-
in-chief, Jay Lebow, Anthony Chambers, and Doug Breunlin, who are both
family therapists and family scholars, and over 20 associate editors have
recruited an impressive array of talented contributors to create a truly ency-
clopedic compilation of entries.
Couple and family therapy is a vital area within the broader field of mental
health treatment. With relational science and systemic concepts at its founda-
tion, the field of couple and family therapy includes an array of empirically
derived methods for approaching couples and families that effectively treat a
wide variety of common problem areas. The past decade has witnessed a
tremendous surge in the practice of couple and family therapy as well as
interest in this endeavor, accompanied by an explosion of relevant research
and important advances in treatment. Given the multifaceted nature of couple
and family therapy, this online and print reference work seeks to provide
readers with easily accessible, high-quality, research-based information across
multiple disciplines. Because the field of couple and family therapy has been in
existence for over 70 years, many of its original ideas are lost in books and
chapters that are out of print. Furthermore, given the array of varying
approaches in what is a pluralistic multidisciplinary field, writings are
published in diverse places and within parallel literatures. Scholars and stu-
dents alike, therefore, are often challenged to locate concise sources for core
information in this body of work. Conscious of the field’s rich history, the
encyclopedia includes entries that cover both early seminal contributions
(including homeostasis, marital schism, second-order cybernetics) and more
recent developments.
The Encyclopedia of Couple and Family Therapy addresses a critical need
for comprehensive and scientifically reliable information regarding this
domain. Consisting of approximately 1000 entries written by experts in the
specific area of each entry, it covers the most important theories, approaches to
practice, core concepts, specific strategies, and bodies of evidence relevant in
the field, as well as its most important contributors and sites. It also extends to
cover the closely related area of relationship education as well as couple and
family therapy. Like no other reference, this encyclopedia is a single source
that provides authoritative and extensive coverage of critical topics germane to
the field, including the delineation of systemic concepts, training and super-
vision issues, systemic assessment, the history of the field and its contributors,
v
vi Preface
systemic interventions, and descriptions of the many models of couple and

family therapy. This comprehensive resource also emphasizes topics relating
to the conceptualization, treatment, and assessment of common problems
facing couples and families. Furthermore, this text not only provides state-
of-the-art coverage of important topics, but also cements the legacy and
identity of couple and family therapy as effective modalities for treating a
range of problems facing the human condition.
The encyclopedia includes entries that overview broad areas such as family
therapy or attachment, more specific concepts and approaches such as emo-
tionally focused therapy and family structure, and even more specific topics
such as enactment or family boundaries. It covers each of the specific area of
research and each of the specific approaches in the field, regardless of the
underlying therapeutic orientation. Therefore, it ranges widely and compre-
hensively across cognitive-behavioral, emotion-focused, psychoanalytic,
third-wave behavioral, post-modern, intergenerational, common factor, inte-
grative, and other relevant models.
The encyclopedia format enables readers to readily access a vast array of
information relating to their professional and clinical needs. As an online
resource, it is updated at frequent intervals with the latest information relevant
to the field. Its target audience include psychologists (including clinical,
counseling, family, and developmental psychologists); counselors; social
workers; marriage and family therapists; psychiatrists; family life educators;
nurses; and family physicians; as well as graduate and undergraduate students
with an interest in this area. We hope you, the reader, find it as useful as we
have found it exciting and informative to compile.
IL, USA Jay L. Lebow

August 2019 Anthony L. Chambers
Douglas C. Breunlin
About the Editors
Jay L. Lebow, Ph.D., ABPP, is Senior Scholar and Senior Therapist at The
Family Institute at Northwestern, and Clinical Professor of Psychology at
Northwestern University. He is Editor-in-Chief of the journal Family Process.
He has authored seven books and edited seven other books, including Treating
the Difficult Divorce: A Practical Guide for Psychotherapists, Couple and
Family Therapy: An Integrative Map of the Territory, Research for the Psy-
chotherapist, Common factors in Couple and Family Therapy (with Doug
Sprenkle and Sean Davis), Integrative Systemic Therapy (with Bill Pinsof,
Doug Breunlin, Bill Russell, Cheryl Rampage, and Anthony Chambers),
Clinical Handbook of Couple Therapy (with Alan Gurman and Doug Snyder),
Handbook of Family Therapy (with Tom Sexton), and Encyclopedia of Couple
and Family Therapy (with Anthony Chambers and Doug Breunlin). He is also
author of 200 articles and book chapters, most of which focus on couple and
family therapy, research about psychotherapy, therapy for high conflict
divorce, and research and practice. He is the author of many review papers
summarizing the state of theory, practice, and research in couple and family
therapy, including the decade review of couple therapy for Journal of Marital
and Family Therapy, the decade review of couple therapy research for Journal
of Marital and Family Therapy, the summary of couple and family therapy for
The Handbook of Psychology, the summary of integrative methods for the
Handbook of Family Therapy, two papers about the practice of integrative
family therapy in Family Process, a paper describing a method for treatment of
high conflict couples in divorce in Journal of Family Psychology, and sum-
maries of methods of family therapy in the Comprehensive Handbook of
Psychiatry and the Psychologist PDR. Dr. Lebow is a major proponent of
integrative methods of practice in couple and family therapy and movement
vii
viii About the Editors
toward a common base for practice. He wrote a column for a decade for the
Psychotherapy Networker on the relationship of research and practice, and
now writes an editorial for each issue of Family Process.
Dr. Lebow has engaged in clinical practice, supervision, and research for
over 40 years, is board certified in couple and family psychology, and is an
American Association for Marriage and Family Therapy approved supervisor.
He has received the Society of Couple and Family Psychology’s Family
Psychologist of the Year Award as well as the American Family Therapy
Academy’s Lifetime Achievement Award. He served as President of the
Society of Couple and Family Psychology and served for many years on the
Board of Directors and as committee chairs for the American Family Therapy
Academy.
Anthony L. Chambers, Ph.D., ABPP, is the Chief Academic Officer and a

Licensed Clinical Psychologist on staff at The Family Institute at Northwest-
ern University. Dr. Chambers is also the Director for Northwestern
University’s Center for Applied Psychological and Family Studies and is a
Clinical Professor in the Department of Psychology. Dr. Chambers is the
former Coordinator of Research, Director of the Couple Therapy program,
Core Faculty member of the MFT program, and Director of the Postdoctoral
Fellowship program at The Family Institute. He is also one of the few
psychologists nationwide board certified in treating couples (ABPP).
Dr. Chambers is also a former President of the American Psychological
Association’s Society for Couple and Family Psychology (Division 43).
Dr. Chambers received his undergraduate degree in Psychology from
Hampton University and completed his M.A. and Ph.D. in Clinical Psychol-
ogy from the University of Virginia (Department of Psychology). He com-
pleted his internship and postdoctoral clinical residency at Harvard Medical
School and Massachusetts General Hospital (HMS/MGH), specializing in the
treatment of couples. Dr. Chambers was also the Dr. John J.B. Morgan Post-
doctoral Fellow specializing in couple therapy and psychotherapy research at
The Family Institute at Northwestern University.
Dr. Chambers embraces the scientist-practitioner model of therapy by using
research to inform clinical practice. Thus, in addition to maintaining a very
large clinical practice comprised of 90% couples, Dr. Chambers also engages
in scholarly writing, teaching, and public speaking aimed at disseminating the
About the Editors ix
latest knowledge about how to have a healthy relationship. He is the author of

numerous book chapters, journal articles, and national presentations devoted
to summarizing the science behind assessing and treating common couples’
problems (i.e., communication, trust, intimacy, parenting, conflict resolution).
He has also published and lectured extensively on additional topics, including
the transition to marriage, the transition to parenthood, African American
couples, and interracial couples. Dr. Chambers has also made multiple media
appearances discussing topics such as “Surviving Infidelity” and “Avoiding
marriage’s No. 1 pitfall: Money troubles”.
Dr. Chambers’ professional accomplishments have resulted in becoming a
Fellow of the American Psychological Association and its Division of Couple
and Family Psychology, a Fellow of the American Academy of Couple and
Family Psychology, and a Diplomat of the American Board of Couple and
Family Psychology. Dr. Chambers is on the Board of Directors of several
academic and professional organizations devoted to strengthening couples and
families, including the Family Process Institute, the American Board of Cou-
ple and Family Psychology, and the American Academy of Couple and Family
Psychology. He also serves on the American Psychological Association’s
Advisory Steering Committee, which oversees the process of establishing
clinical practice guidelines. He is also on the editorial board for the journal
Family Process, and is the Associate Editor for the flagship journal Couple and
Family Psychology: Research and Practice.
Douglas C. Breunlin, MSSA, LMFT, LCSW, is Clinical Professor of Psy-

chology at Northwestern University and holder of the McCormick Tribune
Foundation Chair in Marriage and Family Therapy at The Family Institute at
Northwestern University. He is the Program Director for Master of Science in
Marriage and Family Therapy Program at Northwestern University. He is
licensed in marriage and family therapy and clinical social work and practices
as a senior therapist at The Family Institute at Northwestern University. He has
engaged in clinical practice, supervision, and research on couple and family
therapy for 40 years. He is an Approved Supervisor and Clinical Fellow of the
American Association for Marriage and Family Therapy. His professional areas
of interest have included family therapy training, the integration of family therapy
models, and consultation with school systems and family businesses. He is author
(with Richard Schwartz and Betty Mac Kune Karrer) of Metaframeworks:
Transcending the Models of Family Therapy, Editor (with Howard Liddle and
x About the Editors
Richard Schwartz) of the Handbook of Family Therapy Training and Supervi-

sion, coauthor of Integrative Systemic Therapy: Metaframeworks for Problem
Solving with Individuals, Couples and Families, an Editor-in-Chief of the Ency-
clopedia of Couple and Family Therapy, and the author of over 70 published
articles and chapters in books. He has served on the Editorial Boards of Family
Process, Couple and Family Psychology, the Journal of Marital and Family
Therapy, and the Journal of Family Therapy. He has served as secretary, treasurer,
and board member of the American Family Therapy Academy.
Section Editors
Brian R. W. Baucom Department of Psychology, University of Utah, Salt

Lake City, UT, USA
Maria Borcsa University of Applied Sciences Nordhausen, Nordhausen,

Germany
xi
xii Section Editors
Douglas C. Breunlin The Family Institute at Northwestern University, Cen-

ter for Applied Psychological and Family Studies, Northwestern University,
Evanston, IL, USA
Kristina S. Brown Couple and Family Therapy Department, Adler Univer-

sity, Chicago, IL, USA
Corinne Datchi Seton Hall University, South Orange, NJ, USA

Section Editors xiii
Sean D. Davis California School of Professional Psychology, Alliant Inter-

national University, Sacramento, CA, USA
Rachel M. Diamond University of Saint Joseph, West Hartford, CT, USA
Ryan M. Earl The Family Institute at Northwestern University, Evanston, IL,

USA
xiv Section Editors
Adam R. Fisher The Family Institute at Northwestern University, Evanston,

IL, USA
Brigham Young University, Provo, UT, USA
Molly F. Gasbarrini California School of Professional Psychology, Alliant

International University, Los Angeles, CA, USA
Farrah Hughes McLeod Health, Florence, USA
Eli Karam University of Louisville, Louisville, KY, USA

Section Editors xv
David Kearns University of Iowa, Iowa City, USA
Jay L. Lebow The Family Institute at Northwestern University, Center for

Applied Psychological and Family Studies, Northwestern University,
Evanston, IL, USA
Thorana Nelson Santa Fe, NM, USA

xvi Section Editors
Heather Pederson Council for Relationships, Philadelphia, USA
Kelley Quirk Marriage and Family Therapy Program, Human Development

and Family Studies, Colorado State University, Fort Collins, CO, USA
Mudita Rastogi Illinois School of Professional Psychology, Argosy Univer-

sity, Schaumburg, IL, USA
Section Editors xvii
Jessica Rohlfing Pryor The Family Institute at Northwestern University,

Northwestern University, Chicago, IL, USA
Allen Sabey The Family Institute at Northwestern University, Evanston, IL,

USA
Bahareh Sahebi The Family Institute at Northwestern University, Evanston,

IL, USA
xviii Section Editors
Diana J. Semmelhack Midwestern University, Downers Grove, IL, USA
Margarita Tarragona PositivaMente and Grupo Campos Elíseos, Mexico

City, Mexico
About the Managing Editors
Jessica Rohlfing Pryor, M.S., Ph.D., is full-time faculty in the Counseling

Program (MA) and a Staff Psychologist at The Family Institute at Northwest-
ern University. Dr. Pryor is also a Clinical Lecturer in the Department of
Psychology and Adjunct Faculty in the School of Education and Social Policy
at Northwestern University. Dr. Pryor is a board member of the American
Psychological Association’s (APA) Society for Couple and Family Psychol-
ogy, and also serves on the editorial board for the journal Measurement and
Evaluation in Counseling & Development.
Dr. Pryor completed her Ph.D. in Counseling Psychology at Arizona State
University, and completed her APA-approved internship at the Counseling and
Consultation Services at the University of Wisconsin-Madison. Dr. Pryor
completed a 1-year academic postdoctoral fellowship at Arizona State Uni-
versity, specializing in Counselor Education and Supervision. She also com-
pleted a 2-year postdoctoral fellowship specializing in the treatment of couples
and families at The Family Institute at Northwestern University. Dr. Pryor’s
scholarly pursuits are diverse in interpersonal scope, but predominantly exam-
ine maladaptive expressions and features of perfectionism (e.g., personality,
interpersonal style) and their implications for interpersonal functioning (e.g.,
intimacy, self-disclosure, help-seeking).
xix
xx About the Managing Editors
Adam R. Fisher, Ph.D., is Assistant Clinical Professor at Brigham Young

University, where he sees students for individual, couple, and group therapy,
conducts research related to relationships and religion, and teaches an under-
graduate course on relationships, dating, and sexuality. He is on the editorial
boards of journals in the field, including Family Process, Couple and Family
Psychology: Research and Practice, and the Journal of Couple & Relationship
Therapy. Dr. Fisher maintains a small private practice; his primary areas of
expertise are in working with couples, and with clients with sexual concerns
(e.g., sexual dysfunctions, or sexual behaviors that feel out of control).
Dr. Fisher is also a certified discernment counselor, offering couples who are
considering divorce a brief consultation to help them find clarity regarding
reconciliation or separation. Dr. Fisher completed a postdoctoral fellowship in
couple and family therapy at The Family Institute at Northwestern University
in 2017 and a Ph.D. in Counseling Psychology from Indiana University in
2015, with a minor in human sexuality at the Kinsey Institute. He completed an
M.A. in Counseling from Gonzaga University in 2009.
Contributors
Jukka Aaltonen Department of Psychology, University of Jyväskylä,

Jyväskylä, Finland
Rola O. Aamar Texas Tech University, Lubbock, TX, USA
East Carolina University, Greenville, NC, USA
Dena Abbott Department of Psychology and Behavioral Sciences, Louisiana
Tech University, Ruston, LA, USA
Jonathan S. Abramowitz Department of Psychology and Neuroscience,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Britney Acquaire Seton Hall University, South Orange, NJ, USA
Michael Adams Brigham Young University, Provo, UT, USA
Elizabeth Adedokun Drexel University, Philadelphia, PA, USA
Tamara D. Afifi Department of Communication, University of California,
Santa Barbara, Santa Barbara, CA, USA
Juan Carlos Agundez The Family Institute at Northwestern University,
Evanston, IL, USA
Michelle Ahmed The Family Institute at Northwestern University, Evanston,
IL, USA
Christine Aiello The Family Institute at Northwestern University, Evanston,
IL, USA
Renu Aldrich Virginia Tech University, Blacksburg, VA, USA
James F. Alexander Functional Family Therapy LLC, Seattle, WA, USA
Robert Allan School of Education and Human Development, University of
Colorado Denver, Denver, CO, USA
Sage Erickson Allen Brigham Young University, Provo, UT, USA
Sarah M. Allen Montana State University, Bozeman, ST, USA
Argie J. Allen-Wilson Department of Counseling and Family Therapy,
Drexel University, College of Nursing and Health Professions, Philadelphia,
PA, USA
xxi
xxii Contributors
Rhea Almeida The Institute for Family Services, Somerset, NJ, USA
Aalaa Alshareef The Family Institute at Northwestern University, Evanston,
IL, USA
Zahra Amer University of Tennessee, Knoxville, Knoxville, TN, USA
Austen R. Anderson University of Miami, Miami, FL, USA
Harlene Anderson The Taos Institute, Chagrin Falls, OH, USA
Houston Galveston Institute, Houston, TX, USA
Jared Anderson Kansas State University, Manhattan, KS, USA
Maurizio Andolfi Accademia di Psicoterapia della Famiglia, Rome, Italy
Harry Aponte Drexel University, Philadelphia, PA, USA
Richard Archambault Rhode Island Hospital, Department of Psychiatry,
Providence, RI, USA
Jane Ariel The Wright Institute, Berkeley, CA, USA
Laura Jimenez Arista Arizona State University, Phoenix, AZ, USA
Kiran Arora Long Island University, Brooklyn, NY, USA
Jeremy Arzt Windward Way Recovery, Los Angeles, CA, USA
Rose Ashraf Southern Methodist University, Dallas, TX, USA
Kadie L. Ausherbauer University of Minnesota, Minneapolis, MN, USA
Jason P. Austin Marriage and Family Therapy and Counseling Studies,
University of Louisiana at Monroe, Monroe, LA, USA
Constance Avery-Clark Institute of Sexual and Relationship Therapy and
Training, Boca Raton, FL, USA
Sarah Avery-Leaf The Informatics Applications Group (tiag), Tacoma, WA,
USA
Christiana I. Awosan Seton Hall University, South Orange, NJ, USA
Michael Baglieri Seton Hall University, South Orange, NJ, USA
University of Kansas, Lawrence, KS, USA
Richard W. Bailey Lancaster, PA, USA
Christina Balderrama-Durbin Binghamton University – State University
of New York, Binghamton, NY, USA
Michele Baldwin Chicago Center for Family Heath, Chicago, IL, USA
Jamie Banker California Lutheran University, Thousand Oaks, CA, USA
Donna Baptiste The Family Institute at Northwestern University, Evanston,
IL, USA
Contributors xxiii
Donna Rosana Baptiste The Family Institute at Northwestern University,

Evanston, IL, USA
Bogdan de Barbaro Family Therapy Department, Krakow, Poland
Department of Psychiatry, Jagiellonian University Medical College, Krakow,
Poland
Pietro Barbetta Centro Milanese di Terapia della Famiglia, Milan, Italy
University of Bergamo, Bergamo, Italy
Stephanie Barkley Saint Louis University, Saint Louis, MO, USA
Mary Jo Barrett Center for Contextual Change, Chicago, IL, USA
Robin A. Barry Department of Psychology, University of Wyoming,
Laramie, WY, USA
Bente Barstad Family Unit, Modum Bad, Vikersund, Norway
Brian R. W. Baucom Department of Psychology, University of Utah, Salt
Lake City, UT, USA
Donald H. Baucom University of North Carolina at Chapel Hill, Chapel Hill,
NC, USA
Katherine J. W. Baucom University of Utah, Salt Lake City, UT, USA
Irene Bautista Converse College, Spartanburg, SC, USA
Saliha Bava Mercy College, New York, NY, USA
Taos institute, Chagrin Falls, OH, USA
Steven R. H. Beach University of Georgia, Athens, GA, USA
Austin Beck Kansas State University, Manhattan, KS, USA
Carol Becker Therapy Training Boston, Watertown, MA, USA
Dorothy Becvar Saint Louis University, Saint Louis, MO, USA
Christian Beels New York, NY, USA
Ben K. Beitin Seton Hall University, South Orange, NJ, USA
Kaitlyn Bellingar The Family Institute at Northwestern University,
Evanston, IL, USA
Christopher K. Belous Mercer University, Atlanta, GA, USA
Elisabeth Bennett Gonzaga University, Spokane, WA, USA
Kristin M. Bennion California Institute of Integral Studies, San Francisco,
CA, USA
Intimate Connections Counseling, Orem, UT, USA
xxiv Contributors
Billy Benson The Ackerman Institute for the Family, New York City, NY,
USA
Kristen Benson Appalachian State University, Boone, NC, USA
Lisa A. Benson Harbor-UCLA Medical Center, Los Angeles, CA, USA
Jean Benward San Ramon, CA, USA
Sarah Berland Ackerman Institute for the Family, New York, NY, USA
Ellen Berman University of Pennsylvania, Philadelphia, PA, USA
Natalie Berry Midwestern University, Downers Grove, IL, USA
Bob Bertolino Maryville University, St. Louis, MO, USA
Dale E. Bertram Abilene Christian University, Abilene, TX, USA
Paolo Bertrando Systemic-Dialogical Psychotherapy School, Bergamo,
Italy
Mark H. Bird Healing and Recovery, Lewisville, TX, USA
Gary H. Bischof Western Michigan University, Lee Honors College,
Kalamazoo, MI, USA
Richard Bischoff University of Nebraska, Omaha, NE, USA
Danielle A. Black Center for Applied Psychological and Family Studies, The
Family Institute at Northwestern University, Evanston, IL, USA
The Family Institute at Northwestern University, Chicago, IL, USA
Stephanie Winkeljohn Black Penn State Harrisburg, Middleton, PA, USA
Susana Blanco Thrive Psychological Associates, Miami Lakes, FL, USA
Emily Blefeld Wickford, RI, USA
Stevie Blum The Ackerman Institute for The Family, New York, NY, USA
Elizabeth Boatman Texas Woman’s University, Denton, TX, USA
Guy Bodenmann Department of Psychology, University of Zurich,
Binzmuehlestrasse, Zurich, Switzerland
Rebecca Bokoch Couple and Family Therapy, CSPP Alliant International
University, Los Angeles, CA, USA
Jacek Bomba Department of Psychiatry, Jagiellonian University Medical
College, Krakow, Poland
Faith Johnson Bonecutter University of Illinois at Chicago, Chicago, IL,
USA
Maria Borcsa University of Applied Sciences Nordhausen, Nordhausen,
Germany
Christine Borst Arizona State University, Phoenix, AZ, USA
Contributors xxv
Ulrike Borst Familiendynamik, Heidelberger Institut für systemische

Forschung und Therapie, Heidelberg, Germany
Maya Boustani University of California Los Angeles, Los Angeles, CA,
USA
Tommie V. Boyd Nova Southeastern University Fort, Lauderdale, FL, USA
Tom N. Bradbury University of California, Los Angeles, CA, USA
Rebecca Branda The Family Institute at Northwestern University, Chicago,
IL, USA
Pavan S. Brar Duquesne University, Pittsburgh, PA, USA
Jacqueline Braughton University of Minnesota, Minneapolis, MN, USA
Lois Braverman Ackerman Institute for the Family, New York, NY, USA
Meagan J. Brem University of Tennessee-Knoxville, Knoxville, TN, USA
Alison Brennan Michigan State University, East Lansing, MI, USA
Douglas C. Breunlin The Family Institute at Northwestern University,
Center for Applied Psychological and Family Studies, Northwestern
University, Evanston, IL, USA
J. Gregory Briggs Department of Psychology, Counseling, and Family
Science, Lipscomb University, Nashville, TN, USA
Andrew S. Brimhall East Carolina University, Greenville, NC, USA
Sean Brotherson North Dakota State University, Fargo, ND, USA
Braden Brown East Carolina University, Greenville, NC, USA
Cameron Brown Kansas State University, Manhattan, KS, USA
Jaynie Brown Strengthening Families Foundation, Salt Lake City, UT, USA
Kristina S. Brown Couple and Family Therapy Department, Adler
University, Chicago, IL, USA
Nicole Brown Emerald City Sanctuary, PLLC, Seattle, WA, USA
Scott W. Browning Chestnut Hill College, Philadelphia, PA, USA
Lorrie Brubacher University of North Carolina, Greensboro, NC, USA
D. Bruce Ross III University of Kentucky, Lexington, KY, USA
Chalandra M. Bryant Department of Human Development and Family
Science, University of Georgia, Athens, GA, USA
Katharine Ann Buck Department of Human Development and Family
Studies, University of Saint Joseph, West Hartford, CT, USA
Stephanie Buehler The Buehler Institute, Newport Beach, CA, USA
xxvi Contributors
Kesha Burch The Family Institute at Northwestern University, Evanston,

IL, USA
Nancy Burgoyne The Family Institute at Northwestern University, Evans-
ton, IL, USA
James Butcher University of Minnesota, Minneapolis, MN, USA
Seigie Butler Binghamton University – State University of New York, Bing-
hamton, NY, USA
Rochelle Cade University of Mary Hardin-Baylor, Belton, TX, USA
Benjamin E. Caldwell California State University Northridge, Los Angeles,
CA, USA
Karen Caldwell Appalachian State University, Boone, NC, USA
Trent Call Oklahoma State University, Stillwater, OK, USA
Dana Campagna Alliant International University, Los Angeles, CA, USA
Chloe Campbell Department of Clinical, Educational and Health
Psychology, University College London, London, UK
T. Leanne Campbell Vancouver Island Center for EFT, Nanaimo, BC,
Canada
Warihi Campbell Family Centre Social Policy Research Unit, Wellington,
New Zealand
Hongjian Cao School of Education, Guangzhou University, Guangzhou,
China
Maggie Carey Narrative Practices Adelaide, Adelaide, Australia
Cindy Carlson Department of Educational Psychology, University of Texas
at Austin, Austin, TX, USA
Erica Carpenter Texas Woman’s University, Denton, TX, USA
Alan Carr School of Psychology, University College Dublin and
Clanwilliam Institute Dublin, Dublin, Ireland
Rachel M. Carter University of Rochester, Rochester, NY, USA
Michele Cascardi William Paterson University, Wayne, NJ, USA
Marj Castronova Relational Wellness Institute, Las Vegas, NV, USA
Donjae Catanzariti Seton Hall University, South Orange, NJ, USA
Alejandra Ceja California School of Professional Psychology, Alliant
Marianne Celano Emory University, Atlanta, GA, USA
Jason Cencirulo Los Angeles, CA, USA
Richard Cervantes Behavioral Assessment, Inc, Los Angeles, CA, USA
Contributors xxvii
Anthony L. Chambers The Family Institute at Northwestern University,

Center for Applied Psychological and Family Studies, Northwestern Univer-
sity, Evanston, IL, USA
Jennifer Chang University of Iowa, Iowa City, IA, USA
Megan L. Chapman Adler University, Chicago, IL, USA
Charles Cheesebrough National Council on Family Relations, Minneapolis,
MN, USA
Ruoxi Chen Marriage and Family Therapy and Counseling Studies,
Ronald Chenail Nova Southeastern University, Fort Lauderdale, FL, USA
Jessica ChenFeng California State University – Northridge, Northridge,
CA, USA
Viviana Cheng Asian Academy of Family Therapy, Hong Kong, China
Hee-Sun Cheon Seattle Pacific University, Seattle, WA, USA
Benjamin Cherkasky The Family Institute at Northwestern University,
Evanston, IL, USA
Shannon E. Chien The Family Institute at Northwestern University,
Evanston, IL, USA
Georgeanna A. Chizk East Carolina University, Greenville, NC, USA
Jessica Chou Drexel University, Philadelphia, PA, USA
Jessica L. Chou Queen of Peace Center, St. Louis, MO, USA
Andrew Christensen University of California, Los Angeles, Los Angeles,
CA, USA
Jacob D. Christenson Mount Mercy University, Cedar Rapids, IA, USA
Whitney Christmas The Family Institute at Northwestern University, Evans-
ton, IL, USA
Kelsey T. Chun The Family Institute at Northwestern University, Evanston,
IL, USA
Beth Chung The Family Institute at Northwestern University, Evanston, IL,
USA
Irene Chung The Silberman School of Social Work, City University of New
York, New York, NY, USA
Rocco Cimmarusti Evanston, IL, USA
T. Ciochon Texas Tech University, Lubbock, TX, USA
Judith Coché The Coche Center, Philadelphia, PA, USA
Perelman School of Medicine at the University of Pennsylvania, Philadelphia,
PA, USA
xxviii Contributors
Dan Booth Cohen Wickford, RI, USA

Ralph S. Cohen Central Connecticut State University, New Britain,
CT, USA
Aaron Cohn Saint Louis University, Saint Louis, MO, USA
Danielle Cohn American University, Washington, DC, USA
Jorge Colapinto Minuchin Center for the Family, Woodbury, NJ, USA
Carrie Cole The Gottman Institute, Seattle, WA, USA
Donald L. Cole The Gottman Institute, Seattle, WA, USA
David Collins Pacific Institute for Research and Evaluation (PIRE),
Beltsville, MD, USA
Heather Colquhoun Couple and Family Therapy, Alliant International
University, Sacramento, CA, USA
Deb Coolhart Syracuse University, Syracuse, NY, USA
Daniel K. Cooper University of Minnesota, Minneapolis, MN, USA
Glen Cooper Circle of Security International, Spokane, WA, USA
Shannon Cooper-Sadlo School of Social Work, Saint Louis University, St.
Louis, MO, USA
Jennifer Coppola Syracuse University, Syracuse, NY, USA
Kenneth Covelman Department of Couple and Family Therapy/Council for
Relationships, Jefferson College of Health Professions, Jefferson (Philadel-
phia University + Thomas Jefferson University), Philadelphia, PA, USA
Saviona Cramer Barcai Institute, Tel Aviv, Israel
D. Russell Crane Brigham Young University (Emeritus), Provo, UT, USA
Dev Crasta University of Rochester, Rochester, NY, USA
Duane W. Crawford Kansas State University, Manhattan, KS, USA
Alexander O. Crenshaw University of Utah, Salt Lake City, UT, USA
David A. Crenshaw Children’s Home of Poughkeepsie, Poughkeepsie, NY,
USA
Kathie Crocket Faculty of Education, University of Waikato, Hamilton,
Waikato, New Zealand
Yajaira S. Curiel Palo Alto University, Palo Alto, CA, USA
Carissa D’Aniello University of Nevada Las Vegas, Las Vegas, NV, USA
Teresa D’Astice The Family Institute at Northwestern University, Evanston,
IL, USA
Contributors xxix
Iman Dadras Department of Couple and Family Therapy, Alliant Interna-

tional University – California School of Professional Psychology, Los
Angeles, CA, USA
K. Daniel O’Leary Stony Brook University, Stony Brook, NY, USA
Rachael A. Dansby Texas Tech University, Lubbock, TX, USA
Corinne Datchi Seton Hall University, South Orange, NJ, USA
Frank M. Dattilio Harvard Medical School, Allentown, PA, USA
Christopher M. Davids Westminster College, Salt Lake City, UT, USA
Cheryl Davies Universidad Iberoamericana, Mexico City, Mexico
Joanne Davila Stony Brook University, Stony Brook, NY, USA
Lara Davis California School of Professional Psychology, Alliant Interna-
tional University, Sacramento, CA, USA
Marissa W. Davis California School of Professional Psychology, Alliant
Sean D. Davis California School of Professional Psychology, Alliant
International University, Sacramento, CA, USA
Piero De Giacomo University of Bari Aldo Moro, Bari, Italy
Anne K. DeCore The Family Institute at Northwestern University, Evanston,
IL, USA
Rita DeMaria Couple and Family Therapy Program, Jefferson University,
Philadelphia, PA, USA
Post-Graduate MFT Certificate Program, Council for Relationships,
David Denborough Dulwich Centre, Adelaide, SA, Australia
Stephen K. Denny University of Miami, Miami, FL, USA
Guy S. Diamond Center for Family Intervention, Drexel University,
Rachel M. Diamond University of Saint Joseph, West Hartford, CT, USA
Victoria Dickerson American Family Therapy Academy, Aptos, CA, USA
Carlo C. DiClemente University of Maryland, Baltimore County, Baltimore,
MD, USA
Amanda Dishon-Brown Northern Kentucky University, Highland Heights,
KY, USA
Brian Distelberg Loma Linda University | Loma Linda University Health
Behavioral Medicine Center, Loma Linda, CA, USA
Lee J. Dixon University of Dayton, Dayton, OH, USA
xxx Contributors
Carol Djeddah Ethno-Systemic Narrative School of Psychotherapy, Rome,

Italy
Cody G. Dodd Department of Psychology, Central Michigan University,
Mount Pleasant, MI, USA
Liz Dodge London, UK
William J. Doherty University of Minnesota, St. Paul, MN, USA
David C. Dollahite Brigham Young University, Provo, UT, USA
Brittany Donaldson University of Nevada – Las Vegas, Las Vegas, NV,
USA
Ronda Doonan Community Memorial Health Systems, Ventura, CA, USA
Brian D. Doss University of Miami, Coral Gables, FL, USA
Lisa Dressner The Institute for Family Services, Somerset, NJ, USA
Joanna M. Drinane University of Denver, Denver, CO, USA
Shawndeeia L. Drinkard Alliant International University, Los Angeles, CA,
USA
David Drustrup University of Iowa, Iowa City, IA, USA
Jennifer Duchschere University of Arizona, Tucson, AZ, USA
Catherine Ducommun-Nagy Drexel University, Philadelphia, PA, USA
The Institute for Contextual Growth, Inc., Glenside, PA, USA
Thelma Duffey University of Texas at San Antonio, San Antonio, TX, USA
Norah E. Dunbar Department of Communication, University of California
Santa Barbara, Santa Barbara, CA, USA
Barry Duncan The Heart and Soul of Change Project, Jensen Beach, FL,
USA
M. Duncan Stanton Spalding University, Louisville, KY, USA
Jared Durtschi Kansas State University, Manhattan, KS, USA
Jared A. Durtschi Kansas State University, Manhattan, KS, USA
Jim Duvall JST Institute, Galveston, TX, USA
Lindsay Dwelley California School of Professional Psychology, Alliant
Ryan M. Earl The Family Institute at Northwestern University, Evanston,
IL, USA
Brandon Eddy Texas Tech University, Lubbock, TX, USA
Martha E. Edwards Ackerman Institute for the Family, New York, NY,
USA
Contributors xxxi
Todd M. Edwards Marital and Family Therapy Program, University of San

Diego, San Diego, CA, USA
Ivan Eisler Maudsley Centre for Child and Adolescent Eating Disorders,
South London and Maudsley NHS Foundation Trust, London, UK
Institute of Psychiatry, Psychology and Neuroscience, King’s College London,
London, UK
Kathleen A. Eldridge Graduate School of Education and Psychology,
Pepperdine University, Los Angeles, CA, USA
Cezanne M. Elias Purdue University, West Lafayette, IN, USA
Mony Elkaïm Free University of Brussels, Brussels, Belgium
Corinn A. Elmore Walter Reed National Military Medical Center, Bethesda,
MD, USA
Joanna Elmquist University of Tennessee-Knoxville, Knoxville, TN, USA
Justine Encinas Seton Hall University, South Orange, NJ, USA
Daniel T. Ennaco California School of Professional Psychology, Alliant
Naomi Ennis Ryerson University, Toronto, ON, Canada
Christie Eppler Seattle University, Seattle, WA, USA
Norman B. Epstein University of Maryland, College Park, MD, USA
David Epston Family Therapy Centre, Auckland, New Zealand
Christie Erickson Alpharetta, Georgia
Valentin Escudero Department Psychology, Universidad de A Coruña, A
Coruña, Spain
Kamran K. Eshtehardi California School of Professional Psychology,
Alliant International University, Los Angeles, CA, USA
Sandra Espinoza California School of Professional Psychology, Alliant
Benjamin J. Evans Marriage and Family Therapy and Counseling Studies,
William D. Ewing The Family Institute at Northwestern University,
Chicago, IL, USA
Katherine A. Fackina Department of Professional Psychology and Family
Therapy, Seton Hall University – College of Education and Human Services,
South Orange, NJ, USA
Mariana K. Falconier Virginia Polytechnic Institute and State University,
Falls Church, VA, USA
xxxii Contributors
Celia Jaes Falicov University of California, San Diego, San Diego, CA,
USA
Andrea Leigh Farnham The University of Georgia, Athens, GA, USA
Erin Ferenchick Columbia University, New York, NY, USA
Elena Fernández Grupo Campos Elíseos, Mexico City, Mexico
Nedra Fetterman Imago Relationships International, Washington, DC, USA
Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
Cyrille Feybesse Porto, Portugal
Barbara H. Fiese University of Illinois, Urbana-Champaign, Urbana, IL,
USA
Stephen T. Fife University of Nevada, Las Vegas, Las Vegas, NV, USA
Texas Tech University, Lubbock, TX, USA
K. Finch Texas Tech University, Lubbock, TX, USA
Frank D. Fincham Florida State University, Tallahassee, FL, USA
Brandi C. Fink The University of New Mexico, Albuquerque, NM, USA
Michelle A. Finley Antioch University Seattle, Seattle, WA, USA
Hans Rudi Fischer Familiendynamik, Heidelberger Institut für systemische
Melanie S. Fischer University of North Carolina at Chapel Hill, Chapel Hill,
NC, USA
Linda Stone Fish Syracuse University, Syracuse, NY, USA
Adam R. Fisher The Family Institute at Northwestern University, Evanston,
IL, USA
Lesley Fisher The Family Institute at Northwestern University, Evanston, IL,
USA
Mary A. Fisher Mary Fisher Psychotherapy, PLLC, Salt Lake City, UT, USA
CJ Eubanks Fleming Elon University, Elon, NC, USA
Douglas Flemons Nova Southeastern University, Fort Lauderdale, FL, USA
Autumn Rae Florimbio University of Tennessee-Knoxville, Knoxville, TN,
USA
Paul Florsheim University of Wisconsin Milwaukee, Milwaukee, WI, USA
Karen Focht The Family Institute at Northwestern University, Evanston, IL,
USA
Contributors xxxiii
Sallie Foley University of Michigan, Ann Arbor, MI, USA

Roberto Font Multicultural Family Institute, Highland Park, NJ, USA
Heather Foran Alpen-Adria-University Klagenfurt, Klagenfurt, Austria
Rex L. Forehand The University of Vermont, Burlington, VT, USA
Catherine Weigel Foy The Family Institute at Northwestern University,
Evanston, IL, USA
Peter Fraenkel The City College of New York, New York, NY, USA
Cynthia Franklin The Steve Hicks School, The University of Texas at
Austin, Austin, TX, USA
Steffany J. Fredman The Pennsylvania State University, University Park,
PA, USA
Jill Freedman Evanston Family Therapy Center, Evanston, IL, USA
Laura M. Frey Couple and Family Therapy Program, Kent School of Social
Work, University of Louisville, Louisville, KY, USA
Myrna L. Friedlander University at Albany/State University of New York,
Albany, NY, USA
Alan E. Fruzzetti Department of Psychiatry, McLean Hospital/Harvard
Medical School, Belmont, MA, USA
Ben Furman Helsinki Brief Therapy Institute, Helsinki, Finland
James L. Furrow Fuller Graduate School of Psychology, Pasadena, CA,
USA
Jerry Gale University of Georgia, Athens, GA, USA
Kami L. Gallus Oklahoma State University, Stillwater, OK, USA
Rashmi Gangamma Syracuse University, Syracuse, NY, USA
Molly F. Gasbarrini California School of Professional Psychology, Alliant
Bob Geffner Institute on Violence, Abuse, and Trauma, San Diego, CA,
USA
Diane R. Gehart Department of Educational Psychology and Counseling,
California State University, Northridge, CA, USA
Emily J. Georgia University of Miami, Miami, FL, USA
Kenneth J. Gergen Swarthmore College, Philadelphia, PA, USA
Mary Gergen Penn State, Brandywine, PA, USA
Armine Gevorkyan California Department of Corrections and Rehabilita-
tion (CDCR), Los Angeles, CA, USA
xxxiv Contributors
Shawn V. Giammattei Quest Family Therapy, San Francisco Bay Area, CA,
USA
The Rockway Institute, California School of Professional Psychology at
Alliant International University, San Francisco, CA, USA
Valerie Gifford University of Alaska Fairbanks, Fairbanks, AK, USA
Eliana Gil Gil Institute for Trauma Recovery and Education, Fairfax, VA,
USA
Dan Gill The Family Institute at Northwestern University, Evanston, IL,
USA
Lynn Gilman Indiana University, Bloomington, IN, USA
Adriana Gil-Wilkerson Adjunct Faculty, Our Lady of the Lake University,
Houston, TX, USA
Elizabeth Glaeser The Gender and Family Project, Ackerman Institute for
the Family, New York, NY, USA
Tatiana Glebova Alliant International University – California School of
Professional Psychology, Sacramento, CA, USA
Dawn L. Glover California School of Professional Psychology, Alliant
Shirley Glynn University of California – Los Angeles, Los Angeles, CA,
USA
Edith Goldbeter Institut d’Etudes de la Famille et des Systèmes Humains,
Brussels and ULB, Brussels, Belgium
Marvin R. Goldfried Stony Brook University, Stony Brook, NY, USA
Rhonda N. Goldman Illinois School of Professional Psychology at Argosy
Virginia Goldner Psychology Department, New York University, New
York, NY, USA
Jacob Z. Goldsmith The Family Institute at Northwestern University,
Evanston, IL, USA
Joanna Goldsmith Boston College School of Social Work, Somerville, MA,
USA
Chris J. Gonzalez Department of Psychology, Counseling, and Family Sci-
ence, Lipscomb University, Nashville, TN, USA
Natali Gonzalez Texas Tech University, Lubbock, TX, USA
Vived Gonzalez California School of Professional Psychology, Alliant Inter-
national University, Sacramento, CA, USA
Alliant International University, Irvine, CA, USA
Eric T. Goodcase Kansas State University, Manhattan, KS, USA
Contributors xxxv
Adia Gooden The University of Chicago, Chicago, IL, USA

Amanda Goodman Alliant International University, Los Angeles, CA, USA
Thelma Jean Goodrich The University of Texas, Houston, Houston, TX,
USA
Anastasia Gorden Alliant International University, Sacramento, CA, USA
Elana Gordis University at Albany, SUNY, Albany, NY, USA
Donald A. Gordon Family Works, Ohio University, Athens, OH, USA
Kristina Coop Gordon University of Tennessee, Knoxville, Knoxville, TN,
USA
Nicole Goren University of San Diego, San Diego, CA, USA
John M. Gottman The Gottman Institute, Seattle, WA, USA
Jeffrey Goulding Seton Hall University, South Orange, NJ, USA
Erika L. Grafsky Virginia Polytechnic Institute and State University,
Blacksburg, VA, USA
Claudia Grauf-Grounds Seattle Pacific University, Seattle, WA, USA
Shelley K. Green Nova Southeastern University, Fort Lauderdale, FL, USA
Gilbert J. Greene The Ohio State University College of Social Work,
Columbus, OH, USA
Paul S. Greenman Université du Québec en Outaouais, Gatineau, QC,
Canada
Institut du Savior Montfort, Ottawa, ON, Canada
Ottawa Couple and Family Institute, Ottawa, ON, Canada
J. Gregory Briggs Department of Psychology, Counseling, and Family
James L. Griffith Department of Psychiatry and Behavioral Sciences, The
George Washington University, Washington, DC, USA
Hannah Grigorian University of Tennessee-Knoxville, Knoxville, TN,
USA
David Grove LISW-S, LIMFT-S, Hilliard, OH, USA
Nicole Sabatini Gutierrez California School of Professional Psychology,
Alliant International University, Irvine, CA, USA
Laura F. Gutierrez Duarte California School of Professional Psychology,
Angela K. Guy Clinical Psychology, California School of Professional
Psychology at Alliant International University, Alhambra, CA, USA
Erin Guyette Kansas State University, Manhattan, KS, USA
xxxvi Contributors
Kaylyn E. Gyden Purdue University Northwest, Hammond, IN, USA

Christopher M. Habben Friends University, Overland Park, KS, USA
Judy Haefner University of Michigan Flint, Flint, MI, USA
Laura Hagen The Family Institute at Northwestern University, Evanston, IL,
USA
David Hale University of Louisiana, Monroe, LA, USA
Cadmona A. Hall Department of Couple and Family Therapy, Adler
Ryan Hamann Seattle Pacific University, Seattle, WA, USA
Mo Therese Hannah Siena College, Loudonville, NY, USA
Advanced Clinician, Imago Relationship Therapy/Imago Relationships
International, Glen Ellyn, IL, USA
Melanie F. Hansen Utah State University, Logan, UT, USA
Tracy Hansen Hansen Hearts Counseling, Fargo, ND, USA
Claire Hapke Couple and Family Therapy, CSPP Alliant International
Brooklyn, NY, USA
David M. Haralson East Carolina University, Greenville, NC, USA
Nathan Hardy Oklahoma State University, Stillwater, OK, USA
Steven M. Harris University of Minnesota, Minneapolis, MN, USA
Kathryn Harrison Department of Communication, University of California-
Santa Barbara, San Diego, CA, USA
Erica E. Hartwell University of Nevada – Las Vegas, Las Vegas, NV, USA
Ashley M. Harvey Colorado State University, Fort Collins, CO, USA
Rebecca Harvey Southern Connecticut State University, New Haven, CT,
USA
F. Targol Hasankhani Chicago, IL, USA
Noah Hass-Cohen Couples and Family Therapy Masters and Doctoral
Programs, California School of Professional Psychology at Alliant Interna-
tional University (Los Angles), Alhambra, CA, USA
Trevan G. Hatch Brigham Young University, Provo, UT, USA
Elaine Hatfield Department of Psychology, University of Hawai’i,
Honolulu, HI, USA
David Hauser The Family Institute at Northwestern University, Evanston,
IL, USA
Alan J. Hawkins Brigham Young University, Provo, UT, USA
Contributors xxxvii
Blendine P. Hawkins University of Oregon, Eugene, OR, USA

Erinn Hawkins Griffith University, Gold Coast, QLD, Australia
Stephen N. Haynes University of Hawaiʻi at Mānoa, Honolulu, HI, USA
Grace E. Hazeltine California School of Professional Psychology, Alliant
Yaliu He The Family Institute at Northwestern University, Evanston, IL,
USA
Katie M. Heiden-Rootes Saint Louis University, Saint Louis, MO, USA
Joel Hektner North Dakota State University, Fargo, ND, USA
Natasha Helfer-Parker Symmetry Solutions, Wichita, KS, USA
Karen B. Helmeke Western Michigan University, Kalamazoo, MI, USA
Scott W. Henggeler Family Services Research Center, Medical University of
South Carolina, Charleston, SC, USA
Jessica S. Henry Hays State Prison, Trion, GA, USA
Kristen Herdegen The Family Institute at Northwestern University, Evans-
ton, IL, USA
Martha Hernández Family Support Services at Ronald McDonald House at
Stanford, Palo Alto, CA, USA
Pilar Hernandez Graduate School of Education and Counseling, Lewis and
Clark College, Portland, OR, USA
Joanna Herres The College of New Jersey, Ewing Township, NJ, USA
Alexis Hershfield Alliant International University, Los Angeles, CA, USA
Katherine Hertlein University of Nevada – Las Vegas, Las Vegas, NV, USA
Heather Hessel University of Minnesota, Minneapolis, MN, USA
David Hewison Tavistock Relationships, London, UK
Richard E. Heyman Family Translational Research Group, New York Uni-
versity, New York, NY, USA
William Hiebert Marriage and Family Counseling Service, Rock Island, IL,
USA
Angela Hiefner Department of Family and Community Medicine, Saint
Louis University, St. Louis, MO, USA
Sarah Hillier University of Saint Joseph, West Hartford, CT, USA
Eric Hinojosa Texas Wesleyan University, Fort Worth, TX, USA
Jennifer Hodgson East Carolina University, Greenville, NC, USA
Kent Hoffman Circle of Security International, Spokane, WA, USA
xxxviii Contributors
Jasara N. Hogan University of Utah, Salt Lake City, UT, USA

Aaron Hogue Center on Addiction, New York, NY, USA
Amy Hollimon Functional Family Therapy, LLC and Private Practice,
Fairhope, AL, USA
Richard Holm Minuchin Center for the Family, Woodbury, NJ, USA
Eugene Holowacz The Ohio State University, Columbus, OH, USA
Laura Holt University of Missouri-St. Louis, St. Louis, MO, USA
Derek Holyoak Texas Tech University, Lubbock, TX, USA
Kyle C. Horst California State University, Chico, Chico, CA, USA
Department of Psychology, California State University, Chico, Chico, CA,
USA
Courtney Horwath Alaska Counseling and Consulting, LLC, Wasilla, AK,
USA
George Howe Department of Psychology, The George Washington Univer-
sity, Washington, DC, USA
Alexander Lin Hsieh Alliant International University, Sacramento, CA,
USA
Shelly Xiaoyan Huang The Family Institute at Northwestern University,
Evanston, IL, USA
Anna Huber Macquarie University, Sydney, NSW, Australia
Clayton C. Hughes Couples Resource Collective, Sacramento, CA, USA
Jessica A. Hughes Veterans Health Administration, San Diego, California,
USA
Rachel L. Hughes Saint Louis University, Saint Louis, MO, USA
Jarodd W. Hundley Marriage and Family Therapy and Counseling Studies,
Christina Hunger Institute of Medical Psychology, University Hospital
Heidelberg, Heidelberg, Germany
Marjha Toni Hunt Couple and Family Therapy, Alliant International
Quintin Hunt Center for Family Intervention, Drexel University, Philadel-
phia, PA, USA
Maliha Ibrahim Center for Family Intervention, Drexel University,
Edward A. Igle Philadelphia Child and Family Therapy Training Center,
Contributors xxxix
Evan Imber-Black Marriage and Family Therapy, Mercy College, Dobbs

Ferry, NY, USA
Center for Families and Health, Ackerman Institute for the Family, New York
City, NY, USA
Kay Ingamells Narrative Apprenticeship, Auckland, New Zealand
Kyle Isaacson Fuller Graduate School of Psychology, Pasadena, CA, USA
Shannon Iverson Illinois School of Professional Psychology at Argosy
Gihane Jérémie-Brink The Family Institute at Northwestern University,
Evanston, IL, USA
Barbara Józefik Department of Psychiatry, Jagiellonian University Medical
College, Krakow, Poland
Barry J. Jacobs Crozer-Keystone Family Medicine Residency Program,
Springfield, PA, USA
Elizabeth Jacobsen The Family Institute at Northwestern University,
Chicago, IL, USA
Charles M. Jaffe Rush University, Chicago, IL, USA
Clea R. M. James The Family Institute at Northwestern University, Evans-
ton, IL, USA
Neslihan James-Kangal University of Cincinnati, Cincinnati, OH, USA
Matthew Jarvinen Fuller Theological Seminary; School of Psychology,
Pasadena, CA, USA
Jake Jensen East Carolina University, Greenville, NC, USA
Mathew D. Johnson Department of Psychology, Binghamton University,
Binghamton, NY, USA
Natalie Johnson Texas Tech University, Lubbock, TX, USA
Patrick S. Johnson California State University, Chico, Chico, CA, USA
Department of Psychology, California State University, Chico, Chico, CA, USA
Sheri L. Johnson University of California, Berkeley, Berkeley, CA, USA
Sue M. Johnson The International Centre for Excellence in Emotionally
Focused Therapy, The University of Ottawa, Ottawa, ON, Canada
Courtney K. Johnson-Fait Arizona State University, Tempe, AZ, USA
Agnes Jos Community Treatment, Inc. (COMTREA), Comprehensive
Health Center, St. Louis, MO, USA
Xiaoyan Ju Hangzhou Normal University, Hangzhou, China
Social Work Department, China Youth University for Political Studies,
Beijing, China
xl Contributors
Alexander Julian Brigham Young University, Provo, UT, USA

Caroline Kalai Graduate School of Education and Psychology, Pepperdine
Andrzej Kapusta Department of Philosophy and Sociology, Maria
Curie-Sklodowska University, Lublin, Poland
Eli Karam University of Louisville, Louisville, KY, USA
Shazia Kareem MDFT Connecticut, Miami, FL, USA
Betty M. Karrer Evanston, IL, USA
Florence W. Kaslow Kaslow Associates, Palm Beach Gardens, FL, USA
Florida Institute of Technology, Melbourne, FL, USA
Nadine J. Kaslow Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, GA, USA
Heather Katafiasz The University of Akron, Akron, OH, USA
Rini Kaushal The Family Institute at Northwestern University, Evanston,
IL, USA
David V. Keith Department of Psychiatry, SUNY Upstate Medical Univer-
sity, Syracuse, NY, USA
G. K. Keitner Alpert Medical School of Brown University, Providence,
RI, USA
Gabor Keitner Rhode Island Hospital; Brown University, Providence,
RI, USA
Lisa Kelledy Northcentral University, San Diego, CA, USA
Adrian B. Kelly School of Psychology and Counselling, Queensland
University of Technology, Brisbane, QLD, Australia
Shalonda Kelly Rutgers, the State University of New Jersey, New Bruns-
wick, NJ, USA
Kelly Kennedy Converse College, Spartanburg, SC, USA
Nikki Kennedy The University of Ottawa, International Centre for Excel-
lence in Emotionally Focused Therapy, Ottawa, ON, Canada
Jonathan Kerth Willamette University, Salem, OR, USA
Michele Kerulis The Family Institute at Northwestern University, Evanston,
IL, USA
Kyle D. Killian Capella University, Minneapolis, MN, USA
Alexandra King University of Nevada – Reno, Reno, NV, USA
Karni Kissil Jupiter, FL, USA
Contributors xli
David Kitchings The Family Institute at Northwestern University, Evanston,

IL, USA
Emily C. Klear The Family Institute at Northwestern University, Evanston,
IL, USA
Sarah A. B. Knapp California School of Professional Psychology, Alliant
Kayla Knopp University of Denver, Denver, CO, USA
Carmen Knudson-Martin Lewis and Clark Graduate School of Education
and Counseling, Portland, USA
Anya Kogan Veterans Administration, Palo Alto, CA, USA
Christopher Kokoski Council on Prevention and Education: Substances
(COPES), Louisville, KY, USA
Irina Kolobova Center of Excellence for Integrated Care, Cary, NC, USA
Douglas Kopp Functional Family Therapy LLC, Seattle, WA, USA
Melani Kovarkizi California School of Professional Psychology, Alliant
Kelsey Kristensen The Family Institute at Northwestern University,
Evanston, IL, USA
Katarina Krizova Virginia Tech, Blacksburg, VA, USA
Barry Krost Healing Body Therapeutics, Chicago, IL, USA
Karol L. Kumpfer University of Utah, Salt Lake City, UT, USA
Michelle Kwintner Ithaca, NY, USA
Theressa L. LaBarrie The Family Institute at Northwestern University,
Chicago, IL, USA
Lindsay T. Labrecque Department of Psychology and Neuroscience,
University of Colorado Boulder, Boulder, CO, USA
Adele Lafrance Laurentian University, Sudbury, ON, Canada
Jordan Lahr University of Saint Joseph, West Hartford, CT, USA
Richard Lally Minuchin Center for the Family, Woodbury, NJ, USA
Angela Lamson East Carolina University, Greenville, NC, USA
Jing Lan The Family Institute at Northwestern University, Evanston,
IL, USA
Judith L. Landau ARISE Network, Linking Human Systems, LLC & LINC
Foundation Inc., Boulder, CO, USA
Laura Landry-Meyer Human Development and Family Studies, Bowling
Green State University, Bowling Green, OH, USA
xlii Contributors
Crystal Duncan Lane Western Michigan University, Kalamazoo, MI, USA

Jay Lappin Minuchin Center for the Family, Woodbury, NJ, USA
Martha LaRiviere Antioch University New England, Keene, NH, USA
Glenn Larner Australian and New Zealand Journal of Family Therapy,
Sydney, NSW, Australia
Judith Lask London, UK
Laurie Lassiter Leverett, MA, USA
Kevin K. H. Lau Counseling and Counseling Psychology, Arizona State
University, Tempe, AZ, USA
Justin A. Lavner University of Georgia, Athens, GA, USA
David D. Law Utah State University, Logan, UT, USA
Erika Lawrence The Family Institute at Northwestern University, Evanston,
IL, USA
Dominique Lawson Midwestern University, Downers Grove, IL, USA
Florencia Lebensohn-Chialvo University of San Diego, San Diego, CA,
USA
Jay L. Lebow The Family Institute at Northwestern University, Center for
Applied Psychological and Family Studies, Northwestern University,
Evanston, IL, USA
Christie Ledbetter Alabama Psychological Services Center, Madison, AL,
USA
Combrinck-Graham Lee LifeBridge Community Services, Bridgeport, CT,
USA
Gabriel Lee Azuza Pacific University; Apple, Azusa, CA, USA
Michael Lee Azusa Pacific University, Azusa, CA, USA
Minsun Lee Seton Hall University, South Orange, NJ, USA
Mo Yee Lee The Ohio State University College of Social Work, Columbus,
OH, USA
Nicholas Lee Radford University, Radford, VA, USA
Sara J. Lee Didi Hirsch Mental Health Services and Alliant International
University (CSPP), Los Angeles, CA, USA
Wai Yung Lee Asian Academy of Family Therapy, Hong Kong, China
Aitia Family Institute, Shanghai, China
Katherine A. Lenger University of Tennessee, Knoxville, Knoxville, TN,
USA
Contributors xliii
Antonella Leonelli Family System Psychotherapist, Trainer Trainee at I.E.F.

Co.S.T.Re., Rome, RM, Italy
Reed Letsinger Mental Research Institute, Palo Alto, CA, USA
Sue Levin Adjunct Faculty, Our Lady of the Lake University, Houston, TX,
USA
The Taos Institute, Chagrin Falls, OH, USA
Suzanne Levy Center for Family Intervention Science, Drexel University,
Howard A. Liddle Public Health Sciences and Psychology, University of
Miami School of Medicine, Miami, FL, USA
Julie Liefeld Southern Connecticut State University, New Haven, CT, USA
Juan Luis Linares Red Europea y latinoamericana de Escuelas Sistémicas/
European and Latin American Network of Systemic Schools, Barcelona, Spain
Marion Lindblad-Goldberg Philadelphia Child and Family Therapy
Training Center, Philadelphia, PA, USA
Deanna Linville University of Oregon, Eugene, OR, USA
Eve Lipchik Milwaukee, WI, USA
Jennifer Litner Evanston, IL, USA
Jessica R. M. Liu California School of Professional Psychology, Alliant
Zhengyi Liu Skidmore College, Saratoga Springs, NY, USA
Julia W. K. Lo Department of Social Work, The Chinese University of Hong
Kong, Hong Kong, China
Dean Lobovits Narrative Approaches, Berkeley, CA, USA
Lorna London Midwestern University, Downers Grove, IL, USA
Sylvia London Grupo Campos Elíseos, Mexico City, Mexico
Janie Long Duke University, Durham, NC, USA
Michael Lopez California School of Professional Psychology, Alliant Inter-
national University, Los Angeles, CA, USA
Lena M. Lopez Bradley Loma Linda University, Loma Linda, CA, USA
Jennifer M. Lorenzo Department of Psychology, University of Maryland,
Baltimore Country, Baltimore, MD, USA
Natale Losi Ethno-Systemic Narrative School of Psychotherapy, Rome, Italy
Wolfgang Loth Diplom-Psychologe, Systemische Gesellschaft, Bergisch
Gladbach, Germany
Genny Lou-Barton Alliant International University, Sacramento, CA, USA
xliv Contributors
Heather A. Love Kansas State University, Manhattan, KS, USA

Mallory Lucier-Greer Florida State University, Tallahassee, FL, USA
Ellen P. Lukens Columbia School of Social Work, New York, NY, USA
Wade Luquet Imago Relationships International, Washington, DC, USA
Social Work, Gwynedd Mercy University, Gwynedd Valley, PA, USA
Chris Lyford Psychotherapy Networker, Washington, DC, USA
Brandon Lyons Northcentral University, San Diego, CA, USA
C. R. Macchi Arizona State University, Phoenix, AZ, USA
Melinda MacDonald Marriage and Family Therapy Program, University of
Saint Joseph, West Hartford, CT, USA
Porter Macey Texas Tech University, Lubbock, TX, USA
Cloe Madanes Madanes Institute, San Diego, CA, USA
Stephen Madigan Vancouver School for Narrative Therapy, Vancouver, BC,
Canada
W. Madsen Family-Centered Services Project, Watertown, MA, USA
Michel Maestre PSYCOM, Villeneuve d’Ascq, France
Cátia Magalhães Polytechnic Institute of Viseu, Viseu, Portugal
Jeffrey J. Magnavita Glastonbury, CT, USA
Annette Mahoney Bowling Green State University, Bowling Green,
OH, USA
Samuel Major The Family Institute at Northwestern University, Evanston,
IL, USA
Anne Brennan Malec Symmetry Counseling, Chicago, IL, USA
Jill Malik Department of Social Sciences, Suffolk County Community
College, Brentwood, NY, USA
Jean Malpas New York, NY, USA
The Gender and Family Project, Ackerman Institute for the Family, New York,
NY, USA
Abigail Mansfield Alpert Medical School of Brown University, Providence,
RI, USA
Rhode Island Hospital; Brown University, Providence, RI, USA
Atina Manvelian University of Arizona, Tucson, AZ, USA
Claudia Manzi Athenaeum Centre for Family Study and Research, Catholic
University of Milan, Milan, Italy
Mary Ann Marchel College of St. Scholastica, Duluth, MN, USA
Contributors xlv
Sandra Marco Mexico City, Mexico, Mexico

Davide Margola Faculty of Psychology, Università Cattolica del Sacro
Cuore, Milan, MI, Italy
J. Maria Bermudez Department of Human Development and Family
Science, Marriage and Family Therapy Program, University of Georgia,
Athens, USA
Laurie Markham USC Rossier School of Education, Los Angeles, CA,
USA
Loren D. Marks Brigham Young University, Provo, UT, USA
David Marsten Miracle Mile Community Practice, Los Angeles, CA, USA
Matthew Martin Arizona State University, Phoenix, AZ, USA
Erin Martinez University of Michigan, Ann Arbor, MI, USA
Anna Mascellani Accademia di Psicoterapia della Famiglia, Rome, Italy
Corina Teofilo Mattson The Family Institute at Northwestern University,
Evanston, IL, USA
Richard E. Mattson Department of Psychology, Binghamton University,
Binghamton, NY, USA
Stephen May University of Louisiana at Monroe, Monroe, LA, USA
Darryl Maybery Department of Rural and Indigenous Health, Monash
University, Moe, Australia
Julia McAnuff Department of Couple and Family Therapy, Alliant Interna-
tional University – California School of Professional Psychology, Los
Angeles, CA, USA
Barry McCarthy American University, Washington, DC, USA
Jennifer McComb The Family Institute at Northwestern University, Evans-
ton, IL, USA
Megan McCoy Firm Foundations Counseling, Columbia, SC, USA
Kristin McDaniel Saint Louis University, Saint Louis, MO, USA
Susan H. McDaniel University of Rochester Medical Center, Rochester, NY,
USA
Teresa McDowell Lewis and Clark Graduate School of Education and
Counseling, Portland, USA
Christi R. McGeorge North Dakota State University, Fargo, ND, USA
Monica McGoldrick Multicultural Family Institute, Highland Park, NJ,
USA
Psychiatry Department, Rutgers University, Robert Wood Johnson Medical
School, Highland Park, NJ, USA
xlvi Contributors
Ryan A. McKelley University of Wisconsin-La Crosse, La Crosse, WI, USA

Charlotte J. McKernan Colorado State University, Fort Collins, USA
Patrick Mckiernan University of Louisville, Louisville, KY, USA
Allison M. McKinnon Department of Psychology, Binghamton University,
Binghamton, NY, USA
Robert J. McMahon Simon Fraser University, Burnaby, BC, Canada
B.C. Children’s Hospital, Vancouver, BC, Canada
Kaja McMaster University of California, Berkeley, Berkeley, CA, USA
Sheila McNamee University of New Hampshire, Durham, NH, USA
Douglas P. McPhee Utah State University, Logan, UT, USA
Gustavo R. Medrano The Family Institute at Northwestern University,
Evanston, IL, USA
Tatiana Melendez-Rhodes Department of Counselor Education and Family
Therapy, Central Connecticut State University, New Britain, CT, USA
Tai Mendenhall University of Minnesota, St. Paul, MN, USA
Marcos Mendez Kansas State University, Manhattan, KS, USA
Brett Merrill Brigham Young University, Provo, UT, USA
Cindy M. Meston University of Texas at Austin, Austin, TX, USA
Linda S. Metcalf Texas Wesleyan University, Fort Worth, TX, USA
Jessica Jarick Metcalfe University of Illinois, Urbana-Champaign, Urbana,
IL, USA
Andrea S. Meyer Mercer University School of Medicine, Macon, GA, USA
Dixie Meyer Saint Louis University, Saint Louis, MO, USA
Shalini Lata Middleton Alliant International University, Sacramento, CA,
USA
Kristof Mikes-Liu University of Sydney, Sydney, NSW, Australia
Bobbi J. Miller Regis University, Denver, CO, USA
Darbi M. Miller The Family Institute at Northwestern University, Evanston,
IL, USA
Rachel D. Miller Couple and Family Therapy Department, Adler University,
Chicago, IL, USA
Richard B. Miller Brigham Young University, Provo, UT, USA
Brianna Mintz Counseling Psychology, University of Oregon, Eugene, OR,
USA
Marsha Mirkin Lasell College, Newton, MA, USA
Contributors xlvii
Amanda M. Mitchell University of Louisville, Louisville, KY, USA

Lauren Mitchell Seton Hall University, South Orange, NJ, USA
Sara Moini California School of Professional Psychology/AIU-LA, Los
Angeles, CA, USA
Candice M. Monson Ryerson University, Toronto, ON, Canada
Rodrigo Morales Martínez Universidad Alberto Hurtado, Santiago, Chile
Jessica M. Moreno California State University, Sacramento, Sacramento,
CA, USA
David M. Morgan Department of Psychology, Counseling, and Family
Melinda Ippolito Morrill Harvard Medical School, Boston, MA, USA
Mary Morris The Family Institute, Faculty of Life Sciences and Education,
University of South Wales, Pontypridd, Wales, UK
Jacob Mosgaard Kongens Lyngby, Denmark
Kelly Mothner Hermosa, CA, USA
Karen Mottarella Department of Psychology, University of Central Florida,
Orlando, FL, USA
Efrossini Moureli Institute of Systemic Thinking and Psychotherapy,
Thessaloniki, Greece
Wenting Mu University of Illinois at Urbana Champaign, Champaign, IL,
USA
Hannah Muetzelfeld University at Albany/State University of New York,
Albany, NY, USA
Joan A. Muir Brief Strategic Family Therapy Institute ® (BSFT®), Univer-
sity of Miami Miller School of Medicine, Miami, FL, USA
Megan J. Murphy Purdue University Northwest, Hammond, IN, USA
Meka Murray School of Social and Behavioral Sciences, Northcentral Uni-
versity, San Diego, CA, USA
Paul Murray West Vancouver, BC, Canada
Bertranna A. Muruthi Marriage and Family Therapy Program, Virginia
Tech - Northern Virginia Center, Falls Church, VA, USA
Hannah S. Myung Fuller Graduate School of Psychology, Pasadena, CA,
USA
Aikin Nancy Sacramento-Davis EFT Center, Davis, CA, USA
International Center for Excellence in Emotionally Focused Therapy, Ottawa,
Canada
xlviii Contributors
Susan Nash Department of Family and Community Medicine, Baylor

College of Medicine, Houston, TX, USA
Rajeswari Natrajan-Tyagi Couples and Family Therapy Masters and
Doctoral Programs, California School of Professional Psychology at Alliant
International University (Irvine), Irvine, CA, USA
Robert J. Navarra The Gottman Institute, Seattle, WA, USA
Cara A. Nebeker-Adams Brigham Young University, Provo, UT, USA
Jenae M. Neiderhiser Department of Psychology, The Pennsylvania State
University, University Park, PA, USA
Thorana Nelson Santa Fe, NM, USA
José Nesis Ministry of Justice and Human Rights, Buenos Aires, Argentina
Ottar Ness University College of Southeast Norway, Notodden, Norway
Rebecca Newland Department of Psychiatry and Human Behavior, Alpert
Medical School of Brown University, Bradley/Hasbro Children’s Research
Center, East Providence, RI, USA
Jessica Newsome Seton Hall University, South Orange, NJ, USA
Tamara L. Newton University of Louisville, Louisville, KY, USA
Hoa N. Nguyen Virginia Polytechnic Institute and State University, Blacks-
burg, VA, USA
Teresa P. Nguyen University of California, Los Angeles, CA, USA
Trang Nguyen The Family Institute at Northwestern University, Evanston,
IL, USA
Michael P. Nichols College of William and Mary, Williamsburg, VA, USA
Jason Nicol The Couples Research Institute, Geneva, IL, USA
Arthur C. Nielsen The Family Institute at Northwestern University,
Chicago, IL, USA
Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
The Chicago Institute for Psychoanalysis, Chicago, IL, USA
Mike Niznikiewicz University of Illinois, Urbana Champaign, Champaign,
IL, USA
Robert J. Noone Center for Family Consultation, Evanston, IL, USA
Maxine Notice Antioch University New England, Keene, NH, USA
Kathryn M. Nowlan University of Miami, Coral Gables, FL, USA
David Nylund California State University, Sacramento, Fair Oaks, CA, USA
Gender Health Centre, Sacramento, CA, USA
Contributors xlix
Thomas G. O’Connor University of Rochester Medical Center, Rochester,

NY, USA
Katherine O’Neil Center for Applied Psychological and Family Studies, The
Family Institute at Northwestern University, Evanston, IL, USA
Mary Ellen Oliveri Bethesda, MD, USA
David H. Olson Family Social Science, University of Minnesota, St. Paul,
MN, USA
Mary Olson Institute for Dialogic Practice, New York, NY, USA
Michael Olson St. Mary’s Hospital and Regional Medical Center, Grand
Junction, CO, USA
Yasmine Omar Rutgers, the State University of New Jersey, New
Brunswick, NJ, USA
Nicole Ortiz Clinical Psychology, California School of Professional Psychol-
ogy, Alliant International University, Los Angeles, CA, USA
Diana Padilla Texas Wesleyan University, Fort Worth, TX, USA
Marcelo Pakman Amherst, MA, USA
Gail Palmer International Centre for Excellence in Emotionally Focused
Therapy, Ottawa, ON, Canada
Renos K Papadopoulos University of Essex, Colchester, UK
Yajaira Y. Paparone Staff Psychiatrist St. Joseph’s Hospital Health Center
Child Psychiatrist, Elmcrest Children’s Residential Treatment Facility,
Syracuse, NY, USA
Patricia L. Papernow Institute for Stepfamily Education, Hudson, MA,
USA
David Paré University of Ottawa, Ottawa, ON, Canada
Elizabeth Oshrin Parker University of Iowa, Iowa City, IA, USA
M. L. Parker Marriage and Family Therapy Program, University of Saint
Joseph, West Hartford, CT, USA
Natasha Helfer Parker Symmetry Solutions, Wichita, KS, USA
Aleja Parsons University of Denver, Denver, CO, USA
Jo Ellen Patterson Marital and Family Therapy Program, University of San
Diego, San Diego, CA, USA
Rebecca Patterson Center for Applied Psychological and Family Studies,
The Family Institute at Northwestern University, Evanston, IL, USA
Terence Patterson University of San Francisco, San Francisco, CA, USA
Rikki Patton The University of Akron, Akron, OH, USA
l Contributors
Aikin Paul Sacramento-Davis EFT Center, Davis, CA, USA

International Center for Excellence in Emotionally Focused Therapy, Ottawa,
Canada
Jennifer Pearlstein University of California, Berkeley, Berkeley, CA, USA
Noelany Pelc Department of Psychology and Family Therapy, Seton Hall
University, South Orange, NJ, USA
Maria Pelczar University of Nevada Las Vegas, Las Vegas, NV, USA
Kimberly Z. Pentel University of North Carolina at Chapel Hill,
Chapel Hill, NC, USA
Gina Pera Adult ADHD-Focused Couple Therapy, San Francisco Bay Area,
CA, USA
Roberto Pereira Red Europea y latinoamericana de Escuelas Sistémicas/
European and Latin American Network of Systemic Schools, Bilbao, Spain
Michael A. Perelman Department of Psychiatry, Reproductive Medicine and
Urology, Weill Cornell Medicine/New York Presbyterian, New York, NY,
USA
MAP Education and Research Foundation, New York, NY, USA
Adrian K. Perkel Bellevue Therapy Centre, Cape Town, Western Cape,
South Africa
Dustin Perkins Texas Tech University, Lubbock, TX, USA
Daniel Perlman University of North Carolina – Greensboro, Greensboro,
NC, USA
Nathan C. D. Perron Counseling@Northwestern, The Family Institute at
Northwestern University, Evanston, IL, USA
Nicholas S. Perry Department of Psychology, University of Utah, Salt Lake
City, UT, USA
Georgina Peters The Family Institute at Northwestern University, Evanston,
IL, USA
Colleen M. Peterson University of Nevada, Las Vegas, NV, USA
Julie A. Peterson The Family Institute at Northwestern University, Evans-
ton, IL, USA
Barbara Petkov Multicultural Family Institute, Highland Park, NJ, USA
Sueli Petry Multicultural Family Institute, Highland Park, NJ, USA
J. Douglas Pettinelli Saint Louis University, Saint Louis, MO, USA
Taylor Pettway The Family Institute at Northwestern University, Evanston,
IL, USA
Jasmine Pickens Alliant University, Sacramento, CA, USA
Contributors li
Timothy F. Piehler University of Minnesota, Twin Cities, Minneapolis, MN,

USA
Fred Piercy Virginia Tech University, Blacksburg, VA, USA
Sasha McAllum Pilkington Hospice North Shore, Auckland, New Zealand
William M. Pinsof Pinsof Family Systems, LLC, Chicago, IL, USA
Patricia Pitta Department of Psychology, St. John’s University, Jamaica,
NY, USA
Elizabeth Brawner Pittman Atlanta, GA, USA
Viviana Ploper The Family Institute at Northwestern University, Evanston,
IL, USA
Marcela Polanco Our Lady of the Lake University, San Antonio, TX, USA
Mina Polemi-Todoulou Scientific Council Member, The Athenian Institute
of Anthropos, Athens, Greece
Sara Pollard Rees-Jones Center for Foster Care Excellence, University of
Texas Southwestern Medical Center, Dallas, TX, USA
Valeria Pomini First Department of Psychiatry, National and Kapodistrian
University of Athens, Athens, Greece
Libby Poulin Colorado State University, Fort Collins, CO, USA
Shruti Singh Poulsen University of Colorado Denver, Denver, CO, USA
Bert Powell Circle of Security International, Spokane, WA, USA
Nydia Garcia Preto Multicultural Family Institute, Highland Park, NJ, USA
Jacob Priest University of Iowa, Iowa City, IA, USA
James O. Prochaska Clinical and Health Psychology, University of Rhode
Island, Kingston, RI, USA
Janice M. Prochaska Prochaska Change Consultants, Mill Valley, CA, USA
Julie L. Prosser Colorado State University – Applied Social and Health
Psychology, Fort Collins, CO, USA
Tidarat Puranachaikere The Family Institute at Northwestern University,
Evanston, IL, USA
Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Jeanette Purvis Department of Psychology, University of Hawai’i,
Honolulu, HI, USA
Bob Pushak Family Works, Ohio University, Athens, OH, USA
Deidre Quinlan Circle of Security International, Duluth, MN, USA
Kelley Quirk Marriage and Family Therapy Program, Human Development
and Family Studies, Colorado State University, Fort Collins, CO, USA
lii Contributors
Incia Rachid The Family Institute at Northwestern University, Evanston, IL,

USA
Forogh Rahim Drexel University, Philadelphia, PA, USA
Marilisa Z. Raju California School of Professional Psychology, Alliant
Anne Hearon Rambo Nova Southeastern University Fort, Lauderdale, FL,
USA
Cheryl Rampage The Family Institute at Northwestern University,
Evanston, IL, USA
Ashley K. Randall Counseling and Counseling Psychology, Arizona State
University, Tempe, AZ, USA
Mike Rankin Louisville, KY, USA
Paul Rasmussen Adler Institute, Columbia, SC, USA
Mudita Rastogi Illinois School of Professional Psychology, Argosy
University, Schaumburg, IL, USA
Wendel Ray University of Louisiana Monroe, Monroe, LA, USA
Swathi M. Reddy The Steve Hicks School, The University of Texas at
Austin, Austin, TX, USA
Jeffrey L. Reed University of Kentucky, Lexington, KY, USA
Susan Regas California School of Professional Psychology, Los Angeles,
CA, USA
Peter Reiner Northwestern University Feinberg School of Medicine,
Chicago, IL, USA
Samuel B. Rennebohm Seattle Pacific University, Seattle, WA, USA
Laura Restle Alpen-Adria-University Klagenfurt, Klagenfurt, Austria
Lillian Reuman Department of Psychology and Neuroscience, University of
North Carolina at Chapel Hill, Chapel Hill, NC, USA
Andrea Reupert Krongold Clinic, Faculty of Education, Monash University,
Clayton, Victoria, Australia
Yveline Rey CERAS, Grenoble, France
Jamila Evans Reynolds Tallahassee, FL, USA
Kathryn Rheem Washington Baltimore Center for EFT, Falls Church, VA,
USA
Galena K. Rhoades University of Denver, Denver, CO, USA
Tess Rhodes University of Ottawa, Ottawa, ON, Canada
Natalie M. Richardson East Carolina University, Greenville, NC, USA
Contributors liii
Shelley Riggs Department of Psychology, University of North Texas,

Denton, TX, USA
Lane L. Ritchie University of Denver, Denver, CO, USA
Alannah Shelby Rivers Department of Psychology and Neuroscience,
Baylor University, Waco, TX, USA
Hye-Sun Ro Couple and Family Therapy Program, California School of
Professional Psychology, Alliant International University, Los Angeles, CA,
USA
Paige D. Roane Nick Finnegan Counseling Center, Houston, TX, USA
Houston Family Therapy, Houston, TX, USA
Michael Robbins Functional Family Therapy LLC, Seattle, WA, USA
Peter Rober KU Leuven, Leuven, Belgium
Alice F. Roberts Bountiful, UT, USA
Kelly Roberts University of North Texas, Denton, TX, USA
Janet Robertson Antioch University New England, Keene, NH, USA
Arthur L. Robin Children’s Hospital of Michigan, Detroit, MI, USA
Dennis, Moye, and Associates, Bloomfield Hills, MI, USA
W. David Robinson Utah State University, Logan, UT, USA
Briana L. Robustelli Department of Psychology and Neuroscience,
McKenzie K. Roddy University of Miami, Coral Gables, FL, USA
Roy H. Rodgers Professor Emeritus, University of British Columbia,
Vancouver, BC, Canada
Irma Rodríguez Grupo Campos Elíseos, Mexico City, Mexico
Craig Rodriguez-Seijas Stony Brook University, Stony Brook, NY, USA
Thomas Roesler Department of Psychiatry and Behavioral Medicine, Uni-
versity of Washington School of Medicine, Seattle, WA, USA
Jessica Rohlfing Pryor The Family Institute at Northwestern University,
Chicago, IL, USA
Michael J. Rohrbaugh George Washington University, Washington, DC,
USA
John S. Rolland The Chicago Center for Family Health, University of
Chicago, Chicago, IL, USA
Lee A. Rosén Colorado State University, Fort Collins, CO, USA
Andrew H. Rose Texas Tech University, Lubbock, TX, USA
liv Contributors
Anthony Rose Counseling Psychology Doctoral Student, Brigham Young

University, Provo, UT, USA
Tziporah Rosenberg University of Rochester School of Medicine and Den-
tistry, Rochester, NY, USA
David Rosenthal Columbia University, New York, NY, USA
Michelle Rosselli William Paterson University, Wayne, NJ, USA
Amy Roth Chestnut Hill College, Philadelphia, PA, USA
Karen Rothman University of Miami, Miami, FL, USA
Jenna Rowen The Family Institute at Northwestern University, Evanston, IL,
USA
Marcy Rowland Hollidaysburg, PA, USA
James Ruby The Family Institute at Northwestern University, Evanston, IL,
USA
Nancy Ruddy Department of Family and Social Medicine, Montefiore Med-
ical Center, Einstein College of Medicine, Bronx, NY, USA
William P. Russell The Family Institute at Northwestern University, Evans-
ton, IL, USA
Kevin Russell Santa Rosa, CA, USA
Jody Russon Center for Family Intervention Science, Drexel University,
Allen Sabey The Family Institute at Northwestern University, Evanston, IL,
USA
Brad Sachs Stevens Forest Professional Center, Columbia, MD, USA
Bahareh Sahebi The Family Institute at Northwestern University, Evanston,
IL, USA
Illinois School of Professional Psychology, Schaumburg, IL, USA
Sadaf Sahibzada California School of Professional Psychology, Alliant
International University, Sacramento, CA, USA
Brittany Salerno Clinical Psychology, California School of Professional
Psychology at Alliant International University, Los Angeles, CA, USA
Sarah K. Samman Alliant International University, San Diego, CA, USA
Matthew R. Sanders Parenting and Family Support Centre, The University
of Queensland, Brisbane, QLD, Australia
Keith Sanford Department of Psychology and Neuroscience, College of Arts
and Sciences, Baylor University, Waco, TX, USA
Anna Santowski The Family Institute at Northwestern University, Evanston,
IL, USA
Contributors lv
John Sargent Tufts Medical Center, Boston, MA, USA

Peggy Sax Re-authoring Teaching, Inc, Middlebury, VT, USA
Jill Savege Scharff International Psychotherapy Institute, Chevy Chase,
MD, USA
Michele Scheinkman Ackerman Institute for the Family, Manhattan, NY,
USA
Kristin S. Scherrer Department of Social Work, Metropolitan State Univer-
sity of Denver, Denver, CO, USA
Karin Schlanger Mental Research Institute, Palo Alto, CA, USA
Cydney Schleiden Texas Tech University, Lubbock, TX, USA
Arist von Schlippe Familiendynamik, Heidelberger Institut für systemische
Tara Schlussel California School of Professional Psychology, Alliant Inter-
national University, Los Angeles, CA, USA
Sonja Schoenwald Medical University of South Carolina, Charleston, SC,
USA
Ciera E. Schoonover Department of Psychology, Central Michigan Univer-
sity, Mount Pleasant, MI, USA
William E. Schult Couples Resource Collective, Sacramento, CA, USA
Kyle Schultz University of Pennsylvania, Philadelphia, PA, USA
Erin J. Schuyler Adler Institute, Columbia, SC, USA
Richard Schwartz Harvard Medical School, Brookline, MA, USA
Roger Schwartz Department of Couple and Family Therapy, Alliant Inter-
national University – California School of Professional Psychology, Los
Angeles, CA, USA
Maria Schweer-Collins Prevention Science, University of Oregon, Eugene,
OR, USA
Jochen Schweitzer Institute of Medical Psychology, University of Heidel-
berg Medical School, Heidelberg, Germany
Jenna C. Scott Florida State University, Tallahassee, FL, USA
Lisa Scott Brigham Young University, Provo, UT, USA
Shelby Scott Denver Veterans Affairs Medical Center, Denver, CO, USA
J. Scott Fraser School of Professional Psychology, Wright State University,
Dayton, OH, USA
Ryan B. Seedall Utah State University, Logan, UT, USA
lvi Contributors
Mary V. Seeman Department of Psychiatry, University of Toronto, Toronto,

ON, Canada
Jaakko Seikkula Department of Psychology, University of Jyväskylä,
Jyväskylä, Finland
Natasha Seiter Marriage and Family Therapy/Applied Developmental
Science Program, Colorado State University, Fort Collins, CO, USA
Matthew D. Selekman Partners for Collaborative Solutions, Evanston, IL,
USA
Stanley Selinger The Family Institute, Evanston, IL, USA
Diana J. Semmelhack Midwestern University, Downers Grove, IL, USA
Gita Seshadri Alliant International University, Sacramento, CA, USA
Monica Sesma-Vazquez University of Calgary, Calgary, AB, Canada
Thomas L. Sexton FFT, Bloomington, IN, USA
Steven Shamblen Pacific Institute for Research and Evaluation (PIRE),
Beltsville, MD, USA
Samuel Shannon University of Louisiana Monroe, Monroe, LA, USA
Alyson F. Shapiro San Diego State University, San Diego, CA, USA
Kimberly Sharky Enliven Chicago, Chicago, IL, USA
Neha Sharma Tufts University School of Medicine, Boston, MA, USA
Fei Shen Texas Tech University, Lubbock, TX, USA
Emily Sher School of Osteopathic Medicine, A.T. Still University, Mesa,
AZ, USA
Tamara G. Sher The Family Institute at Northwestern University, Evanston,
IL, USA
Hannah Sherbersky University of Exeter, Exeter, Devon, UK
Judith P. Siegel New York University, New York, NY, USA
Jacqueline Françoise Sigg Carrero Sociedad Mexicana de Prácticas
Narrativas y Trabajo Comunitario S.C., Mexico, Mexico
Timothy Sim The Hong Kong Polytechnic University, Hong Kong, China
Mima Simic Maudsley Centre for Child and Adolescent Eating Disorders,
South London and Maudsley NHS Foundation Trust, London, UK
Bethany Simmons California Lutheran University, Thousand Oaks, CA,
USA
George M. Simon The Minuchin Center for the Family, Woodbury, NJ, USA
Madalyn Simpson The Family Institute at Northwestern University, Evans-
ton, IL, USA
Contributors lvii
Jefferson Singer Connecticut College, New London, CT, USA

Rupsha Singh Department of Psychology, University of Maryland,
Baltimore Country, Baltimore, MD, USA
Karen Skerrett Adjunct Faculty: The Family Institute and Center for Family
Studies at Northwestern University, Evanston, IL, USA
Eizabeth A. Skowron Counseling Psychology and Prevention Science,
University of Oregon, Prevention Science Institute, Eugene, OR, USA
Noel Slesinger Northwestern University Feinberg School of Medicine,
Evanston, IL, USA
Carlos E. Sluzki Department of Psychiatry, George Washington University,
Washington, DC, USA
Global and Community Health and Conflict Analysis and Resolution, George
Mason University, Fairfax, VA, USA
Amy D. Smith Marriage and Family Therapy/Applied Developmental
Science Program, Colorado State University, Fort Collins, CO, USA
Marriage and Family Therapy Program, Human Development and Family
Studies, Colorado State University, Fort Collins, CO, USA
Carla P. Smith Mercer University, Atlanta, GA, USA
Dana K. Smith Oregon Research Institute, Eugene, OR, USA
Miranda Smith University of Louisville, Louisville, KY, USA
Olga Smoliak University of Guelph, Guelph, Canada
Douglas K. Snyder Texas A&M University, College Station, TX, USA
Alexandra H. Solomon The Family Institute at Northwestern University,
Evanston, IL, USA
Kristy L. Soloski Texas Tech University, Lubbock, TX, USA
Andy Solovey ACSW, LISW-S Behavioral Therapist Solutions Counseling,
Dublin, OH, USA
Jinsook Song Antioch University New England, Keene, NH, USA
Terry Soo-Hoo California State University East Bay, Hayward, CA, USA
Stephen Southern The Family Institute at Northwestern University,
Evanston, IL, USA
Jacqueline Sparks Department of Human Development and Family Studies,
University of Rhode Island, Kingston, RI, USA
Chelsea Spencer Kansas State University, Manhattan, KS, USA
Todd Spencer Oklahoma State University, Stillwater, OK, USA
Paul Spengler Ball State University, Muncie, IN, USA
lviii Contributors
Susan Sprecher Illinois State University, Normal, IL, USA

Mandy Squires University of Nevada, Las Vegas, Las Vegas, NV, USA
Sally St. George University of Calgary, Calgary, AB, Canada
Michael Stadter Stadter and Prelinger Psychotherapy and Consultation,
Bethesda, MD, USA
International Psychotherapy Institute and Washington School of Psychiatry,
Washington, DC, USA
Mark Stanton Azusa Pacific University, Azusa, CA, USA
Katelyn Steele Alliant International University, Los Angeles, CA, USA
Frederick Steier University of South Florida, Tampa, FL, USA
Fielding Graduate University, Santa Barbara, CA, USA
Kyle R. Stephenson Willamette University, Salem, OR, USA
Emma Sterrett-Hong University of Louisville, Louisville, KY, USA
Morgan A. Stinson Mercer University School of Medicine, Macon, GA, USA
Sandra Stith Kansas State University, Manhattan, KS, USA
Cheryl L. Storm Pacific Lutheran University, Tacoma, WA, USA
Ted N. Strader Council on Prevention and Education: Substances (COPES),
Louisville, KY, USA
CLFC National Training Center, Resilient Futures Network, LLC, Louisville,
KY, USA
Peter Stratton Leeds Family Therapy and Research Centre, University of
Leeds, Leeds, UK
George Stricker Argosy University, Arlington, VA, USA
Johanna Strokoff University of Illinois at Chicago, Chicago, IL, USA
Tom Strong University of Calgary, Calgary, Canada
Gregory L. Stuart University of Tennessee-Knoxville, Knoxville, TN, USA
Bradford D. Stucki Human Development, Virginia Tech, Blacksburg, VA, USA
Laura Sudano University of California, Department of Family Medicine and
Public Health, San Diego, CA, USA
Winston Salem, NC, USA
Michael E. Sude Department of Psychology, La Salle University, Philadel-
phia, PA, USA
Tetiana Sukach Texas Tech University, Lubbock, TX, USA
Jana Sutton University of Louisiana Monroe, Monroe, LA, USA
Ben Swerdlow University of California, Berkeley, Berkeley, CA, USA
Contributors lix
José Szapocznik University of Miami, Miami, FL, USA

Amanda Szarzynski Converse College, Spartanburg, SC, USA
Robert Taibbi Charlottesville, VA, USA
Taimalie Kiwi Tamasese Family Centre Social Policy Research Unit,
Wellington, New Zealand
Takeshi Tamura International Committee, Tokyo, Japan
Chun Tao Counseling and Counseling Psychology, Arizona State University,
Tempe, AZ, USA
Daniel Tapanes Loma Linda University | Loma Linda University Health
Behavioral Medicine Center, Loma Linda, CA, USA
Margarita Tarragona PositivaMente and Grupo Campos Elíseos, Mexico
City, Mexico
Negar Taslimi Alliant International University – California School of
Professional Psychology, Irvine, CA, USA
David Taussig The Family Institute at Northwestern University, Evanston,
IL, USA
Sadie Teal Seattle Pacific University, Seattle, WA, USA
David Tefteller The University of Akron, Akron, OH, USA
Umberta Telfener Centro Milanese di Terapia della Famiglia, Milan, Italy
Patrick S. Tennant The University of Texas at Austin, Austin, TX, USA
Nick Finnegan Counseling Center, Houston, TX, USA
Corina M. Teofilo Mattson The Family Institute at Northwestern University,
Evanston, IL, USA
Lee A. Teufel-Prida The Family Institute at Northwestern University,
Evanston, IL, USA
John W. Thoburn Department of Clinical Psychology, Seattle Pacific Uni-
versity, Seattle, WA, USA
Elizabeth Doherty Thomas The Doherty Relationship Institute, Saint Paul,
MN, USA
Frank N. Thomas Texas Christian University, Fort Worth, TX, USA
Jermaine Thomas Cornerstone Counseling Center of Chicago, Chicago, IL,
USA
Volker Thomas The University of Iowa, Iowa City, IA, USA
Christopher Thompson Seton Hall University, South Orange, NJ, USA
Kareigh Tieppo The Family Institute at Northwestern University, Evanston,
IL, USA
lx Contributors
Terje Tilden Modum Bad Research Institute, Vikersund, Norway

Margaret Tobias Department of Psychology and Neuroscience, University
of Colorado Boulder, Boulder, CO, USA
Thomas C. Todd Red Cross Services to the Armed Forces, Louisiana, New
Orleans, LA, USA
Willie Tolliver Silberman School of Social Work at Hunter College, New
York, NY, USA
Jenae P. Torres Loma Linda University, Loma Linda, CA, USA
Maru Torres-Gregory The Family Institute at Northwestern University,
Evanston, IL, USA
Fany Triantafillou Systemic Association of Northern Greece, Thessaloniki,
Greece
Peter Troiano Central Connecticut State University, New Britain, CT, USA
Lina Truong Willamette University, Salem, OR, USA
Eleftheria Tseliou Laboratory of Psychology, Department of Early
Childhood Education, University of Thessaly, Volos, Greece
Hsinlien Tiffany Tsou The Family Institute at Northwestern University,
Evanston, IL, USA
Chunyue Tu Brigham Young University, Provo, UT, USA
Flora Tuhaka The Family Centre, Wellington, New Zealand
Karen M. T. Turner Parenting and Family Support Centre, The University
of Queensland, Brisbane, QLD, Australia
Brie Turns Texas Tech University, Lubbock, TX, USA
Markie L. C. Twist University of Wisconsin-Stout, Menomonie, WI, USA
Valeria Ugazio Director of European Institute of Systemic-relational Ther-
apy, Milan, Italy
University of Bergamo, Milan, Italy
Stephanie Shepard Umaschi Department of Psychiatry and Human Behav-
ior, Alpert Medical School of Brown University, Bradley/Hasbro Children’s
Research Center, East Providence, RI, USA
Damir S. Utržan University of Minnesota, Twin Cities, Minneapolis, MN,
USA
Nicole Van Ness Connected Couples (Private Practice), Fort Worth, TX, USA
Flora Tuhaka: deceased.

Contributors lxi
Risë VanFleet Family Enhancement and Play Therapy Center, Inc.,

International Institute for Animal Assisted Play Therapy, Boiling Springs, PA,
USA
Yolanda de Varela International Psychoanalytical Association – Interna-
tional Institute for Psychoanalytic Training, Panama, Republic of Panama
International Psychotherapy Institute, Washington, DC, USA
Katherine Vaughan Drexel University, Philadelphia, PA, USA
Sara Vicendese LMFT, Los Angeles, CA, USA
Sara Villegas-Boykins California School of Professional Psychology,
Tina Pittman Wagers Department of Psychology and Neuroscience,
Amy C. Wagner The Family Institute at Northwestern University, Evanston,
IL, USA
Jeni Wahlig Antioch University, Keene, NH, USA
Charles Waldegrave The Family Centre, Wellington, New Zealand
Nicole Walker University of Nevada – Las Vegas, Las Vegas, NV, USA
Froma Walsh Chicago Center for Family Health and Firestone Professor
Emerita, The University of Chicago, Chicago, IL, USA
Kelsey J. Walsh Arizona State University, Tempe, AZ, USA
Richard Wampler Michigan State University, Haslett, MI, USA
Linna Wang Alliant International University, San Diego, CA, USA
Binghuang A. Wang Binghamton University – State University of New
York, Binghamton, NY, USA
Linda Wark Indiana University – Purdue University, Fort Wayne, IN, USA
Allison Waterworth American Board of Professional Psychology, Chapel
Hill, NC, USA
Marlene F. Watson Drexel University, Philadelphia, PA, USA
Rachel Weddle Regis University, Denver, CO, USA
Lindsey M. Weiler University of Minnesota, St. Paul, MN, USA
Linda Weiner Institute of Sexual and Relationship Therapy and Training, St.
Louis, MO, USA
Geri D. Weitzman Los Altos, CA, USA
Amelia Welch The Family Institute at Northwestern University, Evanston,
IL, USA
lxii Contributors
Tim Welch Human Development and Family Studies, Michigan State

University, East Lansing, MI, USA
Melissa Wells Lewis and Clark, Portland, OR, USA
Doug Wendt Brigham Young University, Provo, UT, USA
Diana Westerberg Department of Psychiatry and Human Behavior, Alpert
Medical School of Brown University, Bradley/Hasbro Children’s Research
Center, East Providence, RI, USA
Mark A. Whisman Department of Psychology and Neuroscience, Univer-
sity of Colorado Boulder, Boulder, CO, USA
Cheryl White Dulwich Centre, Adelaide, Australia
Latalia D. White The Family Institute at Northwestern University, Evanston,
IL, USA
Mark B. White Department of Marriage and Family Sciences, Northcentral
University, San Diego, CA, USA
Jason B. Whiting Brigham Young University, Provo, UT, USA
Sarah W. Whitton University of Cincinnati, Cincinnati, OH, USA
Stephanie A. Wiebe The Ottawa Hospital, The University of Ottawa, Inter-
national Centre for Excellence in Emotionally Focused Therapy, Ottawa, ON,
Canada
Jason L. Wilde Dixie State University, St. George, UT, USA
Marte Ostvik-de Wilde Counseling and Applied Behavioral Studies,
University of Saint Joseph, West Hartford, CT, USA
Daniel B. Wile Oakland, CA, USA
Emily Wilensky The Family Institute at Northwestern University, Evanston,
IL, USA
Sarah A. Wilhoit University of Dayton, Dayton, OH, USA
Elaine Willerton School of Social and Behavioral Sciences, Northcentral
University, San Diego, CA, USA
Elisabeth Esmiol Wilson Pacific Lutheran University, Tacoma, WA, USA
Lauren Wilson Saint Louis University, Saint Louis, MO, USA
Dara Winley Drexel University, Philadelphia, PA, USA
Alicia E. Wiprovnick University of Maryland, Baltimore County, Baltimore,
MD, USA
Dawn M. Wirick The Family Institute at Northwestern University, Evanston,
IL, USA
Contributors lxiii
Katie C. Wischkaemper William C. Tallent VA Outpatient Clinic,

Knoxville, TN, USA
Irene C. Wise Illinois School of Professional Psychology at Argosy
University, Schaumburg, IL, USA
Armeda Stevenson Wojciak University of Iowa, Iowa City, IA, USA
Catalina Woldarsky Meneses Geneva, Switzerland
Psychology and Counseling Department, Webster University Geneva,
Bellevue, Switzerland
Caitlin Wolford-Clevenger University of Tennessee-Knoxville, Knoxville,
TN, USA
Beatrice Wood State University of New York, Buffalo, NY, USA
Nathan D. Wood University of Kentucky, Lexington, KY, USA
Sarah B. Woods Department of Family Sciences, Texas Woman’s Univer-
sity, Denton, TX, USA
Scott R. Woolley Alliant International University, Los Angeles, CA, USA
Amy Wu The Family Institute at Northwestern University, Evanston, IL,
USA
Dan Wulff University of Calgary, Calgary, AB, Canada
Jing Xie University of Houston, Houston, TX, USA
Kimi Yatsushiro University of Alaska Fairbanks, Fairbanks, AK, USA
Janet Yeats LMFT LLC, Minneapolis, MN, USA
Ester Yesayan Los Angeles, CA, USA
Jiwon Yoo Seton Hall University, South Orange, NJ, USA
Karen Young Windz Institute, Oakville, ON, Canada
Fangzhou Yu Counseling Department, The Family Institute at Northwestern
University, Evanston, IL, USA
Kevin Yu The Family Institute at Northwestern University, Evanston, IL,
USA
Chloé E. Zessin California Lutheran University, Port Hueneme, CA, USA
Nan Zhou Faculty of Education, Beijing Normal University, Beijing, China
Qinyi Zhu Family Institute at Northwestern University, Evanston, IL, USA
Angelina M. Ziegler The Family Institute at Northwestern University,
Chicago, IL, USA
Max Zubatsky Department of Family and Community Medicine, Saint
Louis University, St. Louis, MO, USA
A
AAMFT Approved Supervisor counseling (MFC; Stevens-Smith et al. 1993).

Training In the early beginnings of the field, more specifi-
cally in 1949, the accrediting body of the
Sarah K. Samman1 and Gita Seshadri2 AAMFT, later titled the Commission on Accred-
1
Alliant International University, itation for Marriage and Family Therapy Educa-
San Diego, CA, USA tion (COAMFTE), identified and established what
2
Alliant International University, Sacramento, constituted a competent MFT/MFC (Kosinski
CA, USA 1982). In 1971, the AAMFT further legitimized
and added value to the field by initiating rigorous
trainings for the AAMFT Approved Supervisor
Name of Entry status* (Lee et al. 2004). At the turn of the century,
the field of MFT was one of only two fields
AAMFT Approved Supervisor Training requiring additional training to “designate super-
visors, define supervisors’ qualifications, and
require supervisor training” (Todd and Storm
Synonyms 2002, p. 4). This training process offers profes-
sional development options for AAMFT
AAMFT Approved Supervision Designation; Supervisors-in-Training (SIT)* and future
AAMFT Approved Supervisor Designation; AAMFT Approved Supervisors* at both the mas-
AAMFT Approved Supervisor Program; ters and doctoral levels. The AAMFT Supervisor
AAMFT Approved Supervisors; Approved Designation* and distinction is a hallmark of
Supervisor status; Supervisor-in-Training (SIT) COAMFTE accreditation.
Introduction Description
For more than 75 years, the American Association Members of the AAMFT, initially the American
for Marriage and Family Therapy (AAMFT) vol- Association of Marriage and Family Counselors
untarily established its professional identity (AAMFC; Kosinski 1982; Stevens-Smith et al.
developing formalized education and training 1993), believed the field of MFT/MFC deserved
standards and responsibilities for the field of a distinct professional identity in contrast to main-
marriage and family therapy (MFT; AAMFT stream theoretical and clinical fields at the time. In
2016; Kosinski 1982) and marriage and family 1974, the AAMFT became the first official body
J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy,
https://doi.org/10.1007/978-3-319-49425-8
2 AAMFT Approved Supervisor Training
that enforced accreditation standards for graduate comprehensive experience for students beginning
and post-degree training (Kosinski 1982; Stevens- their careers in the field and preparing for future
Smith et al. 1993) to reflect the autonomous the- autonomous clinical practice (Stevens-Smith et al.
oretical and clinical discipline of MFT/MFCs. 1993). COAMFTE also accredits doctoral-level
This was possible through the institution of programs with advanced specialization in curric-
COAMFTE (Stevens-Smith et al. 1993), the ula and training in the field of MFT. These
establishment of licensure requirements for the programs commonly require a COAMFTE
profession (Kosinski 1982; West et al. 2013), as accredited master’s degree curriculum as a prereq-
well as the development of supervisory standards uisite (Stevens-Smith et al. 1993). The doctoral
through the AAMFT Approved Supervisor Pro- curriculum focuses on “emphasizing research,
gram* (Kosinski 1982). Since then, it has become theory construction, supervision, and advanced
one of a handful of credentialing organizations by clinical skills” (Stevens-Smith et al. 1993, para.
which to obtain the education, training, and certi- 19). Thus, it is unsurprising that obtaining a
fication necessary to ensure quality supervisory COAMFTE accredited degree is beneficial for
skills, primarily those around the evaluation of the licensure or certification process at the local
students’ basic as well as advanced professional and national level.
and clinical competencies to ensure ethical and
effective therapeutic care. AAMFT and Licensure
The AAMFT has evolved and thrived, from Licensure is the legal privilege to practice within
tentatively drawing lines in the sand to a particular field (West et al. 2013); it provides
establishing the gold standard for the field of the basis for regulatory oversight and reimburse-
MFT. The AAMFT succeeded at creating and ment (AAMFT 2016). A vast majority of MFT
regulating stringent training and supervision stan- professionals believe licensure is the crowning
dards to ensure both students and professors were achievement after years of effort and hard work
validating a terminal degree. Members of the in the field. With regard to licensure, AAMFT
AAMFT realized that their systemic approach to state divisions collaborated to establish the
accreditation processes through COAMFTE, in Department of Divisional Affairs (West et al.
addition to clinical and supervisory professionals 2013) and, in 1987, provided seed money to
working in collaboration along with licensing establish the Association of Marital and Family
boards, professors, and students, would ensure Therapy Regulatory Boards (AMFTRB; West
the systemic process could succeed. The follow- et al. 2013). In the early 1990s, the AAMFT,
ing sections expand upon the successes of this through the AMFTRB, succeeded in obtaining
process. licensure and certification statuses for MFTs
nationally (West et al. 2013). While the
AAMFT Accreditation Process AAMFT initially took a leadership role in
The AAMFT provides recognition of MFT- establishing professional standards, state licen-
related education through COAMFTE grounded sure boards began taking on a leadership and
in a 2-year, at minimum, terminal master’s degree regulatory role in all 50 states and the District
in MFT. The degree adheres to AAMFT curricular of Columbia (West et al. 2013). Due to the inde-
guidelines for students and clinical training exper- pendent needs of each state, West et al. found that
tise of supervisors (West et al. 2013). Unsurpris- prelicensing requirements for individual states
ingly, the curriculum in COAMFTE programs and the AAMFT in comparison data for 2007
reflects the foundation of MFT and involves a and 2012 differed and, at times, would conflict.
systemic and interactional lens with consideration Despite best efforts to collaborate between the
to case conceptualization, assessment and evalu- AAMFT and state regulatory boards, the authors
ation, diagnosis, treatment, and attention to diver- found that AAMFT guidelines were commonly
sity issues facing individuals, couples, and more stringent reflecting quality graduate guide-
families. These guidelines ensure the most lines and providing stronger opportunities for
AAMFT Approved Supervisor Training 3
licensure at the national level. These ongoing AAMFT Supervision

conflicts led in small part to the AAMFT mem- Todd and Storm (2002) viewed the supervisory
bership passing legislation to restructure the experience as a developmental process within a A
AAMFT and dissolve state divisions in 2018 large continuously evolving supervisory system.
with the desire to reestablish the AAMFT as the In other words, supervision is the relationship by
central regulatory organization. The restructure which the supervisor monitors and evaluates the
also provided opportunities to create personal quality of the supervisee’s professional and clini-
interest groups based on the needs of each par- cal development, competencies, and services
ticular state. (West et al. 2013) within the immediate supervi-
In the meantime, California currently is an sory relationship as well as the larger practice
exception to this rule due in large part to differ- setting (Todd and Storm 2002). Supervisors then
ing regulatory values as well as the concentrated act as gatekeepers by ensuring students graduate
number of MFTs in the state comparable to the with the requisite skills and competencies needed
combined number of MFTs nationwide. Thus, toward licensure (West et al. 2013). Thus, the
California maintained the AAMFT professional AAMFT supervisory guidelines are essential
relationship while withdrawing from the components of the training experience working
AAMFT as its regulating body for licensure, toward higher-quality graduate and postgraduate
and the state is not currently included in the work in consideration of COAMFTE regulation.
national exam. The Board of Behavioral Sci-
ences is currently tasked with regulating MFT AAMFT Approved Supervision Training
licensure in the State of California. Additionally, The field of MFT has considerably evolved.
in 1998, advocates for California licensure reg- Quality supervision by skilled and proficient
ulation established the California Association of clinicians is essential to shape MFT professionals
Marriage and Family Therapists (CAMFT) to and influence the growing mental health profes-
bridge this gap between profession and sion in multiple aspects of professional identity.
licensure. In order to ensure quality and rigor, the AAMFT
believed creating a supervision credential would
AAMFT Membership contribute to the growth and development of
The AAMFT offers several membership opportu- therapists in both prelicensure (i.e., obtaining
nities for individuals specializing in MFT in the supervision during practice and development as
USA: student, preclinical fellow, and clinical fel- a Supervisor-in-Training* [SIT*]) and post-
low (AAMFT 2018b). Affiliates may join the licensure (i.e., providing mentorship supervision
AAMFT; however, this category includes profes- for developing clinicians and SITs) experiences.
sionals licensed in alternative fields/disciplines Smith et al. (2002, see also AAMFT 2016)
with specializations/emphases in MFT/MFC reported that pursuing the SIT* credentialing pro-
(AAMFT 2018b). The AAMFT offers the student cess allows those wanting to become AAMFT
category to those enrolled in a graduate or post- Approved Supervisors* to (1) develop an under-
graduate certificate program; the preclinical fel- standing of the various models of supervision,
low is for master’s graduates working toward (2) develop a personal philosophy of supervision,
licensure in any US state; and the clinical fellow (3) forge relationships with other professionals in
is for those who are fully licensed MFTs in any US the form of supervisor/supervisee relationships,
state (AAMFT 2018b). AAMFT members in any (4) use and review cases (verbal, audio, video,
of the above categories, with the exception of and/or live), and (5) expand the systemic unit of
affiliates, are eligible to pursue the AAMFT supervision from a dyad to multiple systems (i.e.,
Approved Supervisor Training process and must supervisor of supervision/mentor as well as super-
be a preclinical fellow or clinical fellow to obtain visees). SITs* are simultaneously advocates, wit-
their AAMFT Approved Supervisor Designation* nesses, and participants of multiculturalism (race,
(AAMFT 2016). ethnicity, etc.) and diversity (e.g., gender, sexual
4 AAMFT Approved Supervisor Training
orientation, socioeconomic status, religio- Equivalent Supervisors to go around. Nevertheless,

spiritual identification, ability, etc.) in addition to supervisors with an AAMFT Supervisor Designa-
explicit attention to the AAMFT ethical codes, tion* have completed all necessary training to com-
federal and state regulations, and the values of prehensively mentor SITs through the supervisory
the AAMFT membership and organization as a process.
part of the contextual supervision process. Additional roadblocks include AAMFT’s lessen-
The SIT* is also available to doctoral students in ing control over the initial requirements of those
COAMFTE accredited programs offering supervi- pursuing a degree in MFT. The education and train-
sion courses. Students are required to take 30 h of ing experiences are increasingly difficult to evaluate,
applicable supervision courses in the form of two both in quality and uniformity, especially in non-
classes (i.e., Fundamentals of MFT Supervision and COAMFTE accredited MFT programs (West et al.
Advanced Supervision in MFT; AAMFT 2016). 2013). This includes differences in practicum and
Doctoral students can then complete all other state requirements and the fact that agencies are less
requirements of the AAMFT Supervision Designa- likely to be able to provide AAMFT Approved
tion* while completing their degree or thereafter Supervisors* on staff (West et al. 2013). Thus,
within 5 years of starting the Fundamentals of MFT advocates encourage more support for the
MFT Supervision course. At the culmination of AAMFT Supervisor Designation* as well as what
SIT hours, the AAMFT Approved Supervisor* can- it stands for due to its established foundation for
didate would have completed the following: (1) a quality clinical training and supervision.
30-h supervision course; (2) 36 h of supervision,
where 18 of the hours are completed within the last Significance and Uniqueness of the AAMFT
2 years of training; (3) a minimum of 9 months of Supervisor Training
continuous supervision with at least 2 AAMFT An area of distinction with the AAMFT Approved
trainees; (4) 180 h of supervision of trainees, with Supervisor Designation* is the emphasis on diver-
90 of the hours completed within the last 2 years of sity and multiculturalism. The AAMFT Code of
training; and (5) a philosophy of supervision paper Ethics (AAMFT 2018a) and principles has a section
that is reviewed and approved by the SIT’s supervi- on nondiscrimination as follows: “Marriage and
sor. Candidates must ensure they join the preclinical family therapists provide professional assistance to
fellow or clinical fellow category before applying persons without discrimination on the basis of race,
for the SIT* designation. For further requirements, age, ethnicity, socioeconomic status, disability, gen-
see the most current version of the AAMFT der, health status, religion, national origin, sexual
Approved Supervision Designation: Standards orientation, gender identity or relationship status”
Handbook (AAMFT 2016). (p. 3). Designation as an AAMFT Approved Super-
visor* inherently emphasizes attention to interac-
Challenges with Access to AAMFT Approved tional and contextual influences around diversity.
Supervisors* Despite these multicultural emphases and contextual
While there is strength and backing to the AAMFT values, Northey (2004) highlighted that MFTs in his
Supervisor Designation* credential, there are a few study were predominantly Caucasian, and this pres-
roadblocks. There are tens of thousands of licensed ence automatically influences supervisory experi-
MFTs nationwide; however, only a few are AAMFT ences when extended systems do not reflect
qualified supervisors, and fewer are available for national representations. Based on this, the encour-
trainee and intern supervisory mentorship. This cre- agement is for supervisors to explore these dynam-
ates a challenge around replicability and reliability. ics and be sensitive to how supervision attends to
Restrictive graduate programs may assign pre- multicultural and diversity issues and needs. They
approved practicum sites and supervisors to interns further emphasized that other forms of diversity
and trainees without consideration for goodness of need to also be acknowledged (e.g., socioeconomic
fit. There may not even be enough AAMFT status, sexual orientation, gender, etc.) as well as
Approved Supervisors* or AAMFT Approved power dynamics.
ABCT Couples Research and Treatment Special Interest Group 5
Lastly, as the field of MFT evolves with the education in marriage and family therapy. Journal of
turn of the century, AAMFT has provided more Teaching in Marriage and Family, 2(2), 127–151.
Stevens-Smith, P., Hinkle, J. S., & Stahmann, R. F. (1993).
opportunities for technology by including it as an A comparison of professional accreditation standards in A
aspect of supervision, i.e., providing the supervi- marriage and family counseling and therapy. Counselor
sion and refresher courses online (AAMFT Education and Supervision, 33(2), 116–126. https://doi.
2018b). The commitment to technological acces- org/10.1002/j.1556-6978.1993.tb00274.x.
Todd, T. C., & Storm, C. L. (Eds.). (2002). The complete
sibility is evidenced by AAMFT’s official pro- systemic supervisor: Context, philosophy, and prag-
vider status for online courses since June 2015. matics. Lincoln: Authors Choice Press.
They have also added a supervisor directory for West, C., Hinton, W. J., Grames, H., & Adams, M. A.
both students, clinicians, and supervisors who are (2013). Marriage and family therapy: Examining the
impact of licensure on an evolving profession. Journal
AAMFT members as a form of networking and of Marital and Family Therapy, 39(1), 112–126.
connection. Members can view this link after https://doi.org/10.1111/jmft.12010.
signing into the AAMFT website: https://www.
aamft.org/AAMFT/supervision/AS_Designation.
aspx. Other resources for supervisors on the
ABCT Couples Research and
website include samples of informed consent
Treatment Special Interest
with SIT, ways to structure supervision, and a
Group
supervisor’s theoretical orientation.
Dev Crasta1, Kayla Knopp2, Brian R. W.
Baucom3 and Katherine J. W. Baucom4
Cross-References 1
University of Rochester, Rochester, NY, USA
2
University of Denver, Denver, CO, USA
▶ Multicultural Family Institute 3
Department of Psychology, University of Utah,
Salt Lake City, UT, USA
4
University of Utah, Salt Lake City, UT, USA
References
AAMFT. (2016). Approved supervision designation: Stan-

dards handbook. Retrieved from https://www.aamft. Name of the Organization or Institution
org/Documents/Supervision/2016%20Supervision%20
Forms/Jan_2014_AS_Handbook_ver_Oct_%202016. ABCT Couples Research and Treatment Special
pdf. Interest Group
AAMFT. (2018a). Code of ethics. Retrieved from https://
www.aamft.org/Documents/Legal%20Ethics/AAMFT-
code-of-ethics.pdf.
AAMFT. (2018b). Join/reinstate/upgrade today!
Synonyms
Retrieved from https://www.aamft.org/AAMFT/Mem
bership/Join_AAMFT/Shared_Content/Membership/ AABT couples SIG; ABCT couples SIG; Couples
New_Join_Application/Join_AAMFT.aspx?hkey=b16 SIG
a4aa7-0e1e-47d4-b47f-5fb8ebdd28a9.
Kosinski, F. A. (1982). Standards, accreditation, and licen-
sure in marital and family therapy. Personnel and Guid-
ance Journal, 60(6), 350–352. Introduction
Lee, R. E., Nichols, D. P., Nichols, W. C., & Odom, T.
(2004). Trends in family therapy supervision: The past
25 years and into the future. Journal of Marital and
The Couples Research and Treatment Special Inter-
Family Therapy, 30(1), 61–70. https://doi.org/10.1111/ est Group (Couples SIG) of the Association for
j.1752-0606.2004.tb01222.x. Behavioral and Cognitive Therapies (ABCT, for-
Northey, W. (2004). Who are marriage and family thera- merly known as Association for the Advancement
pists? Family Therapy Magazine, 3(6), 10–13.
Smith, A. L., Smith, G. T., Stephens-West, G., &
of Behavior Therapy, or AABT) is a consortium of
Gallagher, M. A. (2002). The virtual leap to on-line researchers and clinicians focused on couples
supervisory education: An examination of distance research and practice. The Couples SIG was
6 Absent but Implicit in Narrative Couple and Family Therapy
founded by a group of psychology researchers supported best practices. Currently, the interventions
actively developing couples therapies. The Couples supported by research within the Couples SIG
SIG is steadily growing in size and productivity and include (but are not limited to) behavioral and
currently has 215 members (Eubanks-Fleming cognitive-behavioral couple therapy (BCT/CBCT),
2015). As a part of the ABCT, the Couples SIG integrative behavioral couple therapy (IBCT), emo-
promotes empirically supported treatment of cou- tionally focused therapy (EFT), couple relationship
ples and relationship problems both by promoting education (CRE), and specializations of these
basic research into relationship functioning and clin- approaches focused on couples with concurrent psy-
ical research into the assessment, prevention, and chological and medical issues such as PTSD, sub-
treatment of couple problems. stance use, depression, cardiovascular disease, and
cancer. The Couples SIG also contributes to the
overall quality and output of ongoing research in
Contributions the field by emphasizing topics such as research
methodology, grant funding, and translational issues
The Couples SIG encourages professional network- in their conference programming as well as advo-
ing primarily through programming at the annual cacy efforts.
ABCT convention, including a preconference work-
shop focused on current issues in couples research Cross-References
and treatment, a business meeting, and an evening
social for the whole SIG as well as a student-only ▶ Behavioral Couple Therapy
portion. Additionally, members of the SIG are active ▶ Cognitive Behavioral Couple Therapy
poster and symposia presenters, clinical training ▶ Emotion-Focused Therapy for Couples
workshop leaders, panelists, and members of clini- ▶ Integrative Behavioral Couple Therapy
cal roundtables at each convention. During the year, ▶ PREP Enrichment Program
the Couples SIG continues to encourage communi-
cation between its members through its website
(www.abctcouples.org), a biannual newsletter, and References
an email list serve. All online forums accommodate
both discussion about research issues and clinical Eubanks-Fleming, C. J., (2015). ABCT Couples SIG Trea-
support for providers specializing in couples surer’s Update (C. Carrington, A.M. Parsons, & K.Z.
Pentel, Eds.). Couples Research & Therapy Newsletter,
therapy.
21(2), 4.
The Couples SIG also encourages the growth
and development of the next generation of couples
researchers. At the annual ABCT convention, the
Absent but Implicit in
Couples SIG sponsors many student presentations
Narrative Couple and Family
at the Friday Night Welcoming Cocktail Party’s SIG
Therapy
Poster Exposition and an all-student symposium at
the general convention to help feature student work.
Saviona Cramer
Additionally, the Couples SIG has created the
Barcai Institute, Tel Aviv, Israel
Robert L. Weiss Student Poster Award to recognize
outstanding student research. The Couples SIG also
maintains resources for students looking to special- Every expression can be considered to be founded
ize in couples work including a list of doctoral pro- upon its contrast, which I refer to as the ‘Absent But
grams and APA-approved internships that have a implicit.’ (White 2005)
strong couples focus.
Finally, the SIG advocates for the visibility of In narrative therapy, “Absent But Implicit” refers
relationship research both within and outside of both to an understanding regarding how people
ABCT and encourages dissemination of empirically ascribe meaning to experiences (values, hopes,
Absent but Implicit in Narrative Couple and Family Therapy 7
beliefs, purposes) and to a practice of seeking Clinical Example

entry points toward developing preferred stories.
Inspired by Derrida (1978), White (2000) Anna’s father asked me to meet with her. “She’s A
suggested that people ascribe meanings to experi- become so withdrawn.” However, he explained,
ences in relation to other experiences, by “she doesn’t go anywhere alone anymore,” so they
contrasting them with other experiences, by what would bring her and accompany her in the therapy
they are and by what they are not. sessions (one of the fortunate times I didn’t need to
He described how it can be useful in thera- persuade the family to participate in therapy).
peutic conversations to listen for values, hopes, In the first session, Anna (aged 16) sat quietly
and purposes that, while absent from the prob- while her parents told me that she had begun high
lem story, may be implied by it, as the backdrop school 3 months ago “and everything changed.”
on which the explicit problems are given After school, they said, she stays in her room all
meaning. day, mostly in bed. She rarely comes to the table
Using what White calls “double listening,” in for dinner; they bring a tray to her bed. She’s cut
addition to listening for explicit “unique out- herself off from her friends, and when she has to
comes,” the therapist also listens for unmentioned go to the mall, she asks her parents to go with her.
values, beliefs, and intentions that contrast with After understanding that no recent trauma was
the problem-saturated story and may imply what involved, I asked Anna about the expressions of
is precious to this person, couple, or family. the problems in her life and their influences on her
“These implied experiences are a rich source of relationships and on her “private story” (the story
alternative stories” (Freedman and Combs 2008). she tells herself about herself). Anna responded in
Furthermore, based on the narrative premise that “internalized language” (as most people do), see-
no one is a passive recipient of hardship, the ing herself and the problem as one: “I’m so needy;
therapist looks for acts of resistance that have I need my parents all the time, I’m afraid to go out
been performed and the skills that have been alone with my friends, I feel so sad.”
used in performing them, which may augment Following the narrative map of separating
sense of personal agency. between people and their problems, I began an
White (in workshops in 2006–2008) proposed externalizing conversation with Anna, hoping that
a “map” of Absent But Implicit practices, which in the space created between her and the problem,
Carey et al. (2009) compiled in a “scaffold”: we would find preferred directions. I asked what
name would she give to her problem? And could
1. The Expression – of problems and their she imagine how it looks? She said “Blue Depen-
influence dency; it looks like a big blue monster who looks
2. What the Complaint or Expression is in Rela- at me with sad eyes and tells me I won’t succeed
tion to – externalization alone. It makes me feel blue all the time.” We
3. Naming the Response or Actions – discovering discussed the ways in which Blue Dependency
acts of resistance had recruited her to this lifestyle. As she spoke,
4. Skills or Know-How that are Expressed in the tears began rolling down her cheeks. I asked her
Action what the tears meant to her. Anna said that Blue
5. Intentions and Purposes – of actions and plans Dependency had such a bad influence on her life.
for life I asked whether Blue Dependency opposed some-
6. What is Given Value To – the “Absent But thing she treasured – perhaps joyfulness? maybe
Implicit” self-reliance? or something else? She looked at me
7. Social and Relational History of What Is and said “Yes, Self-Reliance.” She told how she
Absent But Implicit – connections with people used to be able to do almost anything on her own,
who share the values how proud she had been of that, how much self-
8. Connecting Actions Over Time and Into the reliance had always meant to her, and how she
Future – around the Absent But Implicit missed it in her life now.
8 Acceptance in Couple and Family Therapy
I inquired about her acts of resistance against References

Blue Dependency and her intent in those acts.
We discussed how those tears might be a protest Carey, M., Walther, S., & Russell, S. (2009). The absent but
implicit – A map to support therapeutic enquiry. Family
against Blue Dependency. We (Anna, her par-
Process, 48(3), 319–331.
ents, and I) then explored when had Anna begun Derrida, J. (1978). Writing and difference. Chicago: Uni-
to value self-reliance. We spoke about stories of versity of Chicago Press.
self-reliance in her past and how meaningful Freedman, J., & Combs, G. (2008). In A. S. Gurman (Ed.),
Clinical handbook of couple therapy. New York: The
they were to her. We connected them to her
Guilford Press. Chap. 8.
intentions, actions, and dreams in the present White, M. (2000). Re-engaging with history: The absent
and started to think about what her next steps but implicit (chapter 3). In M. White (Ed.), Reflections
will be if she continues to hold the value of self- on narrative practice: Essays & interviews
(pp. 35–58). Adelaide: Dulwich Centre Publications.
reliance close to her heart.
White, M. (2005). The International Journal of Narrative
I asked about stories of self-reliance in the Therapy and Community Work, 3&4, 15.
family and in their social and cultural history.
We prepared a genogram with all family mem-
bers. Her parents told stories of their own self-
reliance and of Anna’s independence as a child.
We heard that her grandparents were Holocaust Acceptance in Couple
survivors who had built a new life out of utter and Family Therapy
destitution and how the family felt blessed
by that. Kathryn M. Nowlan, McKenzie K. Roddy and
The focus of our conversations moved from the Brian D. Doss
story of Blue Dependency to the preferred story of University of Miami, Coral Gables, FL, USA
Sassy Self-Reliance. We developed a family pro-
ject of telling, retelling, and witnessing – and joint
planning and doing. Introduction
The practice of Absent But Implicit opened
new possibilities for Anna and her family to Acceptance in couple and family therapy refers to
work together to find and thicken preferred stories the process of individuals becoming more patient
in their lives. and sympathetic when problems arise because the
individual recognizes that there are natural and
understandable reasons for the way the individual,
the partner, and the relationship are. Within an
Cross-References intervention context, acceptance helps individuals
soften the impact of relationship aspects and
▶ Deconstructive Listening in Couple and Family dynamics that are likely unamendable to change,
Therapy even if the partner makes attempts to change.
▶ Dulwich Centre Through acceptance, individuals relinquish the
▶ Externalizing in Narrative Therapy with Cou- struggle to change others’ behavior, learn to see
ples and Families differences and problems as opportunities to
▶ Narrative Couple Therapy increase relational closeness and emotional con-
▶ Narrative Family Therapy nection, and develop empathy around the seem-
▶ Problem-Saturated Stories in Narrative Couple ingly intractable issues that drove the individuals
and Family Therapy apart (Christensen and Jacobson 2000). In con-
▶ Re-authoring Teaching trast to more traditional behavioral change tech-
▶ White, Michael niques, acceptance work encourages the
▶ Witnessing in Narrative Couple and Family complainant to change. The process of acceptance
Therapy in couple and family therapy reduces relationship
Acceptance in Couple and Family Therapy 9
distress, facilitates emotional connection, and to take into account the historical context in
increases the likelihood that the parties involved which problems develop and the emotional hurt
are better able to handle future challenges and developed from repeated relationship problems A
relationship issues. that often lead to high relationship distress. All
these problems, which are often present for
treatment-seeking individuals, make it harder to
Theoretical Context for Concept change relationship dynamics. However, the most
important reason that an exclusive focus on
While there has been some work within the family change is likely to be unsuccessful is that many
therapy literature on acceptance, the majority of domains of couple and family life are not modifi-
research has focused on acceptance within couple able by the couple/family. For example, it is not
therapy. Acceptance within couple therapy was possible for an individual to will him/herself to
first introduced as one of the major tenets of feel (or not feel) a certain way. Similarly, person-
integrative behavioral couple therapy (IBCT; ality or other stable traits are not amenable to
Jacobson et al. 2000) in response to limited change. Furthermore, external stresses such as a
long-term efficacy of change-oriented therapy job loss or foreclosure are often out of the couple
approaches. Indeed, IBCT developed as an or family’s direct control. Thus, behavioral
attempt to improve upon traditional couple ther- change techniques alone may be ineffective and
apy models such as traditional behavioral couple insufficient without a simultaneous focus on
therapy (TBCT; Jacobson and Margolin 1979) acceptance of the problems at hand. Indeed, it is
which focused on couples making overt behav- the combination of acceptance and change strate-
ioral change in order to increase relationship sat- gies that is likely to be most effective for most
isfaction (e.g., increasing positive behaviors and relational problems.
decreasing negative behaviors). While change- Treatments with a focus on acceptance such as
oriented approaches such as TBCT are effective IBCT build upon behavior-focused therapies by
in helping some couples make changes and see integrating acceptance strategies with change-
increases in relationship satisfaction, a substantial oriented approaches. Indeed, IBCT has a stronger
number of couples do not benefit from therapy emphasis on creating relationship improvement
and show no clinically meaningful improvement by targeting the controlling variables that often
by end of therapy (Jacobson et al. 2000). impact relationships such as individuals’
A few explanations have been offered as to thoughts, feelings, and desires rather than overt
why overemphasizing behavioral change strate- behavioral change alone. Through acceptance-
gies is not always enough to result in meaningful based approaches, individuals come to a level of
changes for some individuals. One explanation is acceptance whereby they willingly let go of frus-
that approaches like TBCT fail to meet individual tration, hurt feelings, and the struggle to change
needs. Indeed, due to the nature of distress in one another. IBCT and other acceptance-based
treatment-seeking individuals, many partners and approaches in couple and family therapy remove
family members may be unwilling to make the blame and help individuals see a new perspective
changes requested of them or accommodate on the relationship whereby the other party
behavioral change. Moreover, by the time a family involved is no longer conceptualized as being
or couple is attending therapy, they have often deficient, inferior, or at fault.
reached a behavioral impasse due to entrenched
problems in their relationships and the lack of a
“collaborative set” or a mutual understanding that Description
they are both responsible for the problems in the
relationship and, therefore, both need to make Within all couples and families, there are count-
change (Jacobson et al. 2000). Additionally, less natural differences between individuals.
change-oriented treatment approaches often fail Some people tend to be more emotional,
outgoing, or organized than others. Some peo- source of the conflict. Moreover, each partner
ple may be more career driven, and others may feels that, if they give in to the other, the
be more family or interpersonally oriented. problem will only get worse. For example, the -
Many, perhaps most, of these natural differ- individual requesting more cleanliness worries
ences are experienced as just that – differences. his/her partner would never clean up if he/she
The couple or family system is able to adapt to didn’t “nag” the partner. In turn, the
these differences without conflict. Indeed, some partner feels that if he/she “gives in” to the
differences may be a source of strength for a demands to clean, it’s only going to increase
couple. For example, an introvert may appreci- the “nagging.”
ate that his/her partner or family member helps Models of acceptance within couple and fam-
maintain social connections, while the extravert ily therapy posit that acceptance can reduce the
appreciates not having to compete to be the initial unpleasantness of the differences, reduce
center of attention in social settings. However, the process of polarization, and offer an escape
other differences create conflict and distress for from the mutual trap by beginning to view the
the couple or family. problem as a process that is jointly created. By
From an IBCT perspective, distress develops better understanding and accepting one
through a three-phase process. Acceptance is key another’s actions or each other instead of push-
in both avoiding and overcoming this process. In ing for change, individuals gain emotional dis-
the first phase, when an individual experiences a tance from the problem. This emotional distance
difference that is unpleasant, that individual allows them to address the issue without engag-
pushes the other person to change. For example, ing directly or pushing for behavioral change.
if two people differ in their standards for cleanli- Indeed, the response to problematic behavior
ness, one person will often ask the other to pick up moves from being extremely negative in
after him/herself, put dishes in the dishwasher valence (e.g., anger, vulnerability and pain, con-
rather than piling them in the sink, etc. If these tempt) to neutral or positive (e.g., toleration,
requests for change can be accommodated, then appreciation, and understanding), which subse-
no distress develops. However, if the messier per- quently generates a greater sense of emotional
son is unable or unwilling to change, then conflict closeness and intimacy. For the individuals on
around cleanliness develops. the receiving end of the frequent pushes for
In the second phase – called polarization – change, increased acceptance helps them to be
each attempt to change the other person results less reactive. As a result, they, too, learn to
in the partner not only continuing the behavior better accept why the other person is asking for
but often acting more extreme than he or she change, become more understanding of how the
otherwise would. For example, the more the negative pattern developed, and let go of the
individual “nags” his/her partner to be cleaner, aspects of the relationship and other person
the less likely the partner is to be responsive to that they cannot change. They may also learn
those requests. Over time, the clean individual to accept their contribution to the pattern.
becomes more and more upset at even smaller Through this process of acceptance, the desired
instances of messiness. Polarization makes it change becomes more likely to occur. This pro-
hard for the couple to get out of the negative cess is consistent with the literature on individ-
pattern. The repeated requests for change are ual therapy approaches (e.g., acceptance and
often met with hard emotional expressions commitment therapy) which suggests that
such as anger, yelling, and blame (or just simply when individuals are more accepting, do not
walking away without responding), which often judge or blame themselves, or try to stop
increase retaliation or unwillingness to unwanted problems, they move in a direction
compromise. more consistent with their values, can better
In the third phase – called the mutual take action against the problem, and find more
trap – each partner views the other as the sole meaning in their lives.
Application of Concept in Couple the therapist models acceptance by validating

and Family Therapy both partners’ concerns as understandable and
by using nonjudgmental language that removes A
As mentioned, acceptance within couple and fam- blame from each member of the couple. Instead,
ily therapy has arisen largely within the frame- the therapist focuses on the couple’s strength,
work of IBCT. IBCT assumes that problems in begins the narrative that each partner is not at
relationships do not just occur as a result of the fault, and introduces the idea that the couple has
negative behaviors of partners but also in the developed a pattern of behavior and communica-
emotional disruption and reactivity caused by tion that has been getting them stuck. This
these actions. Thus, strategies are implemented approach is essential to the success of couples
in order for couples to not only gain a deeper gaining acceptance and is modeled throughout
understanding of how to communicate or interact therapy.
more healthily (which would be a more skills- Unified detachment interventions continue
based and change-oriented approach) but to throughout the course of treatment. In session,
understand what factors in the relationship make couples explore emotionally salient, negative
relationship problems more likely to occur and interactions that have recently occurred in order
what led to the problems initially. Through an to better understand the context in which the
acceptance approach, couples become less biased, problem developed instead of focusing on who
are better able to reflect on their own behavior, and is to blame. Rather than allowing partners to
learn to stop undermining the relationship by jump into old habits of telling each other why
using blaming, pushy, or hostile communication. they think the other is at fault, therapists encour-
The first intervention used by the IBCT thera- age couples to focus on each of their contributions
pist to promote acceptance is unified detachment. to the recent interaction. By gaining more emo-
Unified detachment helps couples talk about prob- tional distance from the issue, couples begin to
lems rather than engaging in the problematic think of the interaction from an outside perspec-
dynamic. It creates a shift in perspective by label- tive and gain insight into the sequence of events.
ing the problem as an “it” versus a “you,” teaching For example, they think through how the compo-
couples to no longer think of their partner as the nents of the DEEP Understanding such as differ-
cause of the problem. Instead, unified detachment ences, emotional triggers, the impact of stress, and
helps couples develop an objective third party the way they interacted with one another pre-
perspective on the major issues in their relation- vented them from better addressing the problem.
ship by removing blame and promoting active Through unified detachment, partners formulate a
communication. new, more accepting, and less biased narrative of
Unified detachment begins with an initial the negative relationship interactions wherein the
feedback session that takes place within the first partner is no longer to blame.
few weeks of therapy. During the session, the In the second acceptance strategy in
therapist promotes acceptance by beginning to IBCT – empathic joining – the therapist encour-
introduce his/her formulation of the couple’s ages couples to be more open and provides oppor-
major problems and themes. Additionally, the tunities for couples to discuss emotional
therapist formulates a DEEP Understanding of sensitivities and support one another through
the couple’s relationships problems, which is an those emotional disclosures. Problematic relation-
acronym for the couple’s natural differences, ship dynamics often arise because, as partners feel
emotional sensitivities, external stress, and pat- more hurt or distant from each other over time,
terns of interaction that often escalate conflict. they often blame, accuse, or negatively judge their
The components of the DEEP Understanding partners. These negative behaviors and cognitions
help the couple see a more holistic picture of often result in greater separation and defensive-
what is negatively impacting the relationship. ness, which only lead to more relationship
Through discussion of the DEEP Understanding, distress.
For example, take an individual who feels enjoys (e.g., initiating a spontaneous evening out)
emotionally unsupported by his/her partner. could be related to aspects of the partner that
Throughout the relationship, this person has likely create conflict (e.g., lack of follow-through on
learned that being vulnerable with emotions only household tasks). Additionally, partners work to
leads to disappointment as his/her partner may not better tolerate situations that are out of their con-
be the best at validating those emotions or trol. By letting these biased perspectives go and
expressing his/her own. Over time, the partner learning to tolerate what cannot be changed, cou-
who feels unsupported is less likely to share emo- ples increase acceptance which in turn removes
tional sensitivities and more likely to display emotional distance and blame. Throughout this
harder emotions such as anger or contempt. Addi- technique, therapists also model empathy so that
tionally, instead of being vulnerable, he/she is both partners feel heard and understood. Model-
more likely to say a hurtful statement such as, ing this air of acceptance is central to partners
“You are totally unfeeling and don’t know how feeling emotionally safe to be vulnerable, which
to connect with anyone!” This in turn may hurt the in turn helps them to let go of hurt and stop
partner’s feelings, which could result in him/her blaming their partners.
displaying his/her own hard emotional expres- Following IBCT’s model, a few secondary
sions such as yelling or withdrawing. interventions have been developed which also
During empathic joining, the therapist instead focus on acceptance promotion. One intervention
encourages both partners to share their hidden is the marriage checkup, which offers early detec-
emotions – the softer, more vulnerable emotions tion and preventative care for relationship func-
that underlie the reaction that the partner sees tioning. While the intervention is brief and only
(e.g., anger, contempt). After one individual dis- consists of two, 8-hour sessions (one assessment
closes a vulnerable emotion, the therapist works and one feedback session), it helps couples create
with the partner to appropriately support that dis- more intimacy and closeness in their relationship.
closure. If the partner has difficulty doing so, the Indeed, the program promotes greater understand-
therapist supports the disclosure him/herself ing of common relationship issues and differences
(providing a model to the partner) and then between partners, which helps build acceptance.
explores why it was difficult for the partner to Couples who participated in the marriage
support that disclosure. Through these empathic checkup, compared to those in a control group,
joining exercises, the partners become less blam- were significantly more relationally satisfied
ing, more empathetic, and more accepting of each 2 years following the intervention (Córdova
other and the pattern in which they have gotten et al. 2014).
stuck. Empathic joining promotes compassion Another secondary intervention with a focus
and emotional intimacy. Through the subsequent on acceptance is the OurRelationship.com pro-
increase in emotional connectedness, partners gram (Doss et al. 2016). As an online adaptation
become more open to any subsequent changes of IBCT, the program’s goals are consistent with
that are under their control. those of IBCT. Indeed, through online activities,
In the final IBCT strategy to promote accep- the program helps couples select the biggest prob-
tance, therapists help couples with tolerance lem in their relationship, develop a DEEP Under-
building. Through tolerance building, couples standing of the problem, and problem solve
begin to see the differences that first created the solutions tailored to the issue. Throughout the
conflict as natural and as part of portions of their program and through several contacts with study
partner that they do like. For example, differences coaches that promote empathic joining and uni-
that create conflict can be related to traits that they fied detachment, couples gain acceptance and a
initially found attractive (e.g., a partner that is now better understanding of what occurs during emo-
viewed as “irresponsible” could have been ini- tionally salient, negative interactions. By the end
tially viewed as “spontaneous”). Alternatively, of the 8-hour program, the couples reported sig-
aspects of the partner that an individual currently nificantly increased relationship satisfaction,
relationship confidence, and positive relationship lack of emotional intimacy. Between their respon-
qualities as well as reduced negative relationship sibilities to their two teenage daughters and their
qualities (Doss et al. 2016). two careers, Steve and Carmen’s relationship had A
Furthermore, acceptance is a central component taken a backseat. Steve described that the inti-
of other primary interventions such as the Compas- macy in their relationship had degraded to the
sionate and Accepting Relationships through Empa- point where he felt that they were “just room-
thy (CARE) program. CARE encourages couples to mates.” Although he identified that both he and
use prosocial, empathy-based skills and teaches the Carmen were great parents and led fulfilling indi-
importance of acceptance in relationships. Many vidual lives, he felt that the romantic spark they
couples who received CARE reported increased once had was gone. Carmen, likewise, reported
relationship satisfaction, greater affection, and less they were not as close as they used to be and
hostile communications over 3-year follow-up wished they could get back to “being in love.”
(Rogge et al. 2013). While both Steve and Carmen agreed that inti-
Overall, the literature on acceptance within macy was lacking in their relationship, each partner
secondary and tertiary interventions shows that had different ideas of what led to the lack of inti-
acceptance is a key element in enacting positive macy as well as how it should have been fixed.
change for couples. Indeed, IBCT has been shown Steve believed they both became busy with life,
to be effective at increasing relationship satisfac- jobs, and family and that they failed to prioritize
tion and communication and reducing negative the relationship. He thought that if they spent more
relationship behaviors both short and long term time together, the intimacy issue would abate.
(Christensen et al. 2004, 2006). Moreover, accep- Carmen, on the other hand, saw the lack of intimacy
tance has been shown to be a mechanism of as resulting from the fact that they rarely talked
change of treatment gains across acceptance- outside of surface-level conversations or discussing
focused interventions such as IBCT and the mar- their children. She felt the relationship could not
riage checkup (Doss et al. 2005; Hawrilenko improve without first making the effort to dive
et al. 2016). deeper into more emotional conversations, such as
While most of the research on acceptance has through sharing their passions, interests, and goals
occurred within the couple intervention literature, as individuals and as a couple. Her attempts to
acceptance has also shown to be important within engage Steve in these conversations were fre-
family therapy in promoting positive changes in quently, if not always, a letdown. Both partners’
negative family dynamics. Specifically, when attempts to solve the intimacy issue – Carmen push-
acceptance is included in a family therapy ing for deep conversation and Steve wanting to
approach, parents and children learn how to be spend more fun time together – ultimately created
more value-centered, better accept difficult emo- more discord in the relationship.
tions, and stop repeated measures to prevent After a thorough assessment process including
unwanted problems. Acceptance within family standardized measures, an introductory session
therapy results in the reduction of parent- with the couple, and individual sessions with
adolescent conflict and improvements in psycho- each person, the therapist initiated the first accep-
logical flexibility and individual functioning (e.g., tance intervention – unified detachment – in the
Coyne et al. 2011; Greco and Eifert 2004). feedback session. In this session, the therapist
presented the formulation of Steve and Carmen’s
relationship problems to the couple. The therapist
Clinical Example emphasized that there was a natural difference
between Steve and Carmen around emotional
The case of Steve and Carmen can be used to expressiveness. For example, more in touch with
illustrate the use of acceptance in an IBCT frame- her emotions and able to describe how she is
work. After 20 years of marriage, Steve and feeling at any given moment, Carmen became
Carmen sought couple therapy because of their frustrated when Steve could not reciprocate.
Additionally, the therapist hypothesized that Steve about her past relationship and had not shared
Carmen was sensitive to Steve’s inability to those feelings of fear and loneliness. During session,
share his feelings partially due to past experi- she began to share her feelings of fear and hurt
ences. Indeed, Carmen’s previous partner had stemming from her past relationship. Once Carmen
cheated on her and hid his infidelity for over a opened up, it not only gave Steve a fuller picture, but
year by being vague about his whereabouts and it allowed him the opportunity to respond to those
feelings. As a result, Carmen frequently tried to emotions in a soft, kind, and accepting manner.
initiate meaningful conversations with Steve in Additionally, because Steve was not naturally skilled
order to calm her anxieties that he might also be at expressing his emotions, the structure and thera-
cheating on her. When he refused to engage pist’s support during empathic joining helped him
because he felt put on the spot and unable to open up to Carmen in ways that he had not done
connect to his emotions, Steve often raised his previously. By increasing acceptance around their
voice and would ultimately storm out of the room. emotional sensitivities and the natural differences
To help Carmen and Steve better understand between them, Steve and Carmen were more effec-
this negative pattern, the therapist hypothesized tive at healing the relationship. These supportive
that, as a response to Steve’s withdrawal, Carmen interactions, repeated over the course of therapy,
felt rejected, hurt, and lonely – much like she did helped the couple interrupt their previous
in her previous relationship. After receiving con- unproductive pattern of communication, reestablish
firmation that Carmen felt this way, the therapist trust, and build emotional intimacy.
then emphasized that, later, when Steve tried to
placate the situation by offering to watch TVor go
on a walk with Carmen – a good solution to the Cross-References
intimacy issue in his mind – Carmen felt he was
ignoring their earlier fight. Additionally, the ther- ▶ Acceptance Versus Behavior Change in Couple
apist helped Steve identify that he often withdrew and Family Therapy
from Carmen’s attempts to initiate meaningful ▶ Christensen, Andrew
conversations both because communicating emo- ▶ Integrative Behavioral Couple Therapy
tions was challenging for him and because he felt
like it interfered with his attempts to get them to
spend enjoyable, light-hearted times together. References
During the course of therapy, the therapist cre-
ated unified detachment by encouraging Carmen Christensen, A., & Jacobson, N. S. (2000). Reconcilable
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exchange principles. New York: Brunner/Mazel. non-distressed couples.
Jacobson, N. S., Christensen, A., Prince, S. E., Córdova, J., In the context of couple interventions, accep-
& Eldridge, K. (2000). Integrative behavioral couple tance approaches have their origins in integrative
therapy: An acceptance-based, promising new treat-
behavioral couple therapy (IBCT). Based on BCT,
ment for couple discord. Journal of Consulting and
Clinical Psychology, 68(2), 351–355. IBCT was developed by Andrew Christensen and
Rogge, R. D., Cobb, R. J., Lawrence, E., Johnson, M. D., & Neil S. Jacobson in 1995 in an attempt to prolong
Bradbury, T. N. (2013). Is skills training necessary for the positive effects of BCT (Dimidjian et al. 2008).
the primary prevention of marital distress and dissolu-
tion? A 3-year experimental study of three interven-
tions. Journal of Consulting and Clinical Psychology, Description
81(6), 949–961.
There are two common categories of change

techniques – communication skills and behavior
exchange (Christensen et al. 2014). In the speaker-
Acceptance Versus Behavior listener communication skill, therapists help couples
Change in Couple and Family develop methods to share emotion-laden informa-
Therapy tion or perspectives. Partners are encouraged to take
turns being the speaker and the listener, with specific
Karen Rothman1, Emily J. Georgia1 and skills and responsibilities for each role. Using the
Brian D. Doss2 problem-solving communication skill, couples
1
University of Miami, Miami, FL, USA move through a series of sequential steps to reach
2
University of Miami, Coral Gables, FL, USA a solution or compromise to a problem, which
include defining the problem, brainstorming poten-
tial solutions, selecting a solution, and setting a time
Name of Concept to reevaluate that solution. Finally, behavior
exchange teaches couples to identify and implement
Acceptance Versus Behavior Change in Couple more frequent or additional positive behaviors that
and Family Therapy might increase relationship satisfaction.
16 Acceptance Versus Behavior Change in Couple and Family Therapy
There are three categories of acceptance In the feedback session, the therapist utilized
techniques – unified detachment, empathic joining, the acceptance technique of unified detachment to
and tolerance. Unified detachment encourages cou- help the couple conceptualize the problem as a
ples to achieve a more comprehensive and less combination of their natural differences in emo-
blaming conceptualization of their relationship tional expressiveness. The couple also learned
problems, which allows couples to escape their that their problem is intensified because it triggers
destructive patterns. In empathic joining, couples vulnerable emotions in each partner and that, over
are encouraged to disclose their hidden, vulnerable time, their attempts to fix the problem have actu-
emotions; this disclosure softens the hardened ally intensified it. Through subsequent empathic
stance of the partner and provides an opportunity joining interventions, Amy began to share the
to foster emotional closeness. Finally, tolerance softer emotions (e.g., sadness, rejection) she
interventions help individuals view their partner’s feels when Manuel is distant, and he was able to
negative behaviors as part of the broader package of comfort her. These interactions helped her feel
the person – sometimes even components of their more emotionally close, and, as a result, she
partner’s traits they like or initially found attractive. started to reduce her demands and criticisms.
Tolerance also promotes increased self-care and The therapist also used behavioral techniques
self-reliance for each partner. to improve their presenting problems. The thera-
pist taught the couple to utilize the speaker-
listener communication skill, which helped Amy
Application of Concept be less critical of Manuel while simultaneously
helping Manual share his feelings more. Addition-
Research on BCT and IBCT has shown both accep- ally, once the couple began to feel more connected
tance and behavioral change techniques to be effec- during sessions, the therapist assigned behavioral
tive in creating long-term change in couples activation assignments such as date nights to
(Christensen et al. 2010). Clinical experience sug- increase the enjoyable moments the couple
gests that acceptance techniques may be more experienced.
appropriate for presenting problems that are more
emotion-laden or that are out of the couple’s control.
In contrast, BCT may be an especially good fit for
couples who are comfortable with rule-governed Cross-References
behavior or who present to treatment with commu-
nication problems. However, it should be noted that ▶ Acceptance in Couple and Family Therapy
these clinical impressions have not been tested
empirically.
References
Clinical Example Christensen, A., Atkins, D. C., Baucom, B., & Yi, J.
(2010). Marital status and satisfaction five years
following a randomized clinical trial comparing tradi-
In their first session of couple therapy, Manuel tional versus integrative behavioral couple therapy.
reported feeling criticized by his wife Amy, while Journal of Consulting and Clinical Psychology, 78(2),
Amy complained of a lack of emotional intimacy. 225–235.
Christensen, A., Wheeler, J. G., Doss, B. D., & Jacobson,
She attributed this distance to “Manuel’s inability to N. S. (2014). Couple distress. In D. Barlow (Ed.),
open up.” Amy stated that she urges Manuel to talk Clinical handbook of psychological disorders: A step-
to her, to tell her how he’s feeling, and to be there for by-step treatment manual (5th ed., pp. 704–728).
her emotionally. Manuel explained that these New York: The Guilford Press.
Dimidjian, D., Martell, C. R., & Christensen, A. (2008).
requests feel increasingly critical and have resulted Integrative behavioral couple therapy. In A. S. Gurman
in him pulling away even more, which in turn leads (Ed.), Clinical handbook of couple therapy (4th ed.,
Amy to escalate her demands. pp. 73–101). New York: The Guilford Press.
Accommodation in Couple and Family Therapy 17
Theoretical Context for Concept

Accommodation in Couple
and Family Therapy Mapping the origins of accommodation is diffi- A
cult due to the expansive nature of the term. The
Katherine O’Neil1 and Danielle A. Black1,2 first time the concept was theorized was by
1
Center for Applied Psychological and Family Howard Giles to describe the phenomenon of
Studies, The Family Institute at Northwestern changing the way one speaks depending on the
University, Evanston, IL, USA person being spoken to (Swann et al. 2004).
2
The Family Institute at Northwestern University, Although Giles’ accommodation theory is not
Chicago, IL, USA a common reference of family therapy theory, its
designation of the term to define the subcon-
scious way humans adapt to one another serves
Name of Concept as a foundation for how accommodation is con-
ceptualized by psychologists and family
Accommodation therapists.
The construct of accommodation was first
identified and defined by developmental psy-
Synonyms chologist, Jean Piaget. Piaget (1932) defined
accommodation to describe a child’s ability to
Adaptation; Adjustment; Joining adapt their internal schemas to the changing
world. Piaget’s accommodation similarly
describes a type of inherent adaptation. How-
Introduction ever, Piaget’s theory focuses on the individual
context as opposed to a systemic context. Thus,
Accommodation broadly refers to the spontane- Piaget’s definition of accommodation is useful
ous way a system instinctively adapts to coordi- to understand one origin of the construct albeit
nate functioning (Nichols 2017). an individualistic definition. Other theorists
Accommodation has two distinct definitions defined the construct within a relational context
within the field of marriage and family therapy. providing a more useful construct within family
The first is defined through a structural lens and therapy.
describes the techniques a therapist uses to Conversely, Minuchin developed a concep-
make self-adjustments in order to successfully tualization of accommodation originating in his
join with and understand a system’s functioning model of Structural Family Therapy. His
(Minuchin 1974). The purpose of accommoda- perspective of accommodation progressed the
tion in this context is to join with the system to term to encompass patterns of interaction.
create change. Minuchin advanced accommodation from
The second application of accommodation merely linguistic, as suggested by Gilesor
describes the way family members change internal to interpersonal, as suggested by Piaget
or adapt their behavior to decrease another fam- (1932) (Swann et al. 2004). Minuchin’s
ily member’s emotional distress often explanation of accommodation describes the
reinforcing an individual’s maladaptive behav- way a system develops patterned transactions,
ior (Calvocoressi et al. 1995). Within the family or mutually influences ways in which members
system, accommodation maintains maladaptive impact and monitor one other’s behavior
functioning and/or behaviors often through (Minuchin 1974). With a systemic perspective,
subliminal patterns of interaction. Family Minuchin applied the concept of accommoda-
accommodations (FA) often maintain or tion to the therapeutic relationship, thus
increase maladaptive symptoms (Lebowitz creating the technique of joining and
et al. 2012). accommodating.
18 Accommodation in Couple and Family Therapy
Description generally originates from a parent’s natural

empathy toward their children’s distress. In
Accommodation in family therapy refers to two children with social anxiety, separation anxiety,
specific concepts: (1) the therapist adjusting to a or other anxiety disorders, FA can take the form
system’s style while functioning to successfully of a parent speaking for their child, allowing
join and (2) the adapting of a family system by their child to stay home from school, or sleeping
creating mutually influencing patterns to support in their child’s bed. Accommodation becomes a
one another’s functioning. Both applications of problem when it maintains or amplifies a mal-
accommodation include adjusting behavior, adaptive symptom of a disorder. This usually
whether intentional or involuntary. The distinc- means a parent is colluding with their child to
tion between the ways accommodation is concep- avoid situations and/or objects that provoke
tualized is critical to understanding its value to anxiety. For children with OCD, parents accom-
family and couple therapy. modate by helping their child avoid triggering
In the therapeutic relationship, accommodation situations, participate in rituals, and provide
is a necessary step in approaching the alliance. In reassurance, thus maintaining the avoidance
structural therapy (Minuchin 1974), joining and behavior (Lebowitz et al. 2012).
accommodating complement one another and, Overall, accommodation describes a general
when used deliberately, can progress and expedite pattern of sequences that influences the entire
treatment. Minuchin (1974) describes this process system, either the therapeutic system (as defined
of accommodation as a therapist’s adaptation to by Minchin) or the family system (as defined by
the family system through maintenance, tracking, Lebowitz et al. 2012). Accommodation is natural,
and mimesis. Maintenance refers to the accommo- inevitable, and typically occurs without much
dation technique of deliberately supporting a fam- thought. Thus, family therapy aims to bring
ily structure to create change; tracking describes awareness to accommodation as both a therapeu-
the therapist’s accommodating technique of fol- tic technique and a method of acknowledging
lowing the content and process of the system by maladaptive family patterns.
asking clarifying questions, actively listening, and
remaining interested in the system’s communica-
tion; and mimesis refers to human operations that Application of Concept in Couple and
are implicit and spontaneous such as a therapist Family Therapy
adopting the language and style of a system
(Minuchin 1974). Each of these accommodating Accommodation refers to two different clinical
techniques directly applies to family therapy. applications: joining the family and identifying a
In Cognitive Behavioral Therapy (CBT), specific maladaptive behavior pattern within a
the construct of accommodation is defined as a family dynamic. In the first application, refers to
maintenance factor of child anxiety symptoms. the joining process in family therapy, the family
Accommodation is the process by which family therapist adapts or mirrors the communication
members reinforce avoidance behaviors of the style and structure of a family. For structural ther-
anxious child resulting in the increase or mainte- apists (Minuchin 1974), accommodation is man-
nance of the child’s anxiety symptoms (Black datory and intentional. For those practicing a
2017; Lebowitz et al. 2012). Within the CBT different, systemic model, noticing the way a ther-
framework, accommodation is defined as mal- apist accommodates to the family system can
adaptive process as opposed to a therapeutic adap- facilitate joining and bring awareness to the pro-
tive process, interaction that maintains and/or cess of building an alliance with each member
amplifies symptoms and family dysfunction. of a family. Using the structural model, a therapist
Family accommodation (FA) appears differ- can join with a family or couple by accommodat-
ently across anxiety disorders and Obsessive- ing, rather than challenging them (Minuchin
Compulsive Disorder (OCD), although it 1974).
Accommodation in Couple and Family Therapy 19
Family accommodation (FA) is also highly through mimesis by spontaneously mirroring their
relevant to couple and family therapy, as it serves style of humor and joins in the laughter.
to conceptualize patterns of family behavior An example of the second definition of accom- A
that maintain the identified patient’s presenting modation is when a family member reinforces or
problem. FA can constrain systems either in maintains maladaptive symptoms within an indi-
times of change, such as when a family struggles vidual or the family. For example, a therapist
to adapt to new circumstances, or when a parent meets with Luisa, a 10-year-old identified patient
colludes with a child’s symptoms of anxiety, (IP) experiencing OCD symptoms such as
OCD, or other diagnoses (Minuchin 1974; checking her locked doors and rereading home-
Lebowitz et al. 2012). FA exacerbates symptoms work assignments to a point where she feels out of
of some disorders and contradicts the empirically control. The therapist works with Luisa and her
supported method of treatment for anxiety disor- family to understand how she may avoid
ders such as exposure therapy (Merlo et al. 2009). experiencing distress by engaging in her specific
Therefore, a family therapist can use their knowl- rituals such as checking and rereading. After the
edge of accommodating behaviors to reduce therapist discusses this with the family, he notices
symptom severity by interrupting the constraining how Luisa’s mother, Sue, seems unsure in their
pattern of FA. Family therapists can interrupt mal- session. The therapist decides to meet with the
adaptive patterns by teaching a family to recog- parental subsystem separately and reflects his
nize FA, demonstrating ways in which they can observation to Sue and her husband, John. John
decrease FA such as with exposure techniques, begins to nod his head in agreement with the
and guiding them to manage symptoms without therapist and says, “I think Sue has a hard time
accommodating behaviors (Merlo et al. 2009). when she sees Luisa do her rituals so she helps her
[Luisa] so they get done faster.” The therapist
watches Sue as John says this and notices a tear
Clinical Example roll down Sue’s cheek. John turns to her and says,
“Sue, I can imagine it must be really difficult
A therapist works with Chris, the 13-year-old to see your daughter in such distress.” As Sue
identified patient (IP) with a history of trauma, wipes tears and John rubs a hand on her back,
his new guardians, his biological father, Todd, Sue admits that she wants to reduce Luisa’s
and Todd’s partner, Joanna. Before the work stress. Sue then goes on to acknowledge how her
began, the therapist accommodated through main- assistance in Luisa’s rituals reinforces her symp-
tenance by validating Todd’s cause for concern toms, finally seeing how Sue’s actions present as
and empathizing with Chris’s presenting problem accommodation. Together, John and Sue agree to
of anger. In addition, the therapist immediately attempt new actions that reduce accommodation
began to take note of the way the new family in their system.
creates their patterns of interaction. In their third
session, the therapist tracks a pattern where
Joanna interrupts Todd when he is asked a direct Cross-References
question about Chris. Chris responds by scoffing
at Joanna. In tracking this interaction, the therapist ▶ Adolescents in Couple and Family Therapy
can begin to accommodate to the system and ▶ Anxiety Disorders in Couple and Family
notice how the system functions. The therapist Therapy
continues to accommodate when she notices ▶ Cognitive-Behavioral Family Therapy
how the family uses humor to manage discomfort. ▶ Communication in Couples and Families
After Chris’s scoff towards Joanna, Todd makes a ▶ Joining in Couple and Family Therapy
joke about the tension in the room, while Joanna ▶ Joining in Structural Family Therapy
and Chris join him in laughter. When the therapist ▶ Maintenance in Couple and Family Therapy
notices this addition of humor, the therapist adapts ▶ Minuchin, Salvador
20 Ackerman Institute for the Family
▶ Obsessive Compulsive Disorder (OCD) in family. Dr. Ackerman’s idea to position family ther-
Couple and Family Therapy apy as the primary therapeutic modality in the treat-
▶ Structural Family Therapy ment of children was revolutionary at the time.
Following WWII, he began to experiment with
seeing his patients and their families together in
References therapy. A group of grateful families came together
to establish a nonprofit center to support and expand
Black, D. A. (2017). Applying systems to anxiety disor- Nathan Ackerman’s’ work in teaching and training.
ders. In J. A. Russo, J. K. Coker, & J. H. King (Eds.),
A building was donated for this work, which was
DSM-5 and family systems. New York: Springer.
Calvocoressi, L., Lewis, B., & Harris, M. (1995). Family located on the Upper East Side of New York City in
accommodation in obsessive-compulsive disorder. an old brownstone. Dr. Ackerman published,
American Journal of Psychiatry, 152(3), 441–443. taught, and even videotaped his new methods.
https://doi.org/10.1176/ajp.152.3.441.
Documenting clinical work with videotapes became
Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi,
L., Dauser, C., Warnick, E., . . . & Leckman, J. F. the cornerstone in the teaching and training of fam-
(2012). Family accommodation in pediatric anxiety ily therapists at the institute and is the main training
disorders. Depression and Anxiety, 30(1), 47–54. modality to this day.
https://doi.org/10.1002/da.21998.
Although many family therapy institutes formed
Merlo, L. J., Lehmkuhl, H. D., Geffken, G. R., &
Stroch, E. A. (2009). Decreased family accommodation in the 1960s in the USA had a distinctive conceptual
associated with improved therapy outcome in pediatric core or were aligned with the work and thinking of a
obsessive-compulsive disorder. Journal of Consulting specific person, Nathan Ackerman was not very
and Clinical Psychology, 77(2), 355–360. https://doi.
interested in establishing a specific school or theory
org/10.1037/a0012652.
Minuchin, S. (1974). Families and family therapy. of family therapy. However, he was committed to
London: Routledge. the invention and development of clinical innova-
Nichols, M. P., & Davis, S. D. (2017). Family therapy: tions for some of the most difficult problems facing
Concepts and methods. Boston: Pearson.
families and couples. This tradition of developing
Piaget, J. (1932). The moral judgment of the child. London:
Routledge & Kegan Paul. family therapy techniques and ideas around specific
Swann, J., Deumert, A., Lillis, T., & Mesthrie, R. ( 2004). A problem areas continues today in the form of special
dictionary of sociolinguistics. Edinburgh: Edinburgh projects at the institute.
University Press.
Since 1960, the leadership of the Ackerman
Institute (Don Block, Peter Steinglass, and Lois
Braverman), followed Ackerman’s tradition of
Ackerman Institute for the supporting innovation, of developing new ways
Family to work with specific problem areas facing fami-
lies and then feeding these ideas into the training
Lois Braverman program and the clinical services offered to cou-
Ackerman Institute for the Family, New York, ples and families.
NY, USA In August of 2013, the Ackerman Institute for
the Family moved from its original home at
149 East 78th Street to its current location in the
Introduction heart of the Flatiron District. In this move, a state-
of-the-art training institute was built that now
Founded in 1960 by Nathan Ackerman as a training houses the training activities and clinical services
institute, the Ackerman Institute for the Family was of the institute.
initially known as The Family Institute. Nathan
Ackerman, a psychiatrist and psychoanalyst,
believed that if one person in the family had a Location
problem, everyone in the family was impacted and
that the place to solve that problem was in the 936 Broadway 2nd floor, New York, NY 10010
Ackerman Institute for the Family 21
Prominent Associated Figures in the projects was fed back into the training
program and the clinical services. In addition to
Since 1960, many people who have developed workshops and conferences, a program of inter- A
work in special projects at the Institute. This national training was established with ongoing
work resulted in books and articles that have collaborations with family therapy institutes in
influenced others in the field of family therapy. Hong Kong, Argentina, Chile, and Mexico.
This list includes but is not limited to: Nathan Examples of projects that have been conducted
Ackerman (1966), Don Bloch (1972, 1981), Mary historically at the institute include:
Kim Brewster (Brewster and Sheinberg 2015;
Sheinberg and Brewster 2014), Jorge Calipinto • The Family-School Collaboration Project, led
(1995), Martha Edwards (2002), Peter Fraenkel by Howard Wiess
(2006, 2011), Aquilla Fredericks (2014), Virginia • The AIDS Project, led by Gillian Walker and
Goldner (2004; Goldner et al. 1990), Miquel John Patten
Hernandez (Hernandez et al. 1999), Lynn • The Foster Care Project, led by Jorge
Hoffman (1990), Evan Imber-Black (1992, 1993, Colapinto
2011), Laurie Kaplan (Kaplan and Small 2005), • The Infertility Project, led by Mimi Meyers,
Elana Katz (2007), Kitty LaPerriere (1982), Cath- Connie Scharf, David Kezur, and Margot
erine Lewis (2011), Jean Malpas (2011), Peggy Weinshel
Papp (1983, 2000; Papp and Imber-Black 1996; • The Gender and Violence Project, led by Vir-
Papp et al. 2013; Walters et al.1991), Peggy ginia Goldner, Marcia Sheinberg, Gillian
Penn (1982), Michele Scheinkman (2005, 2008; Walker, and Peggy Penn
Scheinkman and Werneck 2010), Marcia • The Making Families Safe for Children Pro-
Sheinberg (1992); Sheinberg and Brewster ject, led by Marcia Sheinberg, Fiona True, and
2014; Sheinberg and True 2008; Sheinberg and Peter Fraenkel
Fraenkel 2001; Sheinberg and Penn 1991), Olga • The Depression Project, led by Peggy Papp
Silverstein (Silverstein and Rashbaum 1995), • The Writing Project, led by Peggy Penn
Sippio Small (Kaplan and Small 2005), Peter • The Alcohol, Drugs, and the Family Project,
Steinglass (1987), Marcia Stern (2008), Judy led by Peter Steinglass
Stern-Peck (2007), Fiona True (Sheinberg and • The Themes and Beliefs Project, led by Evan
True 2008), Gillian Walker (1991), and thandiwe Imber-Black and Peggy Papp
Dee Watt-Jones (1997, 2004, 2010, 2016; Watts- • The Diversity in Social Work Training Pro-
Jones et al. 2007). gram, led by Sippio Small, Laurie Kaplan,
and Ruth Mohr
• Fresh Start for Families, led by Peter Fraenkel
Contributions • The Mentoring Group, led by Miguel
Hernandez, Sippio Small, and Dee Watts-Jones
In a general sense, the Ackerman Institute for the • The Unique Minds Project, led by Gillian
Family can be described as a “think tank,” where Walker, Marcia Stern, Susan Shimmerlik, and
teaching methods and clinical models are contin- Pat Heller
ually invented, practiced, and refined. The insti- • Competent Kids/Caring Classrooms, led by
tute provides (a) direct services to families and Marcia Stern
couples through an on-site clinic, (b) postgraduate
Current projects include:
training in couple and family therapy, and
(c) clinical research initiatives known as “special • Adolescents and their Families Project led by
projects” that focus on the development of new Peggy Papp, Michael Davidovits, and
treatment models and training techniques. Courtney Zazzali
Many projects at the institute have led to arti- • Center for the Developing Child and Family,
cles, books, and training tapes. What was learned led by Martha Edwards
22 Ackerman Institute for the Family
• Center for Families and Health, led by Evan • People change when they feel understood by
Imber-Black the people closest to them.
• Center for Relational Trauma, led by Marcia • People change when they feel hopeful.
Sheinberg and Fiona True • People change when they expand their capac-
• Center for Substance Abuse and the Family, ity to genuinely appreciate the perspectives and
led by Peter Steinglass lived experiences of others.
• Competent Kids/Caring Communities, led by • People change when the meaning attributed to
Zina Rutkin a problem shifts or becomes more comprehen-
• Couples Project led by Michele Scheinkman, sible within its context.
Peggy Papp, and Jean Malpas • People change when they are able to mobilize
• Diversity in Social Work Training Program, resources and work together (Brewster and
led by Sippio Small and Laurie Kaplan Sheinberg 2015).
• Divorce Mediation Project, led by Elana Katz
• Foster Care and Adoption Project, led by Cath- The Ackerman Relational Approach is not a
erine Lewis and Andrea Blumenthal model but a way of thinking and conceptualiz-
• Gender and Family Project, led by Jean Malpas ing family dilemmas that is non-pathologizing
• Justice Project, led by Sarah Berland and and collaborative, searches for the unique
Courtney Zazzali beliefs and meaning each family member attri-
• Language and Writing Project led by Patricia butes to the problem, holds the complexity of
Booth, Joan DeGregorio, and Sally Write the individual as more than their symptoms, and
• Latino Youth and Family Immigration Project: understands how oppressive practices in the
Dimelo en Espanol, led by Silvia Espinal and larger society impact the interior of couple and
Erika Klein family relationships. At the same time, thera-
• Money, Values, and Family Life Project, led by pists are trained to understand how their own
Judy Stern Peck social location impacts their view of the prob-
• Multiracial Families and Couple Project, led lem and how it may influence their interaction
by Dorimar Morales, Keren Ludwig, and with the family or couple in treatment. The list
Mary Kim Brewster of key references reflects some of the seminal
• Resilient Families: Children with Special articles and books written by Ackerman faculty
Needs Project, led by Judy Grossman in the last 50 years that have influenced the
• Serious Mental Illness and the Family Project, thinking and practice of family therapy at the
led by Mary Kim Brewster and Lois institute today.
Braverman
• Talk Race Group Project, led by Aquilla Fred-
erick and Frank Wells References
Ackerman, N. W. (1966). Treating the troubled family.

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oped an approach taught in the training program Bloch, D. A. (1972). Family interaction: A dialogue
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most recent articulation has been in the manual ily Process, 11, 511–512.
Bloch, D. A. (1981). Family therapy training: The institu-
written by Mary Kim Brewster and Marcia tional base. Family Process, 20, 131.
Sheinberg (2015). The Ackerman Relational Brewster, M. K., & Sheinberg, M. (2015). The Ackerman
Approach reflects the following ideas about change: relational approach: A training manual. Unpublished
manuscript.
Colapinto, J. (1995). Dilution of family process in social
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empowerment. ilies. Family Process, 34, 59–74.
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tion. Family Process, 46, 93–107. Walters, M., Carter, B., Papp, P., & Silverstein, O. (1991).
LaPerriere, K. (1982). Family therapy techniques. Family The invisible web: Gender patterns in family relation-
Process, 21, 129–130. ships. New York: The Guilford Press.
Lewis, C. (2011). Providing therapy to children and fami- Watts-Jones, D. (1997). Toward an African American gen-
lies in foster care: A systemic-relational approach. ogram. Family Process, 316, 375–383.
Family Process, 50, 436–452. Watts-Jones, D. (2004). The evidence of things seen and
Malpas, J. (2011). Between pink and blue: A multi- not seen: The legacy of race and racism. Family Pro-
dimensional family approach to gender nonconforming cess, 43, 503–508.
children and their families. Family Process, 50, 453–470. Watts-Jones, D. (2010). Location of self: Opening the door
Papp, P. (1983). The process of change. New York: to dialogue on intersectionality in the therapy process.
Guilford. Family Process, 49, 405–420.
Papp, P. (2000). Couples on the fault line: New directions Watts-Jones, D. (2016). Location of self in training and
for therapists. New York: Guilford. supervision. In K. V. Hardy & T. Bobes (Eds.), Cultur-
Papp, P., & Imber-Black, E. (1996). Family themes: Trans- ally sensitive supervision and training: Diverse per-
mission and transformation. Family Process, 35, 5–20. spectives and practical applications (pp. 16–24).
Papp, P., Scheinkman, M., & Malpas, J. (2013). Breaking New York: Routledge.
the mold: Sculpting impasses in couples’ therapy. Fam- Watts-Jones, R. A., Alfaro, J., & Frederick, A. (2007). The
ily Process, 52, 33–45. role of a mentoring group for family therapy trainees
Peck, J. S. (2007). Money and meaning: New ways to have and therapists of color. Family Process, 46, 437–450.
conversations about money with your clients. Whiting, R. (2003, 1988). Rituals in families and family
New York: Wiley. therapy. New York: W. W. Norton.
24 Ackerman, Nathan
classical psychoanalyst. His interest in integrating

Ackerman, Nathan insights related to the psychodynamic perspective
into a group therapy session paved the way for what
Rajeswari Natrajan-Tyagi has evolved into modern day family therapy. He
Couples and Family Therapy Masters and faced great struggles in challenging and changing
Doctoral Programs, California School of the psychological zeitgeist of his times which was
Professional Psychology at Alliant International steeped in concepts and terminology of intraper-
University (Irvine), Irvine, CA, USA sonal personality theories. Initially, Ackerman
followed the Child Guidance Clinic model of hav-
ing a psychiatrist treat the child while a social
Name worker worked with the mother. However, within
his first year of work at the Menninger clinic,
Ackerman, Nathan Ackerman became a strong advocate of including
the entire family when treating a disturbance in one
of its members. He believed that the mental or
Introduction
physical health of one family member affected
other family members, and that often the best way
Nathan Ackerman is widely acknowledged as a
to treat the individual was to treat the family as a
pioneer in the field of family therapy and is credited
whole. He argued that families acted as a type of
with developing the concept of family psychology.
social unit and just like individuals go through
He was born in Bessarabia, Russia, on November
developmental stages. He was particularly fasci-
22, 1908. Ackerman and his family came to the
nated by intergenerational ties and the role emotions
United States in 1912 when he was only 4-years-
played within the family unit. For this reason,
old. He grew up during the age of anti-Semitism,
Ackerman insisted on the entire family receiving
the great depression, and World War II.
treatment, utilizing family systems therapy, and tra-
ditional psychodynamic therapy into his work as a
Career psychiatrist. He was seen as a phenomenal therapist
with a confronting and charismatic therapeutic style.
He attended the public school system in New York He was seen as a high-affect therapist who can gain
City, earned his Bachelor of Arts degree from quick access to clients’ emotions and make things
Columbia University in 1929 and his Doctor of happen in the room.
Medicine degree from Columbia University in He founded the Ackerman Institute in 1960,
1933. He did his internships at the Menninger which to this day serves as a base for education,
Clinic in Topeka, Kansas, and the Montefiore research, and clinical service for families and
Hospital in the Bronx, New York. At the Men- improving their mental health. Along with his
ninger Clinic, Ackerman was offered a staff posi- colleague Don Jackson, Ackerman founded the
tion which he accepted and in 2 years rose to the first family therapy journal, Family Process,
position of Chief Psychiatrist at that clinic. During which is still the leading journal of ideas in the
World War II, Ackerman lent his services to the field today. Dr. Ackerman published multiple
Red Cross and by the end of the war he was books such as Family Diagnosis: An Approach
offered the position of clinical professor of psy- to the Preschool Child (1938), The Unity of the
chiatry at Columbia University. Family (1938), The Psychodynamics of Family
Life (1958), Treating the Troubled Family
(1966), and Family Process (1970). Nathan
Contributions to the Profession Ackerman served as the president of the Associa-
tion of Psychoanalytic Medicine and was awarded
Ackerman is thought to be one of the pioneers of the Wilfred Hulse Award and the Rudolph Meyer
family psychology. He began his early training as a Award. He died in 1971.
Action as a Stage of Change in Couple and Family Therapy 25
Cross-References and integrated into one’s life (Prochaska and

DiClemente 1984). When individuals in couples
▶ Ackerman Institute for the Family and family therapy need to make a change in per- A
▶ Jackson, Donald sonal or interpersonal behaviors, the stages can be
▶ Philadelphia Child Guidance Clinic helpful for understanding their readiness and moti-
vation (Prochaska et al. 1994). Thus, assessing
stage status enables therapists to match their
References approaches to meet the needs of clients in different
stages of change (see ▶ “Contemplation as a Stage
Barrows, S. E. (1982). Nathan, W. Ackerman as a therapist of Change in Couple and Family Therapy” entry).
and individual: An interview with Donald Bloch and
Moreover, stage status is goal and behavior specific
Kitty La Perriere. The American Journal of Family
Therapy, 10(4), 63–70. https://doi.org/10.1080/ so individuals can differ in readiness based on
01926188208250101. goals (desired amount of contact with in-laws)
Broderick, C. B., & Schrader, S. S. (1981). The history of and behaviors (cutting down or quitting smoking).
professional marriage and family therapy. In A. S.
Gurman & D. P. Kniskern (Eds.), Handbook of family
therapy (pp. 5–35). New York: Brunner/Mazel.
Nichols, M. P. (2011). The evolution of family therapy. In Application of Concept in Couple and
The essentials of family therapy (pp. 7–28). Boston: Family Therapy
Pearson.
Action is the stage that most identify with change.

The pre-action stages represent tasks that get indi-
viduals ready to change. The action stage begins the
Action as a Stage of Change in activities needed to create a new pattern of behavior.
Couple and Family Therapy The plans and commitment generated in the prepa-
ration stage are activated and behavior change is
Carlo C. DiClemente and Alicia E. Wiprovnick begun; a couple tries a new communication strategy,
University of Maryland, Baltimore County, parents begin to change how they manage temper
Baltimore, MD, USA tantrums, or an abusive spouse stops using verbal
abuse to communicate feelings. The tasks of the
action stage are to initiate a plan, continue commit-
Synonyms ment despite difficulties, and revise the plan when it
is not working. After successful creation of a new
Adherence; Coping activities; Engagement; Plan pattern of behavior (often 3–6 months), individuals
implementation; Taking action or families move into the maintenance stage where
the new pattern becomes integrated into the couple
or family behavioral repertoire (Prochaska and
Overview and Theoretical Context DiClemente 1984).
Time is an important consideration during
Stages of Change represent a series of steps and preparation; having a specific time when the
tasks that assist in understanding the multi- change will be implemented and letting others
dimensional nature of intentional behavior change. know increase commitment and the probability
According to the transtheoretical model (TTM), of an attempt at action. A starting point gives
the process begins with an individual in pre- some structure to the change attempt. The action
contemplation and currently not considering stage also represents an important time to engage
change through contemplation (decision making), clients in learning behavior change strategies and
preparation (planning and committing), and action skills needed to successfully implement the plan
(making the change and revising the plan) to reach and act. Examples of skills to be taught during this
maintenance where the new behavior is sustained time are communication skills such as active
26 Action as a Stage of Change in Couple and Family Therapy
listening and using “I statements” to express one- would have temper tantrums whenever he did
self (Jacobson and Christensen 1998). Couples not get his way. Shakira refused to go out shop-
who practice these activities as part of the change ping with Demond because his behavior
plan demonstrate higher readiness to change embarrassed her. At home, she thought that
(Hawrilenko et al. 2016). Brad constantly gave in to avoid the tantrums.
Another key dimension is whether the plan is In the third family counseling session, the coun-
working completely. Plans usually have flaws and selor explained selective attention and how to
there are unanticipated challenges in implementa- ignore the tantrum and reward positive behav-
tion. For example, a parent fails to ignore a prob- iors. The couple found the ideas helpful and
lem behavior or use positive reinforcement and agreed to try these strategies. During the week,
gets into a screaming match with their adolescent; both of them began praising Demond for good
or a husband comes home late for dinner without behavior: playing quietly, working together on a
calling as promised. These are labeled as a slip puzzle, and helping Mom with a chore. Both
(use of the substance that is time limited) or a were surprised that it seemed to be working.
relapse (a return to the problem behavior pattern). On Friday, however, Demond was throwing his
This distinction is critical. Slips indicate that there toys around and instead of ignoring it, Brad,
is a problem in the plan or commitment of the who had had a difficult day at work, kept telling
individual. Relapse indicates that the individual him to stop and then yelled at him. The interac-
or family has given up on the plan of action tion escalated and Shakira started to get angry at
(DiClemente and Crisafulli 2017). Both can be Brad, telling him that he was not trying to do
remediated, but a relapse usually requires what the counselor recommended.
recycling through earlier stages to fix what went The next session both were tense and thought
wrong with the process of change and to ade- that they were not able to do this since it was
quately complete earlier tasks leading to greater creating conflict between them. After assuring
success next attempt (Prochaska et al. 1992). them the foolproof management plan had not yet
Slips, however, are instructive in the sense that been created, the counselor elicited a recommit-
they uncover flaws in the action tasks. Plans may ment to continue to try the strategies, and problem
need to be adjusted or tweaked to accommodate solved the situation. Brad and Shakira agreed that
what went wrong. As long as the decisions made each of them could call a time out if they were
in the contemplation stage and the commitment feeling overwhelmed and angry and let the other,
generated in the preparation stage are still opera- less stressed parent manage Demond whenever
tive, the clients can change the plan rather than possible. After several more weeks of working
abandoning the change. Rigid expectations on the together and implementing the strategies, they
part of client or counselor that everything must go saw a noticeable improvement. They were not
smoothly once action is taken or that a failed plan always able to implement the strategies but were
represents complete failure create discouragement motivated to figure out what went wrong and how
and defeat. In couple counseling, this is particu- to adjust the strategies to fit their situations. Their
larly important because a slip on the part of one behavior change and use of these child manage-
person is often interpreted as a lack of commitment strategies continued even as Demond moved
ment, effort, or ability rather than a glitch in the out of his “terrible twos.”
implementation of the action plan (DiClemente
2015).
Cross-References
Case Example ▶ Contemplation as a Stage of Change in Couple

and Family Therapy
Shakira and Brad constantly argued over how to ▶ Precontemplation in Couple and Family
manage their 2-year-old son, Demond. He Therapy
Addictions in Couple and Family Therapy 27
References conceptualizations of addiction as being limited

to substance dependence and instead referred to
DiClemente, C. C. (2015). Change is a process not a product: addiction as a chronic disease affecting brain
Reflections on pieces to the puzzle. Substance Use and A
reward, motivation, memory, and related circuitry.
Misuse, 50, 1–4. https://doi.org/10.3109/
10826084.2015.1042338. Though debate continues regarding the nature,
DiClemente, C. C., & Crisafulli, M. (2017). Counting etiology, and terms used to describe various
drinks needs a broader view of alcohol Relapse and behavioral addictions, evidence suggests that
Change. Alcoholism Clinical and Experimental
these behaviors often involve a natural reward
Research. 41(2), 266–269.
Hawrilenko, M., Eubanks-Fleming, C. J., Goldstein, A. S., which maintains the behaviors despite the pres-
& Cordova, J. V. (2016). Motivating action and ence of aversive physical, mental, or social
maintaining change: The time-varying role of home- consequences.
work following a brief couples’ intervention. Journal
Gambling disorder is the only behavioral
of Marital and Family Therapy, 42, 396–408. https://
doi.org/10.1111/jmft.12142. addiction recognized by the Diagnostic and Sta-
Jacobson, N. S., & Christensen, A. (1998). Acceptance and tistical Manual of Mental Disorders, Fifth Edition
change in couple therapy: A therapist’s guide to trans- (DSM-5; American Psychiatric Association
forming relationships. New York: Norton.
2013). However, a growing body of research has
Prochaska, J. O., & DiClemente, C. C. (1984). The trans-
theoretical approach: Crossing the traditional bound- applied the addiction model to a number of behav-
aries of therapy. Malabar: Krieger Publishing. iors, including sexual intercourse, pornography
Prochaska, J. O., DiClemente, C. C., & Norcross, J. (1992). use, shopping, video gaming, and Internet and
In search of how people change. American Psycholo-
computer use. Like substance dependence, these
gist, 47(9), 1101–1114.
Prochaska, J. O., Norcross, J., & DiClemente, C. C. (1994). behavioral addictions contribute to a number of
Changing for good: The revolutionary program that emotional, interpersonal, physical, spiritual, and
explains the six stages of change and teaches you how financial difficulties for individuals and their fam-
to free yourself from bad habits. New York: William
ilies. Such difficulties pose a significant threat to
Morrow & Co.
an individual’s recovery process and to the struc-
ture and process of their family system. As such,
clinicians and researchers have made efforts to
Addictions in Couple address the impact of behavioral addictions on
and Family Therapy couples and families. The efficacy of these treat-
ments remains limited.
Meagan J. Brem, Autumn Rae Florimbio and
Gregory L. Stuart
University of Tennessee-Knoxville, Knoxville, Sexual and Pornography Addiction
TN, USA
Theoretical Context and Description. An
increased awareness of sexual addiction among
Synonyms researchers and clinicians developed following
Carnes’ (1992) publication. Sexual addiction,
Behavioral addictions; Impulse control disorders also known as hypersexuality and compulsive
sexual behavior, refers to compulsive, excessive,
out of control, or otherwise problematic sexual
Introduction behaviors (e.g., sexual desire/drive, sexual inter-
course, masturbation, pornography use, sexual
Behavioral addictions, sometimes referred to as chat/video use, and/or engagement in sexual fan-
impulse control disorders, are becoming increas- tasy). According to the behavioral addiction
ingly recognized as treatable addictions. In model for sexual addiction, individuals who
2011, the American Society of Addiction Medi- engage in these behaviors experience craving
cine (ASAM) departed from traditional prior to engagement in sexual activity, impaired
28 Addictions in Couple and Family Therapy
control over sexual behaviors, and continued the presence of early life traumas, and the role
engagement in sexual activity despite negative distortions observed in the family of origin for
consequences. Sexual addiction affects both men both members of the couple, couple therapy
and women of all ages and ethnicities though it is should supplement or follow individual or group
more often reported among men than women. therapy.
Individuals with sexual addiction often endorse Therapists working with couples in which one
co-addictions, including substance use disorders, or both members are affected by sexual addiction
which are often intricately intertwined with sexual must provide a safe, nonjudgmental environment
activity. while promoting good boundaries (Turner 2009).
Application of Concept in Couple and Family It is important that therapists have well-developed
Therapy. Individuals with sexual addiction expe- self-awareness of their own beliefs and experi-
rience a range of consequences including sexually ences regarding sexuality and accept the broad
transmitted infections, unwanted pregnancies, range of sexual expression. Identifying with one
abortion, financial loss, marital- and work-related member of the couple could result in the other
problems, legal issues, and psychiatric feeling alienated, leading to treatment termina-
comorbidities. Partners of such individuals often tion. Research in this understudied domain
share the experience of these consequences in remains limited to primarily white, heterosexual,
addition to feelings of shame, distrust, betrayal, married couples. Marriage and family therapists
anger, traumatization, helplessness, poor self- should therefore consider the potential limitations
esteem, isolation, and diminished sexual intimacy. of applying existing treatment modalities to
As such, a growing number of couples are seeking diverse populations affected by sexual addiction.
therapy with sexually based compulsive behav-
iors as the primary presenting concern. Couple
therapy is considered an important method for Gambling Disorder
rebuilding trust, communication, and intimacy
among couples affected by sexual addiction. Theoretical Context and Description. Gambling
Despite recognition of this importance, limited disorder, sometimes referred to as problematic
resources are available for the treatment of sexual gambling, pathological gambling, or compulsive
addiction within couples. gambling, was reclassified by the DSM-5 (APA
Of the few resources available to clinicians 2013) as a substance-related and addictive disor-
working with this population, the following treat- der. Gambling disorder is broadly characterized
ment aims consistently emerge: psychoeducation by difficulty in limiting time and resources spent
regarding the nature of sexual addiction, restore on gambling and unsuccessful attempts to cut
trust in the relationship, examine cognitive and down on gambling despite significant psycholog-
emotional effects of addiction on each member ical, financial, medical, occupational, or interper-
of the couple, develop adaptive communication sonal consequences. The conceptualization of
patterns, reorient the addicted partner away from problematic gambling as an addiction followed
egocentrism and toward relationship responsive- after observed similarities between substance use
ness, address the broad systemic effects of sexual disorders and problematic gambling with regard
addiction within the family system (e.g., sexuality to symptom presentation, genetic vulnerabilities,
and withdrawal), facilitate forgiveness, establish neurological mechanisms, cognitive deficits, and
healthy boundaries, reduce shame, and increase motivations (Petry 2007). For instance, gambling
intimacy within the partnership and family (e.g., is used by many to cope with aversive internal and
increase time together; Zitzman and Butler 2005). external events. Gambling disorder often
Structural and emotionally focused couple ther- co-occurs with various other psychiatric condi-
apy demonstrated efficacy in accomplishing many tions, including substance use, mood, anxiety,
of these aims. Due to the complex relations and personality disorders. Though gambling dis-
between the development of sexual addiction, order is observed across multiple populations,
young, nonwhite men with low socioeconomic experiencing, (5) linking the past to the present,
status who are separated or divorced are at an and (6) consolidating changes. Similarly, Adapted
increased risk (Petry 2007). Couple Therapy (ACT) for pathological gamblers A
Application of Concept in Couple and Family (Bertrand et al. 2008) aims to support and encour-
Therapy. Couple and familial distress is both a age the gambler’s recovery while relieving the
contributor and consequence of problematic gam- distress experienced within the couple. ACT
bling. Partners of problematic gamblers often involves two overlapping phases of treatment. In
share the burden of financial distress associated the first phase, management of the gambler’s
with gambling in addition to feelings of guilt, problems and symptoms occurs (e.g., a functional
shame, anger, betrayal, and loss of trust and the analysis of gambling behaviors is performed, irra-
burden of upholding responsibilities for the fam- tional cognitions are addressed, and emphasis is
ily alone. These experiences paired with difficulty placed on developing empathy between partners).
in communicating, resolving conflict, and In the second phase, couple dimensions are
maintaining sexual intimacy further exacerbate addressed (e.g., developing caring behaviors, inti-
relationship dissatisfaction within such couples. macy, constructive communication, and problem-
Children and other family members of problem- solving skills). The efficacy of ACT for gambling
atic gamblers often report adverse effects of gam- has yet to be determined.
bling, including neglect, lying, deception, alcohol
and drug problems, and family violence
(Kalischuk 2010). Alternatively, couple conflicts, Other Behavioral Addictions
partner’s efforts to exert control over the gambler,
poor social support, and conflictual attitudes from Theoretical Context and Description. Research
family members are major elements of relapse for examining addictions to various technological
individuals who engage in problematic gambling. devices and activities (e.g., gaming, browsing,
Indeed, gambling may be such an integrated com- social networking, etc.), and compulsive buying
ponent of the family system that eliminating gam- (sometimes referred to as shopping addiction),
bling by means of individual treatment alone may remains controversial and limited. These behaviors
disrupt the dynamics within the family, leading to are oftentimes conceptualized as being more closely
relapse or separation. To address these issues, associated with impulse control disorders and
researchers and clinicians advocate for the inclu- obsessive-compulsive disorders than with addiction.
sion of couple and/or family therapy in the treat- Nonetheless, terms such as “Internet addiction” and
ment of problematic gambling. “shopping addiction” have received increased atten-
There is a paucity of resources for evidence- tion among researchers and clinicians who charac-
based, couple-focused treatments for problematic terize these phenomena as excessive or poorly
gambling with a majority of resources focusing on controlled preoccupations or urges to engage in
individual or group approaches to treatment. Con- these behaviors, leading to impairment and distress
gruence Couple Therapy (CCT), a short-term, (Granero et al. 2016; Shaw and Black 2008). The
integrative, humanistic, and systemic approach, growth of technology and the Internet contribute to
aims to reduce problematic gambling while significant overlap among these behaviors and other
healing the emotional pain within the couple rela- behavioral addictions (e.g., cybersexual addiction,
tionship (Lee and Awosoga 2015). In CCT, gam- online gambling addiction, and online shopping
bling is targeted within couples’ broader and addiction). As with substance use disorders, neuro-
deeper concerns. CCT accomplishes these aims logical evidence suggests individuals with these
during 12, 1-h weekly sessions which span across behavioral addictions have abnormalities in
six phases of treatment: (1) engaging the client, reward-processing regions of the brain. Similarly,
(2) aligning with the couple and assessing couple both reinforcement and punishment systems appear
communication and gambling, (3) facilitating to contribute to the onset and development of these
congruence within the couple, (4) deepening behavioral addictions. Unlike substance use
30 Addictions in Couple and Family Therapy
disorders, these behavioral addictions depend on Case Example

specific cultural mechanisms (e.g., market-based
economy and materialistic values). Whereas more Steve and Sally have been married for 16 years
women than men endorse compulsive buying and have a 12-year-old son. They recently sought
behavior, findings on gender differences in com- couple therapy stating that their relationship was
puter and Internet addiction are mixed. negatively affected by Steve’s pornography use.
Application of Concept in Couple and Family They viewed pornography together during sexual
Therapy. Excessive use of technological activity activities when they first married, which Sally
(e.g., gaming, browsing, social networking, etc.) described as a comfortable, intimate experience.
interferes with relationship functioning and flexi- However, over the past 10 years, Steve became
bility within the family system in various ways. increasingly secretive about his pornography use
Partners’ concerns may include issues with the and began to use pornography alone on a daily
amount of time an individual spends on a techno- basis. Sally reported she was uncomfortable with
logical device, how the technological activity the type of pornography Steve used and the extent
interferes with familial responsibilities and rela- of his use. As a result, she had asked him to
tionship intimacy, and the extent to which a part- discontinue and Steve promised he would not
ner maintains appropriate boundaries with other use pornography anymore. When Sally and
individuals with whom she/he interacts through Steve’s 12-year-old son stumbled across a secret
technological devices. Consequences of excessive file on their computer where Steve had saved
or compulsive technology use may result in pornographic material, Sally became suspicious
disrupted sleep, which may then affect the time that Steve was continuing his pornography use.
and energy an individual puts into relationships. Again, Steve promised to quit using pornography.
Couples in which one or both partners engage in Sally became distrustful of Steve and frequently
some form of technology addiction may experi- searched the house, his computer, and his Internet
ence neglect, betrayal, jealousy, and reduced inti- history on his cell phone to monitor his pornogra-
macy within their relationship. Similarly, phy use. When Sally found evidence of Steve’s
compulsive or excessive buying behaviors may pornography use, they would get in an argument,
create hostility, lack of trust, and financial diffi- causing Steve to become more secretive about his
culties within couples, which may then subse- pornography use. This process transpired
quently and negatively affect buying habits. throughout the last several years of their marriage.
No research has investigated the efficacy of Sally stated that she did not trust Steve anymore,
couple or family therapy for couples in which they lacked intimacy, and she began to perceive
one or both partners exhibit a technology addic- herself as unattractive. She recently threatened to
tion or compulsive buying. Nonetheless, thera- end their marriage over his pornography use.
pists can work to help couples establish Steve argued that he did not have privacy. He
boundaries and rules within their relationship. maintained that he found Sally attractive and that
Exploring couples’ conflicting value systems, his pornography use did not affect his commit-
motivations for and patterns of engaging in comment to her.
pulsive behaviors, and level of intimacy within Steve repeatedly promised he would stop using
the relationship may provide important therapeu- pornography, but was unable to stop and had in
tic directions. Therapists should work to address fact began using more graphic and novel forms of
couples’ use of disparate leisure activities, per- pornography. Steve was addicted to pornography.
ceived neglect, and poor communication skills. Just as many therapists suggest addressing sub-
In cases in which the entire family system is stance use prior to beginning couples’ concerns,
disrupted by such behaviors, family therapists Steve and Sally’s therapist chose to address the
can work to set boundaries on such behaviors addiction components prior to working on their
within the family and replace disparate activities relationship concerns. Once the addiction
with family activities. decreased, the couple system was restructured to
improve marital functioning. Using a structural wounds pornography placed upon their mar-
approach, the therapist focused on reducing the riage. Future sessions focused on maintaining
alliance Steve has with pornography in place of an this process and increasing the time spent with A
alliance between Steve and Sally against the por- one another. Follow-up sessions revealed Steve
nography. The therapist hypothesized that Steve’s and Sally experienced increased relationship
relationship with pornography has strengthened satisfaction.
over the years, while his relationship with Sally
weakened. Steve relied on pornography, instead
of Sally, for comfort. As a result, Sally grew to feel
Cross-References
rejected from Steve.
After providing some psychoeducation regard-
▶ Alcohol Use Disorders in Couple and Family
ing pornography addiction, the therapist helped
Therapy
Steve and Sally identify pornography as a third
▶ Substance Use Disorders in Couple and Family
party in their relationship. Sally agreed that Steve’s
Therapy
pornography use felt like he was having an affair
with another woman and that trust could be restored
by Steve’s pornography discontinuation. The
References
importance of trust and boundaries within the rela-
tionship were discussed, and they conceptualized American Psychiatric Association. (2013). The diagnostic
what would constitute betrayal of trust and bound- and statistical manual of mental disorders (5th ed.).
aries. The couple agreed that cheating, lying, and Washington, DC: Author.
Bertrand, K., Dufour, M., Wright, J., & Lasnier, B. (2008).
secretive behavior impeded trust, and attempting to
Adapted couple therapy (ACT) for pathological gam-
cover up pornography use was similar to secretly bling: A promising avenue. Journal of Gambling Stud-
meeting with an extra-dyadic partner. Sally ies, 24, 393–409.
expressed a desire to discontinue monitoring and Carnes, P. (1992). Out of the shadows: Understanding
sexual addiction (2nd ed.). Minneapolis: CompCare.
detective work as a way to determine Steve’s hon-
Granero, R., Fernández-Aranda, F., Mestre-Bach, G.,
esty. Steve developed a realization that his addiction Steward, T., Baño, M., del Pino-Gutiérrez, A.,
interfered with the type of relationship he wanted Moragas, L., Mallorqui-Bagué, N., Aymami, N.,
with Sally (e.g., one that included trust, open com- Gómez-Peño, M., Tárrega, S., Menchón, J. M., &
Jiménez-Murcia, S. (2016). Compulsive buying behav-
munication, and intimacy).
ior: Clinical comparison with other behavioral addic-
After developing these realizations and goals, tions. Frontiers in Psychology, 7, 1–9.
Steve agreed to keep all of his pornography (e.g., Kalischuk, R. G. (2010). Cocreating life pathways: Prob-
movies, magazines, websites, etc.) in one clearly lem gambling and its impact on families. The Family
Journal: Counseling and Therapy for Couples and
identified location so that Sally would no longer
Families, 18(1), 7–17.
feel the need to search for it. Sally was pleased Lee, B. K., & Awosoga, O. (2015). Congruence couple
and discontinued searching for evidence of therapy for pathological gambling: A pilot randomized
Steve’s use. Steve then agreed that he would controlled trial. Journal of Gambling Studies, 31,
1047–1068.
only review pornographic materials in the
Petry, N. M. (2007). Gambling and substance use disor-
established location with Sally’s permission. ders: Current status and future directions. American
This pleased Sally as she began to trust Steve Journal on Addictions, 16(1), 1–9.
more, and Steve eventually decided to get rid of Shaw, M., & Black, D. W. (2008). Internet addiction:
Definition, assessment, epidemiology, and clinical
his materials as trust and intimacy further devel-
management. CNS Drugs, 22(5), 353–365.
oped in their relationship. Furthermore, Steve Turner, M. (2009). Understanding and treating sexual
began to feel closer to Sally as he began to addictions in couples therapy. Journal of Family Psy-
receive help and comfort from Sally, as opposed chotherapy, 20, 283–302.
Zitzman, S. T., & Butler, M. H. (2005). Attachment, addic-
to shame and anger, when he experienced urges.
tion, and recovery: Conjoint marital therapy for recov-
Sally also received comfort and consolidation ery from a sexual addiction. Sexual Addiction and
from Steve as they focused on healing the Compulsivity, 12(4), 311–337.
32 Addressing Racial Trauma in Therapy with Ethnic-Minority Clients
cognitive wellbeing of ethnic-minority children

Addressing Racial Trauma in and adults (Carter 2007; Bryant-Davis and
Therapy with Ethnic-Minority Ocampo 2006; Utsey et al. 2002). For example,
Clients racism and discrimination experiences have been
related to lower self-esteem and perceptions of
Jamila Evans Reynolds academic success, and greater depression and
Tallahassee, FL, USA anxiety (Contrada et al. 2001; Fisher et al. 2000;
Utsey and Payne 2000). Similar to other more
accepted forms of trauma, such as rape, domestic
Synonyms violence, terrorism, or death of a family member,
racial trauma results in posttraumatic stress like
Discrimination; Race-based traumatic stress; Racial symptoms. However, what makes racial trauma
trauma; Racism; Racist-incident based trauma unique is that racist incidents tend to be an ongo-
ing source of stress for ethnic-minority individ-
uals (Bryant-Davis 2007). In addition, several
Introduction scholars have noted that race-based traumatic
stress can occur in conjunction with other forms
Given the current race-relations in the United States, of trauma and provide a multiplicative effect on
with racially motivated hate crimes, divisive rhe- the trauma survivor (Bryant-Davis 2007; Carter
toric, and political fearmongering occurring almost 2007), further emphasizing the importance of
daily, ethnic-minority families are at an increased identifying racial trauma as its own category of
risk for the development of negative mental health stressor. However, even though there is significant
outcomes. One such outcome that clinicians should research suggesting that experiences of racism
be mindful of and assess for is the development of and discrimination are related to negative health
trauma symptoms, such as fear, anxiety, avoidance, outcomes, there has been resistance from profes-
and helplessness, as a result of directly experiencing sionals to adopt racial trauma as a unique and
or witnessing racist incidents or discrimination. This significant stressor. Studies have suggested that
is also referred to as racial trauma. this is potentially due to the inconsistent and
inconclusive research, the fact that racial trauma
is a relatively new phenomenon in the physical
Description and mental health literature, or that the effects of
racist experiences are simply ignored by the pub-
Racial trauma has been defined as “an emotional lic, and some professionals (e.g., Carter 2007).
injury motivated by hate or fear of a person or group Although there are limitations within the litera-
based on their race or ethnicity; a racially motivated ture, racist incidents can produce stress-like
stressor that overwhelms the capacity to cope; a responses that should be addressed by mental
racially motivated, interpersonal stressor that causes health professionals.
harm or threatens one’s life; or a severe interpersonal
or institutional stressor motivated by racism that
causes fear, hopelessness, or horror” (e.g., Bryant- Special Consideration for Couple and
Davis 2007, pp. 135–136). Family Therapy
Even though ethnic-minorities are at risk for both

Relevant Research experiencing and witnessing race-based traumatic
events daily, very few clinical resources exist to
Research on racial trauma suggests that exposure help address the symptoms related to racial trauma.
to racist incidents are widespread and can influ- This is primarily due to either clinicians failing to
ence the physical, emotional, behavioral, and conceptualize the experience of racism,
Adjunctive Psychopharmacology in Couple and Family Therapy 33
discrimination, and microaggressions, as a traumatic Fisher, C. B., Wallace, S. A., & Fenton, R. E. (2000).
experience, or clients not having the language to Discrimination distress during adolescence. Journal of
Youth and Adolescence, 29(6), 679–695.
describe the intensity of the pain related to racial Hardy, K. V. (2013). Healing the hidden wounds of racial A
trauma. Further, because many ethnic-minorities are trauma. Reclaiming Children and Youth, 22(1), 24–28.
used to their experiences being dismissed or Lee, L. J. (2005). Taking off the mask: Breaking the
invalidated, it is possible that ethnic-minority clients silence – The art of naming racism in the therapy
room. In M. Rastogi & E. Wieling (Eds.), Voices of
may avoid addressing their racial trauma entirely. color: First-person accounts of ethnic minority thera-
However, as our field strives to become culturally pists (pp. 91–115). California: Sage.
sensitive, it is imperative that clinicians are aware of, Utsey, S. O., & Payne, Y. A. (2000). Differential psycho-
sensitive to, and willing to unmask racial trauma in logical and emotional impacts of race-related stress.
Journal of African American Men, 5, 56–72.
the therapy room. The ability to conceptualize racist Utsey, S. O., Chae, M. H., Brown, C. F., & Kelly,
incidents as traumatic will further enhance the men- D. (2002). Effect of ethnic group membership on ethnic
tal health treatment of ethnic-minority children and identity, race-related stress, and quality of life. Cultural
their families. In addition, Lee (2005) suggests that Diversity and Ethnic Minority Psychology, 8, 366–377.
to be effective, power and privilege must be exam-
ined within the therapeutic context, and that denying
the existence and impact would be irresponsible
practice. As such, marriage and family therapists Adjunctive
should work to create a safe environment for Psychopharmacology in
ethnic-minority clients to process their personal Couple and Family Therapy
experiences of racial trauma. Further, it is important
that MFT’s be attune to brief moments of vulnera- Dixie Meyer and Stephanie Barkley
bility by the client, where healing conversations can Saint Louis University, Saint Louis, MO, USA
take place (Lee 2005). Several scholars such as
Bryant-Davis and Ocampo (2006), Carter (2007),
and Hardy (2013) have provided guidelines for Introduction
clinicians to address racial trauma and incorporate
the assessment of racial trauma within already This entry reviews five major categories of psy-
established treatment models. Clinicians are encour- chopharmacological medications used to treat
aged to seek further training so that they are pre- mood disorders, anxiety disorders, bipolar disor-
pared to address all forms of trauma that ethnic- ders, psychotic disorders, and attention-deficit/
minority clients may experience. hyperactivity disorder. The term adjunctive distin-
guishes how therapists should approach medica-
tion. Medication should be viewed as
References supplemental. Only one role of the therapist is as
medication manager with tasks like identifying
Bryant-Davis, T. (2007). Healing requires recognition: The target symptoms to treat with medications,
case for race-based traumatic stress. The Counseling assessing medication responsiveness, confirming
Psychologist, 35(1), 135–143. use as directed, coping with side effects, and
Bryant-Davis, T., & Ocampo, C. (2006). A therapeutic
approach to the treatment of racist-incident-based working with the prescribing physician.
trauma. Journal of Emotional Abuse, 6, 1–22.
Carter, R. T. (2007). Racism and psychological and emo-
tional injury: Recognizing and assessing race-based
traumatic stress. The Counseling Psychologist, 35, Theoretical Framework
13–105.
Contrada, R. J., Ashmore, R. D., Gary, M. L., Coups, E., The systemic perspective notes multiple influ-
Egeth, J. D., Sewell, A., et al. (2001). Measures of ences on the client. Therapists treat the whole
ethnicity-related stress: Psychometric properties, ethnic
group differences, and associations of well-being. Jour- family to use relationships to heal. Working with
nal of Applied Psychology, 31, 1775–1820. the family provides the best support for the
34 Adjunctive Psychopharmacology in Couple and Family Therapy
individual using psychotropic medication. Yet, methylphenidate (e.g., Ritalin and Concerta), are
the medical model should be incorporated into a first-line treatment. Stimulant medication treats
therapy to ensure the client is receiving the best hyperactivity/impulsivity or the combined type of
standard of care. For example, lithium has a suc- ADHD. Non-stimulant medications are used as
cess rate between 48% and53% of clients seeing alternative or adjuncts to stimulants. Non-stimulant
greater than 50% reduction of bipolar disorder medications include alpha-2A-adrenoceptor ago-
symptoms (Girardi et al. 2016). Anticonvulsants nist (e.g., Catapres, Intuniv), selective norepineph-
are effective in 41–53% of cases to reduce mania rine reuptake inhibitors (e.g., Strattera, Vivalan),
with a long-term effect size of about 10% (Poon and norepinephrine–dopamine reuptake inhibitors
et al. 2015). There are similar response rates (e.g., Wellbutrin). Non-stimulant medications treat
across antipsychotics. For example, 40–50% of the inattentive type of ADHD. Non-stimulants are
individuals with a psychotic disorder respond to used in combination with a stimulant to treat the
medication, 30–40% of individuals receive some ADHD combined type. Some side effects for both
symptom relief, and only 20% do not respond to stimulants and non-stimulants are typical like
antipsychotic medications (Smith et al. 2010). decreased appetite and disturbed sleep. Stimulants
Marrying the systemic and medical paradigms have black box warning for cardiovascular risks,
provides a framework that supports treating the and Strattera has a black box warning for suicidal
whole person. thoughts in youth.
Even with medication, 10–30% of individuals still

Rationale for Strategy meet criteria for ADHD (De Sousa and Kalra
2012). Some concerns that the therapist may
Psychotropic medications are frequently pre- address with the client and prescribing physician
scribed to treat mental health concerns. They are include selecting medication by symptoms and
consumed by all age groups. Approximately 3.5% ADHD type, length of time expected to be on
of children were prescribed stimulant medication medication, and side effects such a growth con-
in 2008 to treat ADHD (De Sousa & Kalra 2012). cerns. ADHD symptoms may overlap with other
Benzodiazepines (e.g., Xanax, Valium), associ- disorders (e.g., bipolar). Therapists need to be
ated with treating anxiety, are popular with 5.2% careful in their differential diagnosis to ensure
of adults using them (Olfson et al. 2015). Benzo- the client is receiving the correct treatment. If a
diazepines are about twice as common among client has a history of substance use, using a
women and, as individuals age, the rate increases stimulant medication may not be the best option
with 8.7% of the geriatric population using them. due to abuse potential. Therapists should be aware
Antidepressants are used by approximately 13% how family dynamics have shifted to accommo-
of Americans (National Health and Nutrition date and adjust to a family member living with
Examination Survey 2015). Given the high prev- ADHD. Examining the familial environmental
alence of individuals using psychotropic medica- spaces and how the individual functions across
tions, therapists need to understand their various settings will inform treatment. Including
responsibilities in helping clients manage their the family in the treatment process shifts the fam-
medications. ily dynamics. A lack of family therapy may result
in patterns and stressors that maintain symptoms.
Description of the Strategy Depression Antidepressants are prescribed for

mental health concerns like depression or anxiety
and physical health conditions like chronic pain or
ADHD Medications used to treat ADHD include menopause. There are a variety of antidepressants
stimulants and non-stimulants. Stimulant medica- including monoamine oxidase inhibitors (e.g.,
tions, amphetamine (e.g., Adderall) and Nardil, Marplan), selective norepinephrine reuptake
inhibitors, norepinephrine–dopamine reuptake inhib- depressive episode or those with chronic depres-
itors, serotonin–norepinephrine reuptake inhibitors sion, antidepressants can improve the quality
(e.g., Effexor, Cymbalta), selective serotonin reup- of life. A
take inhibitors (e.g., Prozac, Lexapro), serotonin
antagonists and reuptake inhibitors (e.g., Serzone,
Anxiety Disorders Anxiolytics, minor tranquil-
Desyrel), serotonin modulators and stimulators
izers, treat anxiety disorders. These medications
(e.g., Viibryd, Trintellex), tricyclic antidepressants
target the fight-or-flight response, fear, worry, and
(e.g., Anafranil, Elavil), and tetracyclic antide-
rumination associated with anxiety disorders.
pressants (e.g., Remeron, Asendin). Other types
These medications also treat seizure disorders,
of medications to treat depression or augment
insomnia, alcohol withdrawal, or muscle spasms.
antidepressants include atypical antipsychotics,
Other medications that treat anxiety include
thyroid medications, bipolar medications,
Buspar, barbiturates (e.g., Amytal, Prominal),
St. John’s wort, and SAMe. Antidepressants face
antidepressants (e.g., venlafaxine, Remeron),
controversy due to effectiveness concerns. Meta-
anticonvulsants (e.g., Lyrica, Neurontin), anti-
analyses demonstrate antidepressants may not
hypertensives sympatholytics (e.g., clonidine,
outperform placebo. Other concerns are related
propranolol), antihistamines (e.g., Atarax,
to increased risk of suicide among adolescent
Benadryl), and herbal remedies (e.g., kava,
users and usage of antidepressants in pregnancy
valerian root). Selecting a medication depends
being linked to birth defects and autism spectrum
on the length of need. Medications like barbitu-
disorders. Many side effects are typical of medi-
rates are highly addictive and can be lethal, so
cations like dry mouth, weight gain, or drowsi-
they are rarely prescribed for anxiety. Benzodi-
ness. However, some side effects can cause
azepines can also be addictive and should only
interpersonal problems like sexual side effects or
be prescribed for short-term daily use (i.e.,
are more serious like serotonin syndrome.
2–4 weeks, McIntosh et al. 2004). Benzodiaze-
pines are best prescribed on an as needed basis
Clients considering antidepressants should be
(e.g., during a panic attack). Antidepressant
informed about benefits and concerns. For exam-
medications are beneficial for long-term use to
ple, antidepressants do not outperform psycho-
treat anxiety.
therapy for treatment of depression (Weitz et al.
2015). When individuals do not respond to anti-
depressants, the reason for the lack of remission Benzodiazepines side effects can be typical
may be related to the impetus for depression. like dry mouth, headache, or upset stomach. How-
Research suggests individuals with a history of ever, these medications are not recommended
early life traumas may not respond to traditional when individuals need to be alert, use fine motor
antidepressants (Meyer 2014). Clients should be or cognitive skills. Other troubling conditions are
knowledgeable about the likelihood of needing related to long-term memory issues. Benzodiaze-
antidepressants in the future. About half of all pines can be habit forming. Therapists need to
individuals experiencing depression will not help clients monitor usage. Individuals may have
experience another episode. Yet, when individuals the urge to use benzodiazepines anytime anxiety
go off antidepressants, they are more likely to arises. However, therapists need to communicate
relapse. Most physicians will prescribe an antide- that the symptoms are an adrenalin rush. Helping
pressant beyond the traditional depressive episode clients to reframe the feelings as similar to exer-
lasting 6 months. For those individuals who may cise make the symptoms less scary. Benzodiaze-
not have another depressive episode, they are pines should not be used with alcohol; however,
potentially using a medication longer than needed often individuals use alcohol to self-medicate
and increasing their likelihood of developing their anxiety. This may be particularly dangerous.
another depressive episode. However, for the Benzodiazepines are not recommended in geriat-
half of individuals who will experience another ric population.
36 Adjunctive Psychopharmacology in Couple and Family Therapy
Not only because of genetic predispositions, cardiovascular risk, sleep disturbances, nausea,
depression and anxiety can be a mood shared vomiting, diarrhea, dizziness, drowsiness, and
among family members. While this demonstrates tremors. Therapists should be aware that each
empathy, it may be difficult when family members anticonvulsant effects the body differently. For
experience stress overload. Unfortunately, family example, Lamictal is often used to reduce recur-
members often only synchronize negative not rences of depression.
positive moods (Mancini and Luebbe 2016)
making it difficult for family members to help In consultation with a physician, therapists
their loved ones recover. For example, Nicolas have a responsibility to assess for medication
et al. (2009) found when a family member has appropriateness. Antidepressants should be used
depression, other family members are more likely with caution with bipolar disorder. Antidepres-
to develop mental health distress. When individ- sants should not be used with mania or mixed
uals are depressed, they become less socially episode, history of rapid cycling, and should be
responsive and display fewer positive nonverbal used if clients relapse into depression without an
behaviors adding strain to relationships. Strained antidepressant. Family members may be the first
relationships may increase one’s anxiety. As indi- to notice an individual is relapsing. Family ther-
viduals spend more time with others who cause apy may be a critical component of treatment to
them stress, the stress response may become the address symptom manifestation, increase family
homeostatic state. As individuals become more cohesiveness, and address how this disorder
stressed, they become more sensitive to stress affects the family. Family therapy may enhance
and more easily overload from stress. Working treatment, specifically if the family may be trig-
with a client and their family may be necessary gering symptoms. For example, clients from fam-
to teach the system relaxation techniques to create ilies with higher expressed emotion have a greater
a homeostatic state more tolerant of stress. likelihood of relapse and poorer treatment out-
comes. Implementing family therapy to impact
Bipolar Disorders Bipolar disorders medica- change at the familial level can increase the like-
tions include lithium, anticonvulsants, antipsy- lihood of success for the client.
chotics, and in some cases antidepressants.
Lithium is a standard treatment for bipolar disor- Psychotic Disorders Antipsychotic medica-
ders due to success with mania and reducing tions, known as major tranquilizers or neurolep-
suicidality. It is important that the therapist con- tics, treat psychotic disorders such as
sults with the prescribing physician to ensure schizophrenia or schizoaffective disorder. Older
blood levels and side effects are monitored. Lith- antipsychotic medications (e.g., Haldol,
ium can have severe side effects including dam- Thorazin) are often called conventional, typical,
age to physical health and cognitive impairments or first-generation antipsychotics, and newer med-
such as reduced vigilance, alertness, learning, and ications, atypical antipsychotics, are called
short-term memory. Other side effects include second- (e.g., Risperdal, Zyprexa) and third-
thyroid changes, minor cardiovascular changes, generation antipsychotics (e.g., Abilify). Older
rash and acne-like lesions, weight gain, and preg- medications treat the positive symptoms of
nancy problems. Adherence to medication is dif- schizophrenia, whereas the newer medications
ficult when the client is experiencing or fears side treat the positive and negative symptoms. There
effects. Open communication about what to are similar response rates across types of
expect can help reduce fears. Anticonvulsants antipsychotics.
are the second most common form of bipolar
medication. Anticonvulsants (e.g., Depakote, Antipsychotic medications have a range of side
Lamictal) are often prescribed to reduce mania effects. Some may be mild (e.g., headaches, dry
and work by calming the hyperactivity in the mouth, fatigue). However, all types of antipsy-
brain. Possible side effects include weight loss, chotics may produce dangerous side effects like
extrapyramidal symptoms (movement disorders). role in changing their lifestyle to support the client
Examples include dystonia (muscle spasms), and report concerns. The therapist needs to target
Parkinson-like symptoms (rigidity), tremors, building family bonds as individual who feel A
tardive dyskinesia (jerky movements), akathisia supported report fewer symptoms and relapse.
(restlessness), and bradykinesia (slowness in
movement). Extrapyramidal side effects may be
less frequent with atypicals; however, atypicals Case Example
may increase the risk of developing type 2 diabe-
tes. Other side effects include weight gain, hyper- Kim, a 20-year-old, Korean, female was diag-
lipidemia, gastrointestinal issues, sexual side nosed with schizophrenia in her first year in col-
effects, cognitive concerns, risk of seizure, and lege. After the diagnosis, she moved back home
cardiac dysfunction. The side effects may make with her parents. Kim wants to complete college,
it difficult for individuals to adhere to treatment, but struggles with paranoid delusions. Her delu-
although, most tolerate atypicals more easily than sions are exacerbated when she does not take
typical antipsychotics. medication, but she is concerned the medication
Taking antipsychotic medications may be dif- is poisoning her. Kim’s parents initiated Kim’s
ficult for individuals as some medications therapy to improve medication adherence. In ther-
require behavioral changes multiple times per apy, Kim noted her parents were treating her like a
day (i.e., a large caloric intake at ingestion, no child, stated her goal to live on her own, and
smoking). Individuals needing antipsychotics indicated how terrible her medication made her
usually require multiple medications to manage feel. The therapist suggested Kim’s parents attend
symptoms and side effects, thus, contributing to therapy. The parents noted concerns about Kim’s
more planning difficulties. Other medication ability to live alone if she will not take her med-
adherence challenges include delusions about ication. They were concerned Kim would be con-
the medication, medication affordability, lack fused and hurt herself. Kim felt that they did not
of consistent routine, chaotic home life, lack of trust her. The therapist began by rebuilding the
social support, loss of autonomy, side effects, relationships between Kim and her parents. The
and substance use. Individuals not compliant therapist reframed the parental overprotection as
with medications risk relapse, poor insight, men- concern, provided Kim an outlet to express inde-
tal clarity issues, high-risk behaviors, increased pendence and voice medication concerns. Kim,
aggression, violence, substance use, hospitaliza- her parents, and the therapist met with Kim’s
tion, worse prognosis, and even suicide. Therapy psychiatrist to express concerns about treatment
is an opportunity to confront challenges and adherence, side effects, and Kim’s other medica-
brainstorm solutions. tion concerns. The psychiatrist switched Kim to
Despite challenges, most individuals report another atypical antipsychotic and used a long-
reduce symptoms and lead a more normal life. lasting injectable to improve adherence. The psy-
Improving quality of life requires the client to have chiatrist prescribed a medication to treat side
a good relationship with the therapist and physician. effects and a benzodiazepine for Kim to use
The client needs to communicate their concerns when overwhelmed by her thoughts. The therapist
with their physician and therapist. The therapist started weekly sessions with a medication check-
will see the client more frequently than the physi- in for Kim to voice concerns and the therapist to
cian, thus, may recognize an increase in symptoms assess for medication dependence. Kim moved
before they become problematic. Family therapy into an apartment over her parents’ garage. It
may help to reduce symptoms, alleviate side effects, gave her freedom, but Kim also agreed to have
improve medication adherence, establish patterns of dinner with her parents every night. This ensured
support, foster relationships, develop routines, rec- her parents could provide support, check for
ognize relapse, and help individuals stay socially relapses, and confirm Kim was using her medica-
connected. The family may need to take an active tions as directed.
38 Adlerian Family Therapy
References and the nature of goal-oriented behavior. Adler’s

work also underscores the importance of commu-
DeSousa, A., & Kalra, G. (2012). Drug therapy of attention nity feeling and the necessity of a cooperative
deficit hyperactivity disorder: Current trends. Mens
attitude among community members. He recog-
Sana Monigraphs, 10, 45–69.
Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). nized that individuals are socially embedded
Lithium in bipolar disorder: Optimizing therapy using organisms each striving to enhance quality of
prolonged-release formulations. Drugs in R&D, 16, life while overcoming states of burden and
293–302.
unpleasantness (Adler 1935). Adler recognized
Mancini, K., & Luebbe, A. (2016). Dyadic affective flex-
ibility and emotional inertia in relation to youth psy- the importance of early childhood experiences in
chopathology: An integrated model at two timescales. setting the foundation of the individual’s style of
Clinical Child and Family Psychology Review, 19, life, including the establishment of personal con-
117–133.
victions, beliefs, feelings, and values.
McIntosh, A., Cohen, A., Turnbull, N. et al. (2004). Clin-
ical guidelines and evidence review for panic disorder Adler, along with his students and colleagues,
and generalised anxiety disorder. National Collaborat- established over thirty Child Guidance Clinics
ing Centre for Primary Care. throughout the area of Vienna, Austria, during
Meyer, D. (2014). Candidates for Antidepressants: Assessing
the early decades of the twentieth century
a history of early life stressors CounselingVistas.
Retrieved from http://www.counseling.org/docs/default- (Dreikurs 1958). He welcomed the general public
source/vistas/article_65.pdf?Sfvrsn=8 to come for assistance with family matters and to
Nicolas, G., Desilva, A., Prater, K., & Bronkoski, observe the practice of AFT. By 1934, Hitler’s
E. (2009). Empathic family stress as a sign of family
Nazi party had eradicated these clinics (Dreikurs
connectedness in Haitian immigrants. Family Process,
48, 135–150. 1958; Christensen 2004) and what was a building
Olfson, M., King, M., & Schoenbaum, M. (2015). Benzo- movement in Individual Psychology was stalled
diazepine use in the United States. JAMA Psychiatry, for many years. To escape the Nazi occupation,
72, 136–142.
Adler and many of his followers left Austria,
Poon, S., Sim, K., & Baldessarini, R. (2015). Pharmaco-
logical approaches for treatment-resistant bipolar dis- many immigrating to the United States. Adler
order. Current Neuropharmacology, 13, 592–604. himself intended a move to New York City but
Smith, T., Weston, C., & Lieberman, J. (2010). Schizo- died of a heart attack while lecturing in Scotland
phrenia (maintenance treatment). American Family
in 1937 prior to his permanent move to the United
Physician, 82, 338–339.
Weitz, E., Hollon, S., Twisk, J., et al. (2015). Baseline States.
depression severity as moderator of depression out-
comes between cognitive behavioral therapy
vs. pharmacotherapy: An individual patient data meta-
analysis. JAMA Psychiatry, 72, 1102–1109. Prominent Associated Figures
Alfred Adler, Rudolf Dreikurs, Ray Lowe, Oscar

Christensen, Bronia Grunwald, William and Mim
Adlerian Family Therapy
Pew, Don Dinkmeyer, Jane Nelson, Michael
Popkin, Frank Walton, Raymond Corsini,
Erin J. Schuyler and Paul Rasmussen
Manford Sonstegard, and James Bitter.
Adler Institute, Columbia, SC, USA
Introduction Theoretical Framework
Alfred Adler (1870–1937) was one of the first Basic principles of AFT were derived from The
psychiatrists to use a systemic approach in psy- Individual Psychology of Alfred Adler (Ansbacher
chotherapy (Carich and Willingham 1987). Adler and Ansbacher 1956). These assumptions about
pioneered a holistic approach to therapy human nature are reflective of socially embedded
highlighting the complexities of family dynamics individuals whose actions, decisions, and
Adlerian Family Therapy 39
psychological movement have purpose and mean- and become concerned with issues of fairness;
ing (Dinkmeyer et al. 1979). may feel cheated by the circumstances of life.
Law of movement. Adler argued that move- The youngest tends to be more dependent, socia- A
ment is the most important aspect of life; when ble, and are often the most pampered while find-
movement ends, life ends. Movement is reflected ing their niche apart from older siblings. The only
in how one strives for feelings of worth and secu- child shares characteristics of the oldest, yet tends
rity. Feelings of validation emerge from one’s to be more pampered and may have difficultly
sense of value, satisfaction, and status. Each indi- cooperating with others. Because age differences
vidual within a family strives to discover sources and gender differences can impact the influence of
of worth and validation by developing strategies birth order, psychological birth order is thought
for procuring positive outcomes and ways to over- more important that ordinal birth order.
come challenges. Discipline. Children learn best by way of log-
Purposive behavior/teleology. Movement is ical and natural consequences; consequences that
goal-oriented. The term teleology refers to the are related in no unambiguous or indirect way to
striving for optimal existence that characterized the misdeed. The alternative is arbitrary conse-
all living organisms. As each self-determined goal quence, such as physical discipline, which leads
is subjective, behavior is purposeful without nec- to relationship problems and fails to meet the
essarily being conscious and intentional. Mis- objective of teaching discipline. Dreikurs (1967)
taken beliefs are impacted by this movement and recognized that children, as well as adults, often
influence an individual’s behavior. garner validation and relief from burden via the
Holism. AFT is a holistic approach focusing quest for attention, power, revenge, and via dis-
on the totality of the individual and the totality of plays of inadequacy. While these motives often
the family unit. This includes biological factors, lead to some degree of validation and some relief
personal perceptions and unique interpretations, from burden, lack of cooperation and contribution
and the interactions between the family members, create problems for the individual and too often
not excluding the impact of influences outside of for the individual’s community (e.g., family and
the family such as their social community. later perhaps school).
Phenomenology. Reality is shaped by an indi-
vidual’s interpretation of the world. An individ-
ual’s view of life is subjective and beliefs and Populations in Focus
opinions are not required to match the view of
others. Clashes occur when the interpretations and Adlerian-based parent education (child-guidance)
expectations of one conflict with those of another. and AFT is focused on helping care providers
Family constellation. Each member of a fam- meet the task of raising children who are prepared
ily influences the lives of each other. The constel- to meet the demands of living with others in a
lation of the family includes parents, children, civilized society. While parents cannot control a
extended family members, and other care pro- child’s behavioral choices, they are leaders
viders. Understanding a family’s constellation responsible for creating a cooperative family
provides information of each person’s position atmosphere characterized by encouragement,
and role within the family. While we accept the cooperation, and accountability.
differences as only tendency rather than absolute,
Adler pointed out that oldest children tend to be
more traditional and conservative and are more Strategies and Techniques Used
inclined to follow established rules and satisfy the in Model
expectations of authority figures. Second born
children tend to be less concerned with power AFT is primarily educational, assuming that prob-
and tend to be more competitive and ambitious. lems emerge because members of the family are
Middle children often feel lost in their position discouraged about their place in that family and
40 Adlerian Family Therapy
have embraced strategies that are optimally counter- and move towards fostering positive interactions
productive. between one another. Reorientation requires consid-
Forming a relationship. The therapist gener- eration of alternative beliefs, attitudes, behaviors,
ally interviews parents without children present. and goals that are both realistic and effective. Chil-
Supporting parents as leaders of the family, family dren will learn to take on responsibilities and com-
constellation and routines are explored. During plete unpleasant tasks while cooperating with
the parent interview, rapport is built by demon- others. Parents model respect by allowing children
strating a relaxed interactional dialogue, a friendly to make choices and face logical and natural conse-
and open demeanor and the display of empathy quences of those choices. The parents are encour-
and understanding concerning the family’s situa- aged to withhold criticism, ridicule, coercion, and
tion. This collaborative approach models respect, harshness.
optimism, and encouragement among family An effective therapist educates as necessary and
members. Similarly, children are then interviewed continually encourages. The therapist assigns activ-
to gain insight on their collective and individual ities that build on the strengths of each family mem-
perspectives of the family system. ber and reveals the counter-productive motives.
Psychological investigation. The therapist
continues to collect pertinent facts among family
Research About the Model
members and focuses on the current situation. The
therapist observes and assesses each individual’s
Numerous studies have researched elements of
place and role within the family constellation. Psy-
Adlerian theory, including encouragement, birth
chological birth order (vs. ordinal order), roles
order, social interest, and early recollections
adopted within the family, family values, hierarchi-
(Carlson et al. 2006; Evans et al. 1997; Phelps
cal patterns, and individual niches are considered.
et al. 2001; Watkins and Guarnaccia 1999; Watts
Exploring each family member’s style of movement
and Shulman 2003; Wong 2015). Adlerian psy-
within and outside the family provides valuable
chology is grounded in holistic, optimistic, pur-
information that guides the next phase of therapy.
poseful, and socially embedded theories. These
Disclosure/interpretation. A working hypoth-
basic assumptions of Adlerian psychology and
esis is derived by examining each member’s style
practice are woven throughout various therapeutic
of behavior and contribution to the family system.
orientations, including cognitive-behavioral, pos-
It is essential to address the hidden goals of both
itive psychology, multicultural theory, solution-
parents and children and identify the misdirected
focused theory, and attachment theory. Moreover,
goals, while promoting cooperation among family
practitioners who emphasize individual psychol-
members. Parents are encouraged to consider the
ogy display inherent qualities required throughout
motives behind a child’s behavior, underscoring
the therapeutic process, possess sophisticated set
the child’s desire to belong and feel of value.
of interpersonal skills, offer adaptive explanation
Through appropriate interpretation and subtle
for discouragement, and adjust treatment as
confrontation, family members are able to
needed to fit the client’s goal (Anderson
develop insight concerning their motives and
et al. 2009; Duncan et al. 2010; Neukrug 2010;
harmony-defeating behaviors.
Norcross 2011).
Reorientation. The final phase encourages indi-
viduals to take action and apply what they have
discovered about themselves. Self-awareness will Case Example
ultimately improve during therapy; however, actual
change occurs outside of sessions as family mem- Tom, Susan, and their three children attend their
bers engage with each other. They are encouraged to first session. The therapist meets with parents to
reorient their goals and decision-making process get their observations. They express primary
Adlerian Family Therapy 41
concerns with their middle son, Jonah, who is because school work is your sister’s thing.”
preforming poorly at school and is antagonistic These observations question Jonah’s effort to
with his sisters. assert power and his assumed inadequacy A
Tom does most of the talking and describes when it comes to school work. His belief as the
difficulty managing his time at home and work; only son is verbalized as “I should be in charge
typically works 65 h a week and has minimal and should be smarter, but I can’t function at my
time to engage with his children. Tom notes that sister’s level.” The therapist pays attention to
he relies on Susan to mange the children. Susan each child’s reaction to the interpretation. For
is responsible for much of the child rearing, and Jonah, he discloses feeling more pressure than
while she loves her role as a mother, she is his sisters to do well in school and makes up for
overwhelmed with juggling family life and her it by acting out. The therapist also comments on
own job. Susan works 35 h a week in addition to the frustration that Stacy is feeling given she
“making sure their household runs smoothly.” does well at school, tries to be helpful at home,
Parents agree that while their daughters are gen- and often feels like her efforts are
erally easy to manage, Jonah refuses to do unappreciated. Stacy appreciates that her efforts
homework, antagonizes his sisters, and talks are finally acknowledged. The therapist also
back to his mother. It is noted by the therapist comments on Beth’s curiosity about what all
that Tom did most of the talking, despite being the fuss is about. She smiles.
less involved with the children. This suggests a Understanding the motivation behind mis-
pattern of how men behave (dominant) and how behavior allows opportunities to encourage
women behave (dutiful and obedient). reorientation. Together, the therapist and family
Interview with the children reveals they are members offer suggestions and realistic goals.
here because their mom told them they were The therapist works with Tom and Susan to equal-
coming – a common response. Stacy, age six- ize the power balance within the family and to
teen, states the problem is not with her, but her create logical consequences for Jonah should he
brother. Jonah, age twelve, does not respond and not complete homework. Tom agrees to set special
is clearly unhappy being there. Beth, age eight, time aside for each child throughout the week.
smiles and seems to think the whole endeavor to Susan is more aware of Stacy’s frustration and
be entertaining. From this interaction, the thera- gives her some personal time to spend with
pist saw Stacy as the obedient, compliant child friends. Goals are now aligned for this family.
who also tends to be a bit bossy. Jonah, as a Until the next session, each member will be
second born, has taken a different path to estab- encouraged to take on responsibility of meeting
lish his independence; this includes acting dom- their tasks, respecting the differences everyone
inant and rebuffing schoolwork. Beth has taken experiences, cooperating with each other as they
on the role of entertainer. navigate new behavioral choices, and to be cou-
The therapist evaluates family values, par- rageous as their family adapts and reorients to new
enting style, and roles within the family constel- methods of thinking and behaving.
lation and provides observation/interpretation
of the goals of each member. The therapist
then offers observations and looks for signs of Cross-References
recognition to confirm or dismiss the observa-
tion. For Jonah, the therapist might offer the ▶ Family Rules
following observation: “You seem to have ▶ Family Structure
taken on the role of the man in the family when ▶ Modeling in Couple and Family Therapy
your dad is away and like to call your own shots, ▶ Parenting Skills Training in Couple and Family
but I also wonder if you don’t do your homework Therapy
42 Adolescents in Couple and Family Therapy
References
Adolescents in Couple and
Adler, A. (1935). Fundamental views of individual psy- Family Therapy
chology. International Journal of Individual Psychol-
ogy 1(1), 5–8. Retrieved from https://journal-of-
individual-psychology.scholasticahq.com/ Thomas L. Sexton
Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., FFT, Bloomington, IN, USA
& Vermeersch, D. A. (2009). Therapist
effects: Facilitative interpersonal skills as a predictor of
therapist success. Journal of Clinical Psychology, 65,
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Ansbacher, H. L., & Ansbacher, R. R. (1956). The individual
psychology of Alfred Adler. New York: Basic Books. Adolescents in Families
Carich, M. S., & Willingham, W. (1987). The roots of family
systems theory in individual psychology. Individual Psy-
chology, 43(1), 71. Retrieved from https://journal-of-
individual-psychology.scholasticahq.com/
Introduction
Carlson, J., Watts, R. E., & Maniacci, M. P. (2006). Adle-
rian therapy: Theory and practice. Washington, DC: The systemic approach of couple and family ther-
American Psychological Association. apy has always viewed adolescents as a central
Christensen, O. C. (2004). Adlerian family counseling
part of how families function, struggle, and are
(3rd ed.). Minneapolis: Educational Media Corp.
Dinkmeyer, D., Pew, W., & Dinkmeyer, D. (1979). Adle- able to ultimately make successful clinical
rian counseling and psychotherapy. Monterey: Brooks. changes. Life cycle models of family develop-
Dreikurs, R. (1958). The challenge of parenthood ment suggest that the stable relational patters
(rev. ed.). New York: Hawthorn.
established in families can be disrupted as youn-
Dreikurs, R. (1967). Psychodynamics, psychotherapy, and
counseling. Chicago: Alfred Adler Institute of Chicago. ger children become adolescents. Changing ado-
Duncan, B., Miller, S. D., Hubble, M., & Wampold, B. E. lescent behavior and the ability of the family
(Eds.). (2010). The heart and soul of change: Deliver- relational system to adapt can be critical stress
ing what works (2nd ed.). Washington, DC: American
points for families. In some cases, adolescent
Psychological Association.
Evans, T. D., Dedrick, R. F., & Epstein, M. J. (1997). behavior and the resulting reactions from parents
Development and initial validation of the encourage- create family conflict, negativity, and within-
ment scale (educator form). The Journal of Humanistic family blame that make it difficult for families
Education and Development, 35, 163–174. https://doi.
to successfully solve daily problems. In some
org/10.1002/j.2164-4683.1997.tb00366.x.
Neukrug, E. (2010). Counselling theory and practice. cases, adolescent behavior problems emerge
Brooks/Cole. Pacific Grove, CA. overwhelming the family’s ability to manage.
Norcross, J. C. (Ed.). (2011). Psychotherapy relationships The behavioral expression of a youth’s struggles
that work (2nd ed.). New York: Oxford University Press.
can result in violence, criminal behavior, and
Phelps, R. E., Tranakos-Howe, S., Dagley, J. C., & Lyn,
M. K. (2001). Encouragement and ethnicity in African other consequences for not only the youth but
American college students. Journal of Counseling & also those in the families and community. This
Development, 79, 90–97. https://doi.org/10.1002/ makes youth problems a systemic one affecting
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not only individuals and a likely time for
Watkins, C. E., & Guarnaccia, C. A. (1999). Introduction:
The future of psychotherapy training: Psychodynamic, community-based intervention. For adolescents
experiential, and eclectic perspectives. Journal of and families, this usually means struggles with
Clinical Psychology, 55(4), 381–383. https://doi.org/ the justice system and educational system or
10.1002/(SICI)1097-4679(199904)55:4<381::AID-JCLP
involvement in the mental system.
1>3.0.CO;2-I.
Watts, R. E., & Shulman, B. H. (2003). Integrating Adle- Adolescent behavior problems are one of the
rian and constructive therapies: An Adlerian perspec- most difficult and pervasive of those faced by
tive. New York: Springer. prevention and treatment specialists in the mental
Wong, Y. (2015). The psychology of encouragement: The-
health field (Sexton and Alexander 2006). Schools
ory, research, and applications. The Counseling Psy-
chologist, 43(2), 178–216. https://doi.org/10.1177/ and community-based mental health and counsel-
0011000014545091. ing services face growing referrals of adolescents
Adolescents in Couple and Family Therapy 43
with a wide range of complex clinical problems. Relevant Research

In fact, survey data gathered over the last decade
suggest that the range of adolescent behavior Adolescent Behavior Problems A
problems including drug use/abuse, violence and The behavior problems of adolescents are of sig-
school-related behavior problems, as well as sui- nificant concern in schools, families, and for com-
cide, depression, and anxiety are widespread in munities. Conduct problems of adolescents and
adolescents of all cultures, ethnicities, and from children are the most common referrals to mental
all communities (Sexton and Alexander 2006). health clinics in the Western hemisphere (Sexton
Couple and family psychology brings a and Alexander 2006). Youth who fall into the
unique systemic perspective to understanding broader category of externalizing problems
and helping youth and families (Sexton and account for between one third and half of all
Stanton 2016). The systemic theoretical models child and adolescent clinic referrals (Kazdin
of CFP bring a unique relational perspective to et al. 1992; Sexton et al. 2005).
understanding youth behavior as part of a larger One perspective in understanding problematic
family relational system that serves to both adolescent behavior is the individually focused
maintain problems and as the most likely place diagnostic approach. From this perspective
for lasting clinical intervention. The evidence- adolescent behavior problems are often described
based family-focused clinical treatment models as adolescent-focused. There are two broad cate-
for adolescents, which are based on systemic gories: internalizing and externalizing problems.
theoretical principles, have strong research Internalizing disorders are problems internally
foundations of community-based studies in directed and include clinical symptoms: anxiety,
diverse real-life settings (Sexton et al. 2012; withdrawal, and depression. Internalizing disor-
Sexton and Datachi 2014). As a result, CFP ders are problems internally directed and include
offers a unique platform for understanding ado- clinical symptoms which are anxiety, withdrawal,
lescent behavior (whether problematic or not) and depression. These adolescents are easily over-
and illuminating a pathway for successfully pre- looked in families, schools, and communities;
venting and intervening to help families over- however, the impact of internalizing problems in
come struggles related to adolescence. adolescents is signification in regard to later men-
tal health adjustment, school success, peer strug-
gles, and even teen suicide. In addition,
Description internalizing problems of adolescent can set a
pattern of psychological and behavioral function-
This chapter will briefly focus on the scope of ing that becomes a lifelong pattern of struggle.
issues facing adolescents and families, a systemic Externalizing disorders are those directed to
perspective for understanding family and youth others and the environment. They include oppo-
clinical problems, and a brief overview of suc- sitional, hyperactive, aggressive, and antisocial
cessful ways of clinically intervening with these behaviors. Numerous psychiatric diagnostic cate-
complex issues. The goal is to illustrate the unique gories encompass these areas including attention-
contribution of CFP-based theoretical models and deficit and disruptive disorders. Youth referred to
clinical intervention programs that are specifically the mental health and juvenile justice systems are
aimed at understanding and successfully helping most likely to be ones who fall into the external-
families successfully deal with adolescent behav- izing behavior disorders category (cite the other
ior problems. As such, the focus of this discussion chapter). Early-onset (childhood onset) problems
is on the systemic and relational theoretical that begin in early childhood escalate into more
models understanding problematic youth behav- violent behavior later. Only about 20–40% of the
ior and the evidence-based treatment prevention male adolescent in this category become serious
and intervention programs for helping youth and offenders later in life. Later-onset (adolescent
families. onset) problems that are not there in younger life
are there to appear in adolescent years. Between any other area of psychology, the domain of ado-
60% and 80% of youth these youths are later lescent behavior problems has seen the develop-
identified as serious offenders. ment, maturation, and growth of a number of
A third, frequently overlooked group are at risk successful “evidence-based” treatment programs
adolescents. The problems experienced by youth (Sexton et al. 2011). Of the prevention and treat-
who do not meet the criteria for either internal or ment programs options currently available the
externalizing behavior problems may engage in outcomes suggest that, when implemented with
problem behaviors that put them at risk for model fidelity and clinical competence that youth
becoming involved in the mental health or juve- and families can change drug use and abuse prob-
nile justice system or to experience future psychi- lems, reduce violence, less frequently enter the
atric problems. These youths might be involved in justice system, and when they do, improve to the
truancy, vandalism, stealing, drug use, bullying, degree that they can successfully function in
running away from home, etc. These data led schools, with peers, and in communities (Sexton
Kazdin (2018) to suggest that prevalence rates et al. 2012; Sexton and Datachi 2014).
for youth behavior problems substantially under- Evidence-based treatment and prevention pro-
estimate the scope of the existing problem. It is grams have also been successfully implemented
important to understand these adolescents in local communities and some across entire state-
because this is the population toward which pre- wide systems of care with impressive results. The
vention efforts can be directed to prevent the evolution of evidence-based prevention and treat-
internalizing and externalizing behavior patterns. ment programs for adolescent behavior problems
Equally troubling are the significant number of fits within a broader movement of evidence-based
adolescents in need of mental health treatment. model development in medicine, psychology, and
Epidemiological studies suggest that between other social services (Sexton et al. 2011). There
17% and 22% of adolescents suffer from a signif- are many different prevention and treatment pro-
icant developmental, emotional, and/or behav- grams in the professional literature (Elliott 1998
ioral problem (Kazdin and Whitley 2003). High estimates over 1000); however, few have enough
rates of mental disorders also exist among youth external evidence to suggest that they are effec-
involved in the juvenile justice with an estimated tive. The most effective are family-based or fam-
50–80% of delinquent adolescents meeting the ily therapy intervention programs that are central
criteria for a mental disorder such as conduct- or to CFP.
substance-related disorders (Kazdin 2018). The
economic is significant. Each year, an estimated
600,000 youth cycle through detention centers, Special Considerations for Couple and
with more than 70,000 youth in a juvenile correc- Family Psychology
tional setting on any given day. Generally, though,
involvement in the juvenile justice system has There are two primary implications of the research
been shown to have long-term detrimental effects on adolescents and adolescent problems and
and makes youth more prone to future antisocial effective clinical intervention programs: youth
behavior or criminal activity. Adolescents in the problems are significant, and there are well-
juvenile justice and mental health systems alone established intervention programs that work better
account for billions of dollars in costs to taxpayers than nonspecific approaches (Sexton et al. 2012);
and communities (Elliott 1998). and to be effective, it is important to take a sys-
temic/relational view of the family functioning
Family-Based Treatment Approaches for and clinical problems.
Adolescent Problems
Family therapy plays a central role in the success- Taking a Multisystemic Perspective
ful treatment family conflict and the resulting It is a challenging task to identify and describe
youth behavior problems. Probably more than in youth behavior problems because to a certain
extent, externalizing behaviors is part of the the origins and the facilitating features of these
normal developmental trajectory of the youth. chronic behavioral problems. In this view, it is the
Oftentimes these children are simply labeled as risk and protective factor that operates within and A
having “dysfunctional” behavior. However, it around a core family relational system that serves
should be recognized that they actually have as the most comprehensive way to understand
very complex behavioral profiles and are problematic adolescent behavior.
undoubtedly experiencing a wide range of devel- Risk and protective factors. Risk and protec-
opmental, emotional, and behavioral problems. tive factors approach, based on an established
For example, part of normal adolescent develop- body of etiological research, integrates the epide-
ment includes fighting, withdrawing, disagreeing, miological research into a developmental and
and standing up to authority figures. While helpful multisystemic perspective that enhances success-
in understanding community prevalence rates, ful intervention (Sexton and Turner 2010). Risk
this approach is limited in its individual orienta- and protective patterns describe alterable behav-
tion and lack of help in identifying clinical interior, rather than “labeling” the youth or family with
vention strategies. They are also limited in their characteristics that become stable and enduring.
individually focused scope that often misses fac- This model helps organize the complex informa-
tors in the large social context, within family tion from the multiple systems (individual, family,
factors, or normal family development (Sexton and social). It is a useful way of thinking about
and Alexander 2006). For example, it is not easy problems because it describes them through a
to determine if an oppositional youth is going “probability lens” (determining the likelihood of
through normal adolescent developmental phases problems), rather than in terms of causal relation-
or if those behaviors represent the onset of more ships. The risk and protective factors model can
significant issues. Does fighting, withdrawing, be helpful in organizing critical information, such
disagreeing, and standing up to authority figures as how the multiple systems function in regard to
represent behaviors that are often part of normal difficulties as well as strengths. It allows the inter-
adolescent development? Identification is made ventionist to identify which factors to develop,
even more complex by the various systems in which to work around, and which to attempt to
which with similar behavior problems are identi- decrease. The risk and protective factor approach
fied and the different labels given by these sys- helps define the outcomes of prevention and ther-
tems for similar behaviors (e.g., child welfare, apy for children with these types of problems.
juvenile justice, or mental health). What might Many risk factors are not changeable (e.g., unem-
be considered criminal behavior in the juvenile ployment, biological predisposition, and rela-
justice system is often seen as a mental health tional histories). Thus, successful intervention
disorder in the community mental health center. with adolescent behavior problems involves
While the acting-out behaviors exhibited by these building protective factors to overcome some of
children appear quite similar, each case is unique the more static risk factors. In this way, interven-
in that the behaviors occur at very different times tion focuses on building the resiliency of the child,
in the biological development of the youth and parents, and family.
within very different environmental and family A comprehensive risk-and-protective-factor
contexts. view identifies risk and protective factors in each
CFP has offered a unique and comprehensive of the three areas: individual factors, family fac-
multisystemic approach to understanding adoles- tors, and social factors. These include (1) child
cent behaviors that both help identify how risk variables, including a difficult temperament
problems emerge and where the clinical interven- or high rate of disruptive, impulsive, inattentive,
tion points may be to successfully help family and aggressive behaviors (Campbell and Ewing
relational system adjust and adapt. A CFP, multi- 1990); (2) parenting variables, including ineffec-
systemic approach considers the biological, fam- tive parenting strategies and negative attitudes
ily, and social factors that help explain both (Patterson and Stouthamer-Loeber 1984); and
(3) family variables, apart from the parent–child important when working with adolescents. The
relationship, which include parental psychopa- CFP evidence-based approaches briefly described
thology, marital factors, socioeconomic factors, below illustrate a wide range of reliable, community-
and other stressors (Webster-Stratton 1990). tested programs that, when implemented with
The central role of families. A systemic per- fidelity, result in positive changes of youth and
spective would suggest that within family, risk families.
and protective factors are critical to understand Early prevention approaches. Certain
adolescent behavior (Sexton and Turner 2010). It evidence-based prevention programs have repeat-
is well-accepted that families characterized by edly demonstrated the critical importance of later
conflict (anger and aggression), deficient parent- adolescent behavior on the early family relation-
ing, and family interactions that are cold, ship system and parenting activities. These early
unsupportive, or neglectful contribute to child- prevention efforts are remarkable in that they
hood psychopathology (Knutson et al. 2004). show that changes in the family relational system
For example, as youth struggle, in what are during the infancy period as well as preschool
many times very normal ways, the relational sys- years have demonstrated a considerable reduction
tem around the youth and the family begins to in adolescent behavior problems, particularly for
strain the individual’s and family’s capacity to families at greater social risk (e.g., related to low
manage outside stressors. The decline of these SES and unmarried mothers, weak parental
abilities results in changes in the relational sys- involvement, low educational attainment, marital
tems that develop around the specific behaviors of discord) (Bor 2004; Olds et al. 1998). Two best
the youth. Finally, these stabilized relationships practices for the prevention of adolescent conduct
are connected to the chronic nature of the youth’s problems are early childhood home visitation and
conduct problems. Furthermore, family dynamics the Triple P (“Positive Parenting Program”).
that is unresponsive or rejecting of children likely Nursing Home Visitation Program is designed
exacerbates children’s genetic or temperamental both to promote maternal health-related behaviors
diathesis to the development of conduct disorders early in the child’s life, as well as to promote
and aggression (Repetti et al. 2002). Protective maternal long-term self-development through
parenting factors include the quality of maternal family planning, educational achievement, and
instructions, frequent joint activities, monitoring, participation in the work force. At 15-year follow-
structuring the child’s time, and constructive dis- up, child outcomes (in adolescence) of the nurse
cipline strategies (Hutchings and Lane 2005). home visitation program were observable: fewer
episodes of running away from home, fewer
Intervention Programs arrests and convictions (e.g., recurrent truancy,
The sections below are intended to be an overview destroying parents property), fewer violations of
of the range of types of intervention types of probation, fewer sexual partners, and less frequent
family therapy-based interventions for helping engagement in smoking and alcohol consumption
with adolescent behavior problems, not a system- (Olds et al. 1998). Given these clinical outcomes,
atic review. As noted above, the goal is to illus- it is clear that changing the family relational envi-
trate the central role that CFP models play in the ronment early in life can have an impact on later
treatment of these difficult issues. For a compre- adolescent certain antisocial behaviors.
hensive overview, please note the references Parent skills training. A second set of catego-
below. It is also important to note that the lack of ries of clinical interventions focus on helping par-
research evidence does not mean that a clinical ents with skills to change the ways in which they
intervention approach does not work. Couple and work with their adolescents. Hutchings et al.
family therapy has an impressive research foun- (2004) identified six essential components of par-
dation demonstrating its effectiveness (Sexton enting interventions for the treatment of conduct
et al. 2012). Common factors, or those core disorder: (1) the rehearsal of new parenting skills,
elements of any good therapy, are particularly (2) the teaching of management principles rather
than techniques, (3) the practice of new parenting 3–18) and their families overcomes the experience
strategies at home, (4) the teaching of both of trauma. TF-CBT consists of 12–16 sessions
(nonviolent) sanctions for negative behavior and delivered once a week. A
strategies to build positive relationships, (5) the Multidimensional family therapy (MDFT ) is a
addressing of difficulties in the parental relation- rigorously studied outpatient treatment that inte-
ship, and (6) the early delivery of interventions, as grates family therapy, individual therapy, drug
later interventions are less effective. counseling, and multiple systems-oriented inter-
Psychoeducational approaches. Psycho- vention approaches to treat adolescent drug abuse
education treatment use information and educa- and related emotional and behavioral problems
tion to change youth behaviors with the intent to (Liddle et al. 2002). MDFT builds on knowledge
prevent adolescent behavior problems. For exam- derived from research on risk and protective fac-
ple, the Life Skills Training Program (LST) targets tors related to youth substance abuse in formulat-
middle- and junior high school youth in the pre- ing its assessment and intervention techniques. It
vention of tobacco, alcohol, and marijuana use targets multiple aspects of youth presenting prob-
and abuse through the development of skills that lems through four interdependent modules that
reduce the risk of engaging in high-risk activity together form the adolescent’s psychosocial
(Botvin and Kantor 2000; Botvin 1998). The pro- world, each of which contribute to maintaining
gram consists of three components: drug-related the problematic behavior.
knowledge and skills, personal self-management, Multisystemic therapy (MST) is systematic,
and general social skills. The drug-related knowl- manual-driven, family-based intervention for
edge and skills component targets knowledge and youths and families facing problems of juvenile
attitudes related to drug use through drug educa- delinquency, adolescent conduct disorder, and
tion, discussion of norm expectations related substance abuse (Henggeler et al. 1999). MST
to drug use, and the teaching of skills to resist is an approach derived from social-ecological
media influences as well as peer and social pres- models of behavior, family systems, and social
sures related to drug use. The personal self- learning theories (Henggeler et al. 1993). Targets
management component targets the development of change in MST include individual- and
of skills in decision-making, problem-solving, self- family-level behaviors, as well as outside system
control, and self-improvement, and the general dynamics and resources like the adolescent’s
social skills component targets the development social network. Treatment interventions are on
of skills in communication. an “as-needed” basis, focusing on whatever it
takes to alter individual, family, and systems
Family-Based Treatment Models issues that contribute to the problem behavior.
There are number of family-based and family The typical treatment course for MST implemen-
therapy treatment models that are also central to tation ranges from 2 to 4 months. Multiple-level
the successful treatment to adolescent behavior assessments of family and social systems func-
problems. For example, trauma-focused cognitive tioning are embedded within the treatment pro-
behavioral therapy is designed for adolescents tocol. Like FFT, MST has demonstrated
who experience traumatic events (e.g., child outcomes with a wide range of adolescent exter-
abuse, parental divorce, out-of-home placement, nalizing disorders (conduct disorders, adolescent
family violence) for they are prone to several drug abuse, adolescent mental health issues),
mental health problems and to engaging in high- with families that represent diverse cultural and
risk behaviors. Specific interventions that target ethnic groups, in a number of contexts (Kazdin
the effects of trauma on the youth and their fam- 1997; Sexton et al. 2012).
ilies are needed to foster resilience and decrease Functional family therapy (FFT) is a clinical
the risk of future mental health problems. TF-CBT model that has evolved over the last 35 years built
that has strong empirical support to its effective- on a foundation of integrated theory, clinical
ness in treating children and adolescents (aged experience, and empirical evidence (Alexander
et al. 2013; Sexton and Turner 2010; Sexton and References

Stanton 2016). FFT is a well-developed clinical
model designed to treat at-risk youth aged 11–18 Alexander, J. F., Pugh, C., & Sexton, T. L. (2000). Func-
tional family therapy. In D. S. Elliott (Ed.), Blueprints
with a range of maladaptive behaviors including
for violence prevention (Book 3) (2nd ed.). Boulder:
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A selective review. Australian and New Zealand Jour-
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duced successful outcomes with at-risk youth and Research & Health, 24(4), 250–257.
Botvin, G. (1998). Preventing adolescent drug abuse
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Alexander 2002). FFT has demonstrated outcomes
Violence.
with a wide range of adolescent problems, with Frick, P. J. (1998). Conduct disorders and severe antisocial
families that represent diverse cultural and ethnic behavior. New York: Plenum.
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BrondinoMultisystemic treatment of substance abusing
and dependent delinquents: Outcomes, treatment fidel-
CFP brings a unique multisystemic perspective to ity, and transportability. Mental Health Services
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Name and Type of Measure
In J. Thomas & M. Hersen (Eds.), Understanding
Research in Clinical and Counseling Psychology.
Erlbaum: New Jersey. Adult Attachment Interview (AAI).
50 Adult Attachment Interview
Introduction Description of Measure
The AAI is a semistructured interview and scor- The AAI evolved from research applications to a
ing system developed to assess adult- and tool for use in clinical work. Particularly relevant
adolescent-attachment based on congruence to couple and family therapy, the AAI identifies
between semantic and episodic memories. To how early relationship patterns inform current
illustrate, the semantic descriptor “loving” relational functioning, both in parenting and
about an interviewee’s childhood relationship romantic relationships. It reveals the existence of
with his mother is incongruent with the episodic important losses and traumatic experiences that
memory of being punished for failing to take out might otherwise go unreported. In contrast to
the trash, but is congruent with the memory of self-report measures, the AAI reveals uncon-
being surprised that she comforted the inter- scious states of mind. It also may be used to assess
viewee for failing a history exam. therapeutic outcomes. Finally, the AAI informs
The AAI contains 18 questions that probe decisions regarding custody and foster placement
autobiographical childhood memories, descrip- (Steele and Steele 2008).
tions of relationships with primary caregivers, There are two scales: Experience and State of
and experiences of loss and trauma. Trained Mind. Experience scales include inferred parental
coders analyze responses for coherence of dis- behavior during childhood, drawn from semantic
course, comprised of natural conversational descriptors. State-of-Mind scales assess inter-
maxims, including veracity, concision, rele- viewees’ contemporary state of mind, which
vance, and order (Grice 1975), resulting in denotes mental representations of attachment-
assignment on one of the continuous rating related experiences and are drawn from episodic
scales of attachment: memories (George et al. 1984, unpublished
Secure-Autonomous (F). Transcripts are coher- manuscript).
ent and collaborative, evincing a valuing of
attachment, and offering objective descriptions
of experiences, favorable or not. Psychometrics
Insecure-Dismissive (Ds). Not coherent, exces-
sively brief, characterized by dismissal of attach- In a meta-analysis of a nonclinical sample
ment experiences, and semantic descriptors of of mothers, the classification distribution revealed
childhood relationships with parents that are 58% secure/autonomous, 24% dismissing, 18%
insufficient or contradictory. preoccupied, with approximately 19% unre-
Insecure-Preoccupied (E). Not coherent, solved, with nonclinical fathers similarly distrib-
excessively long, entangled speech, wherein the uted. Unresolved and dismissing categories were
interviewee seems passive, frightened, or angry. overrepresented in samples with low socioeco-
Unresolved (U). Superimposed on the aforemen- nomic backgrounds. Only 8% of clinical samples
tioned classifications if the interview contains evi- were secure (van IJzendoorn and Bakermans-
dence of unresolved experiences of trauma or loss Kranenburg 1996), highlighting a link between
(Hesse 2008). attachment and mental health.
Seventy-eight percent stability (kappa = .63)
was found across the three attachment classifica-
Developers tions (Bakemans-Kranenburg and van IJzendoorn
1993) and is echoed in studies over 18-month and
The Adult Attachment Interview was originally 4-year spans (Crowell et al. 1996; Ammaniti et al.
developed by Carol George, Nancy Kaplan, and 1996). In an assessment of discriminant validity,
Mary Main in (1984). AAI classifications were independent of
Adult Attachment Interview 51
intelligence, social desirability, and autobiograph- until session seven, when the coloring books
ical memory. Reliability of classifications was and board games were removed from the office
high across coders and over time for the three and, the dyad was again invited to play. Jemma A
main categories (78%), though less so for the was observed anxiously searching the selection
unresolved category (Bakermans-Kranenburg of wooden blocks and figurines. When asked
and van IJzendoorn 1993). what Jemma was feeling, Tania retorted, “I
guess playing isn’t her area of expertise, either.”
Tania seemed irritated when pressed further to
Example of Application in Couple and interpret Jemma’s emotions, moreso when
Family Therapy asked to offer her own, and she questioned the
efficacy of therapy, sighing impatiently, “I have
Tania, a successful attorney, presented to therapy a lot of important work to do.” When Tania was
stating, “Mothers should like their children. asked to describe her physical sensations, Tania
I don’t,” and described 28-month-old Jemma as revealed, “This is weird, but my stomach hurts,
incompetent. During the initial session, Jemma and my mouth is really dry. My heart is
played quietly alone in the corner, frequently giv- pounding. My joints ache.” The therapist
ing wary, sideways glances at her mother. Jemma offered, “Something happens for you when you
did not pursue her mother, nor cry, when Tania left see Jemma struggling to play competently.”
to use the restroom, and when Tania returned, Tania choked back tears and said, “I don’t
Jemma continued her subdued play. know what’s going on, but I want to get the
Tania’s AAI included notable incongruence hell out of here.”
between semantic descriptions of childhood rela- Therapy continued productively over the course
tionships with her parents and episodic memories. of 24 months, with Tania moving from the level of
For example, Tania described her relationship somatic complaints and criticism of Jemma, to
with her surgeon father as adoring. However, feelings of anxiety and shame about Jemma’s com-
when providing illustrative instances of adoring, petence, to finally accessing painful feelings of
Tania recalled his refusal to help her with her rejection by her father, and the anxious pressure
science fair project, saying he had adult things to to perform in order to gain connection with him. As
do. Tania proudly reported winning first place, she began to experience tender compassion for
stating, “I want Jemma to be successful.” On the herself as a child, she concurrently viewed
AAI, a reliable coder found Tania’s state of mind Jemma’s behavior more sensitively. Play in the
regarding attachment to be dismissive (Ds). dyad became more improvisational, relied less on
The AAI highlighted Tania’s idealization of structured activities, and most notably, included
her relationship with her father, which the ther- delight. Tania discontinued therapy but returned
apist suspected belied disowned pains of rejec- due to concerns about “repeating patterns” in her
tion, and dismissal of the importance of new romantic relationship. After 12 sessions and
attachment-related feelings. Initial interven- an additional administration of the AAI which was
tions across four sessions involved asking her judged secure (F), therapy was terminated.
to play with Jemma, which she did begrudgingly
and in a stilted manner, stating, “Playing isn’t
my area of expertise.” These sessions saw Cross-References
Jemma carefully coloring in a coloring book,
with Tania impatiently instructing, “Keep the ▶ Attachment Theory
colors inside the lines.” When given the choice, ▶ Attachment-Based Family Therapy
Tania always chose a structured board game. ▶ Circle of Security: “Understanding Attachment
Jemma’s quiet, subdued demeanor persisted in Couples and Families”
52 Adult Child of Alcoholics (ACOA)
References Synonyms
Ammaniti, M., Speranza, A. M., & Candelori, C. (1996). ACOAs

Stability of attachment in hildren and intergenerational
transmission of attachment. Psychiatria dell-Infanzia e
dell-Adolscenza, 63, 313–332.
Bakermans-Kranenburg, M.J., & Van IJzendoorn, M.H. Introduction
(1993). A psychometric study of the Adult Attachment
Interview: Reliability and discriminant validity. Devel-
Nearly 7.5 million children living in the United
opmental Psychology, 29(5), 870–879.
Crowell, J.A., Waters, E., Treboux, D., O’Connor, E., States have at least one parent with an alcohol
Colon-Downs, C., Feider, O., Golby, B., & Posada, problem (SAMHSA 2012). The impact of alcohol-
G. (1996). Discriminant validity of the Adult ism on the family has been well documented
Attachment Interview. Child Development, 67,
(Vaught et al. 2013; Engels et al. 2004; Peterson
2584–2599.
George, C., Kaplan, N., & Main, M. (1984). Adult Attach- et al. 1994), and emerging research continues to
ment Interview protocol. Unpublished manuscript, highlight the long-term effects on adult children of
University of California at Berkeley. alcoholics (ACOAs*) (Haverfield and Theiss 2016;
Grice, P. (1975). Logic and conversation. In P. Cole &
Werner and Malterud 2016; Sanchez-Roige et al.
J. Morgan (Eds.), Syntax and semantics. 3: Speech
acts (pp. 41–58). New York: Academic. 2016). Experiences of children growing up in fam-
Hesse, E. (2008). The adult attachment interview: Pro- ilies with a parent abusing alcohol are subjective,
tocol, method of analysis, and empirical studies. In J. yet research indicates that ACOAs* experience
Cassidy & P. R. Shaver (Eds.), Handbook of attach-
depression, anxiety, low self-esteem, difficulty
ment: Theory, research, and clinical applications
(2nd ed., pp. 552–598). New York, NY: Guilford with interpersonal relationships (Haverfield and
Press. Theiss 2014; McCoy and Dunlop 2016; Salvatore
Steele, H., & Steele, M. (Eds.). (2008). Clinical applications et al. 2016), as well as increased risk for
of the Adult Attachment Interview. New York: The
intergenerational alcohol addiction (Cutler and
Guilford Press.
van IJzendoorn, M.H., & Bakermans-Kranenburg, M. Radford 1999). The formation of the Adult Chil-
(1993). A psychometric study of the Adult Attachment dren of Alcoholics (ACA) was in response to an
Interview: Reliability and discriminant validity. observed need for adult children who
Developmental Psychology, 29, 870–879.
were impacted by parental alcohol addiction and
van IJzendoorn, M. H., & Bakermans-Kranenburg, M.
(1996). Attachment representations in mothers, also to provide a place for individuals who were
fathers, adolescents and clinical groups: A meta- looking for support around shared experiences of
analytic search for normative data. Journal of Con- dysfunction within the family (Adult Children of
sulting and Clinical Psychology, 64, 8–21.
Alcoholics World Service Organization 2006).
Location
Adult Child of Alcoholics
(ACOA) The ACA holds peer-led 12-step programming
in locations throughout communities in the
Jessica L. Chou1 and Bertranna A. Muruthi2 United States and internationally. Members are
1
Queen of Peace Center, St. Louis, MO, USA encouraged to complete the 12-step program,
2
Marriage and Family Therapy Program, Virginia while providing support and discussing shared
Tech - Northern Virginia Center, Falls Church, experiences of family dysfunction. Meetings
VA, USA can be attended in-person, online, and over the
telephone (Adult Children of Alcoholics World
Service Organization 2006). Individuals inter-
Name of Organization or Institution ested in finding a meeting can check the Adult
Children of Alcoholics World Services Organi-
Adult Children of Alcoholics (ACA) zation website for local meetings in their area.
Adult Child of Alcoholics (ACOA) 53
Prominent Associated Figures out child. The hero child is best identified as being
“overly responsible” (Cutler and Radford 1999,
Adult Children of Alcoholics was founded in p. 150) and often taking on the role of the parent. A
New York in 1978 by teenagers from AlaTeen While the placater can be viewed as having qual-
(an extension of Al-Anon). Al-Anon is a peer- ities consistent with wanting to mediate relation-
led support group for individuals who are ships, the adjuster role is associated with a neutral
impacted by another person’s (i.e., family, friend, attitude of the child not caring. The acting out
partner) alcohol use (Al-Anon Family Groups child is viewed as obtaining attention through
2017). Tony A. is credited as the founder and undesired behaviors. As these roles have been
author of the “laundry list,” comprised of 14 com- part of the identity development process and
mon behaviors of ACOAs. This document is reinforced by the family system for years, it is
known as the first ACA literature and the impetus not uncommon that some traits are carried into
for the development of the ACA. Jack E. has been adulthood (Cutler and Radford 1999).
credited with further extending the organization to The ACA program can be a vital support sys-
California (Adult Children of Alcoholics World tems for these shared experiences as ACOAs*
Service Organization 2006). may identify with one or more of the roles
(Cutler and Radford 1999). The ACA prioritizes
the individual by nurturing the inner child and
Contributions (Including What It Is focuses on the solution which is “to become
Known for, Relevance to Couple and your own loving parent” (Adult Children of Alco-
Family Therapy, and Mission and Values, holics World Service Organization 2006, p. 590).
Though not Presented in Separate This is accomplished by allowing emotions devel-
Sections) oped in childhood to be expressed while an indi-
vidual is working towards love and acceptance of
The ACA organization is a 12-step recovery pro- the self (Adult Children of Alcoholics World Ser-
gram adapted from the Alcoholics Anonymous vice Organization 2006). Intrapersonal introspec-
steps [see ▶ “Alcoholics Anonymous, 12-Step tion used by ACA can be reinforced in the
Programs” chapter]. In addition to the 12-steps, therapeutic setting by clinicians.
ACA also adapted the 12 traditions from AA The whole family system is impacted by
which provide guidelines on how to interact parental alcoholism (Haverfield and Theiss
within the support group and with society as a 2014; Vaught et al. 2013). Family functioning
whole. The ACA is built on two guiding charac- for ACOAs* has been identified as more
teristics: (1) purpose of the organization is for destructive compared to nonalcoholic families
children who grew up in families with an alco- indicated by passive communication patterns
holic parent and (2) the focus is on the self and the and hostile expressions of anger (Breshears
inner child that developed as a result of parental 2015). Children who experience parental alco-
alcohol addiction (Adult Children of Alcoholics hol addiction are at high risk for following
World Service Organization 2006). intergenerational patterns of alcohol use and
The belief that children’s identity is formed in other maladaptive behaviors (Cutler and
the context of interpersonal family relationships Radford 1999). Marriage and family therapists
leads ACA to help adult children separate them- must consider becoming familiar with the ACA
selves from the identity of an alcoholic family and literature in order to ensure clinical work is
(Adult Children of Alcoholics World Service complementary and not contradictory. Partici-
Organization 2006). Cutler and Radford (1999) pation in the ACA can assist individuals
utilize Black’s (1990) conceptualization of four in unpacking the development of identity within
roles that are often filled by children impacted a dysfunctional family system among a peer
by parental alcohol addiction: (1) the hero, support group that offers empathy and
(2) the placater, (3) the adjuster, and (4) the acting resources.
54 Adult Child of Alcoholics (ACOA)
Marriage and family therapists must consider Cross-References

the varied perspectives of addiction and the con-
sequential degrees of relational conflict that are a ▶ Addictions in Couple and Family Therapy
result of growing up in a family impacted by ▶ Alcohol Use Disorders in Couple and Family
addiction. For example, some ACOAs* acknowl- Therapy
edge that alcoholism is a disease and that has ▶ Alcoholics Anonymous, 12-Step Programs
aided in maintaining a relationship with their par- ▶ Family of Origin
ent(s), while others have utilized different per- ▶ Stages of Change in Couple and Family Therapy
spectives and experienced their parents as
choosing alcohol over the family and have chosen
to cut parental ties (Jarvinen 2015). Historically,
literature has focused on childhood experiences
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and adult characteristics of ACOAs*, omitting
emphasis on valuable tools and resources to sup- ACA WSO INC. (2006). Adult children of alcoholics/dys-
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reconciliation of some parental relationships Al-Anon Family Groups (2017). Retrieved 26 Jan 2017
from http://www.al-anon.org
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giveness will not be a tool for every ACOAs*, their alcoholic parent. Qualitative Research Reports in
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consider familial composition and substance use holism severity and family topic avoidance about alco-
in the context of different cultural groups. For hol as predictors of perceived stigma among adult
children of alcoholics: Implications for emotional and
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factors related to this population. ing, family management, and parental alcohol norms on
Adult Survivors of Sexual Abuse in Couple and Family Therapy 55
current drinking by black and white adolescents. Journal sexually violated as children often carry wounds
of Research on Adolescence, 4(2), 203–227. that are triggered in current relationships which
Salvatore, J. E., Thomas, N. S., Cho, S. B., Adkins, A.,
Kendler, K. S., & Dick, D. M. (2016). The role of carry similar dynamics to the relationships in A
romantic relationship status in pathways of risk for which the sexual abuse occurred. Interactional
emerging adult alcohol use. Psychology of Addictive cycles of survival are then activated in the couple
Behaviors, 30(3), 335–344. relationship which make it difficult for survivors
Sanchez-Roige, S., Stephens, D. N., & Duka, T. (2016).
Heightened impulsivity: Associated with family history and their partners to feel in control, powerful, and
of alcohol misuse, and a consequence of alcohol intake. connected. Sometimes, intimate adult relation-
Alcoholism: Clinical and Experimental Research, 40(10), ships retraumatize adult survivors. Therapists
2208–2217. who are not trauma informed may unwittingly
Substance Abuse and Mental Health Services Administra-
tion (SAMHSA) (2012). More than 7 million children do the same thing. This chapter will introduce
live with a parent with alcohol problems. Data spot- clinicians to the Collaborative Change Model
light. http://www.samhsa.gov/data/ (CCM), a trauma-informed model of couple ther-
Vaught, E., Wittman, P., & O’Brien, S. (2013). Occupational apy, which helps couples where one or both part-
behaviors and quality of life: A comparison study of
individuals who self-identify as adult children of alco- ners are survivors.
holics and non-adult children of alcoholics. International
Journal of Psychosocial Rehabilitation, 18(1), 43–51.
Werner, A. & Malterud, K., (2016). Children of parents with Description
alcohol problems performing normality: A qualitative
interview study about the unmet needs for professional
support. International Journal of Qualitative Studies on The Collaborative Change Model was first intro-
Health and Well-being, 11, 1–11. https://doi.org/10.3402/ duced by Trepper and Barrett (1986) to treat incest
qhw.v11.30673. in a family context. In the last 30 years, the model
has been practiced worldwide in a variety of set-
tings and for work with individuals, couples, and
families coping with trauma. In its current version,
Adult Survivors of Sexual
the CCM (Barrett and Stone Fish 2014) is a clin-
Abuse in Couple and Family
ically evaluated model that helps practitioners
Therapy
collaborate with other professionals, and the indi-
viduals and families they are involved with, to
Linda Stone Fish1 and Mary Jo Barrett2
1 move from survival mindstates to engaged
Syracuse University, Syracuse, NY, USA
2 mindstates. The model is a blueprint for helping
Center for Contextual Change, Chicago,
professionals engage with each other and their
IL, USA
clients. There are three stages to the model. The
first stage, Creating a Context for Change, is based
on the knowledge that healing begins to occur
Name of Family Form
when people experience safety. The second
stage, Challenging Patterns and Expanding Alter-
Couple therapy.
natives, is the practice of new behavior that leads
away from survival mindstates to engaged
Synonyms mindstates. Individuals acting from engaged
mindstates have access to and incorporate tools
Incest survivors; Childhood trauma survivors that regulate their affect, cognitions, behaviors,
and relationships. The third stage, Consolidation,
integrates new learnings and provides hope.
Introduction The CCM was developed from many years of
working with families whose members had expe-
Childhood sexual abuse often impacts adult rienced complex trauma. Complex trauma is a
romantic relationships. Adults who have been pervasive mindset that develops from historical
56 Adult Survivors of Sexual Abuse in Couple and Family Therapy
and ongoing abusive and violating relationships and Relevant Research About Family Life
contexts. Many clients who have a history of com-
plex trauma come to therapy stuck in survival It is difficult to accurately estimate the number of
mindstates and want help managing their lives. Cli- adult survivors of childhood sexual abuse who
ents with complex trauma often begin the treatment come for couple therapy. If therapists do not take
process having been traumatized in relationships a detailed history, clients may not report past
that have similar characteristics to the ones they abuse. Even if therapists ask, individuals may
are entering into when they seek help. Clinicians, not report, for a variety of reasons. They may
on the other hand, come to the relationship with the not have shared their history with their partner,
explicit understanding that they are to be helpful. In they may not have acknowledged their abuse to
most psychotherapy training, trainees are taught to themselves, they may experience shame that
begin therapy after a brief period of “joining,” move silences them, they may not trust therapy, or
quickly into assessment, followed soon after by believe it is relevant to their current problems.
interventions to challenge unproductive behaviors, It is also difficult to accurately estimate how
thoughts, and feelings. Unfortunately, this rapid many people are adult survivors of childhood
movement toward challenge and change can and sexual abuse because researchers differ on defini-
often does trigger a survival mindstate for clients tion and most believe that sexual abuse itself is
who have experienced complex trauma. underreported (e.g., Briere and Elliott 2003).
Developing a new relationship with a helping Studies done by the Crimes Against Children
professional is stressful as is the change process. It Research Center show that 1 in 5 girls and 1 in
can be disorienting and threatening. Clients often 20 boys are victims and self-report studies show
experience therapy as something that is happening that about 20% of adult females and 5–10% of
to them. They have no idea what to expect and do adult males recall at least one incident of child-
not understand the rules. Lacking a detailed blue- hood sexual abuse (Finklehor 2008). Children
print for the process of therapy the therapist’s who have been sexually abused are more likely
actions may seem confusing, irrelevant, or criti- to be sexually abused again as adolescents and
cal. This stressful situation triggers survival adults (Russell 1986; Messman-Moore and Long
mindstates in which it is virtually impossible to 2003).
achieve therapeutic growth. All of the clients’ Since Russell’s (1986) landmark study on
energies are focused on surviving while in this incest and Herman’s (1992) groundbreaking
state and change is not an option. Therapeutic book comparing the epidemic of childhood sexual
interventions are neutralized and become ineffec- abuse to other forms of trauma, many researchers
tive at best and re-traumatizing at worst. The have studied the effects of sexual abuse while
essence of a trauma-informed model is the active acknowledging that research is limited by the
and transparent use of collaboration. Clients are secrecy surrounding abuse, particularly when it
active members of the treatment team, and are is intrafamilial. Reactions to abuse vary widely
informed consumers throughout treatment. and there is no single profile that defines specific
The CCM follows a clear sequence of stages symptomology related to childhood sexual abuse.
and is at the same time flexible and adaptive to There are, however, some common individual and
therapist style, theoretical model, clinical setting, relational themes.
and client presenting challenge. Helping others At least two decades of reviews of research
grow and change is a creative and sacred process. (e.g., Briere and Elliott 2003) have shown many
The CCM allows each and every client and ther- survivors of childhood sexual abuse suffer low
apist together to design the creative process of self-esteem and symptoms of anxiety and depres-
change that fits their strengths and styles. sion. Some suffer from posttraumatic stress disor-
Trauma-centered interventions are incorporated der, alcohol and drug abuse, self-mutilation,
into the blueprint of the CCM in conversation borderline and bipolar personality disorders, sui-
with the needs of clients. cidal ideation, aggression, and sexual acting out
Adult Survivors of Sexual Abuse in Couple and Family Therapy 57
and dysfunction. Furthermore, adult survivors of explore the idiosyncratic ways that they can main-
childhood sexual abuse are more likely to suffer tain safety in therapy.
from medical problems than the general In the first few sessions with couples, concepts A
population. from neuroscience are introduced that are helpful
Childhood sexual abuse also has consequences in understanding how traumatic experiences in
on adult intimate relationships. Sexual difficulties, childhood continue to impact them today. Often
from pain to avoidance, to low desire, and risky the explanation goes something like this: “So we
sexual acting out, have an impact on the survivor are learning a lot about the brain recently that
and her/his partner. There is also some research, I find helpful in understanding why we do the
which suggests that severe abuse is correlated with things we do and how to change our behavior to
more sexual difficulties (Trickett et al. 2011). cope better. So the three parts of the brain the
Valliancourt-Morel et al. (2016) found that relation- cortex, the limbic area, and the survival brain all
ship status may impact sexual difficulties, discover- have different functions. The cortex, that part of
ing that adult survivors in marital relationships were our brain that pays attention, learns, is thoughtful,
more likely to avoid sex while single survivors were processes information, helps us with impulse con-
more likely to act out sexually. Research shows that trol, etc., is the part of the brain we want to keep
other symptoms related to childhood sexual abuse on line all the time in therapy. We will explore
also have an impact on intimate relationships, like ways to do that as part of the therapy process. The
attachment disorders, affect regulation, a sense of limbic area is the expression and mediation of
powerlessness, and lack of trust. Some survivors, emotions and feelings, including emotions linked
however, do not experience symptomatology to connection with others. It also includes the
related to the abuse when studied as adults. amygdala, which is our danger signal. Sometimes,
Collishaw et al. (2007) attribute the survivors’ when we have had a lot of trauma in our past, the
well-being to their relationships with their parents, danger signal can be over- or underactive and that
adolescent friendships, individual personality char- is something else we will explore as we work
acteristics of the survivor, and the quality of their together. The survival brain is the oldest part of
adult relationships. the brain and has kept us alive since the beginning
of time. It is instinctual and unconscious and
reacts to danger by taking action to keep us safe.
Special Considerations for Couple and Fight, flight, freeze, and tend and befriend are
Family Therapy the four survival options we have when our sur-
vival brain is activated. Adrenalin and cortisol are
Creating Safety released, our pupils dilate, our breathing and heart
When working with adult survivors of childhood rate go up and we are pumped. We defend our-
sexual abuse, a trauma-informed lens is invalu- selves by fighting or running away as fast as we
able. It appears that most trauma-informed models can or taking cover and protecting others or pro-
of couple therapy highlight the importance of tecting ourselves through eliciting support from
safety when working with adult survivors (e.g., safe people. If these three options are not available
Courtois and Ford 2009). This is particularly to us, we can’t fight, we can’t get away, and there
important when working in conjoint sessions is no safe person to tend to us, if we are completely
since couples trigger each other into interactional helpless and out of control, the body has a way of
cycles of survival that create dangerous emotional shutting down and protecting itself. This is the
territory and have the potential to explode in the frozen or dissociated state, almost like we have
therapy room. In stage one of the Collaborative left the room, or some people talk about being out
Change Model (CCM), therapists overtly discuss of body or seeing themselves from afar. The sur-
ways to make the therapeutic environment as safe vival brain often kept us alive as children and
as possible. They talk with clients about what overfunctions now when it is not necessarily
feels safe and what does not and help couples always needed. We will explore many of the
58 Adult Survivors of Sexual Abuse in Couple and Family Therapy
incidences that occur in your current life that therapy so that both partners can work on under-
trigger your survival brain.” standing their reactions and then work towards
The CCM is a stage model that works like a changing those reactions. It is a cycle that both
fractal. The first stage, creating a context for partners engage in and both can change.
change, which includes a plan for titrating safety An example of an interactional cycle of sur-
and challenge, is repeated continuously, moment vival goes something like this. Often when
to moment and session after session. When work- Theresa’s survival brain is triggered, she
ing with adult survivors of childhood sexual abuse becomes convinced that Mattis, her partner of
in couple therapy, this is an essential part of treat- 12 years, is not trustworthy. Theresa was sexu-
ment protocol. Many sexual abuse survivors were ally abused by a stepfather who lied constantly,
perpetrated in relationships with adults who were telling her he felt awful about his drunken
supposed to protect and care for them. Some of the behavior and would stop the sexual violence,
ways therapists attempt to show curiosity and only to repeat it the next time he drank. When
empathy may trigger clients who were groomed Mattis, for example, forgets to call Theresa and
and abused by adults who used similar techniques. let her know he is meeting a friend for a drink,
When the survival brain is triggered, the CCM Theresa’s survival brain is triggered. She
trained therapist helps clients pause and ponder becomes anxious and mistrusting and con-
the trigger, which activates the cortex and helps to vinced he is hiding something from her. She
create safety in the therapeutic relationship. obsessively checks phone records, credit card
statements, social media, and follows him to
Interactional Cycles of Survival work, and weepily question everything he
Also of special consideration in couple therapy with says. This behavior triggers Mattis’s survival
adult survivors of childhood sexual abuse is map- brain. Feeling like a cheating loose when he
ping the couple’s interactional cycle of survival (see believes he has done nothing but be forgetful,
Fig. 1). The cycle is a part of each couple’s dynamic reminds him of growing up with a mother who
that keeps them from supporting each other in times would periodically, for no reason that Mattis
of struggle. It is mapped in the early stages of could understand, trash his bedroom looking
Victim/Survivor Cycle
VULNERABILITIES SURVIVAL
SURVIVAL VULNERABILITIES
M.J. Barrett 1990
Adult Survivors of Sexual Abuse in Couple and Family Therapy, Fig. 1 Victim/Survivor Cycle
Affect in Couple and Family Therapy 59
for drugs or weapons or sexual paraphernalia References

that did not exist. He reacts to Theresa’s behav-
ior by shutting down, stonewalling, leaving the Barrett, M. J., & Stone Fish, L. (2014). Treating complex
trauma: A relational blueprint for collaboration and A
house, which of course, triggers Theresa’s sur-
change. New York: Routledge Press.
vival behavior. Briere, J., & Elliott, D. (2003). Prevalence and psycho-
Once the interactional cycle is mapped in stage logical sequelae of self-reported childhood physical
one of the CCM, the pattern is challenged in stage and sexual abuse in a general population sample of
men and women. Child Abuse and Neglect, 27,
two. Therapists use various techniques to help
1205–1222.
explore how partner’s behavior triggers survival Collishaw, S., Pickles, A., Messer, J., Rutter, M., Shearer,
behavior. The survival behavior may have been C., & Maughan, B. (2007). Resilience to adult psycho-
valuable in the past, and that is sometimes pathology following childhood maltreatment: Evi-
dence from a community sample. Child Abuse &
explored, but now gets in the way of increased
Neglect, 31(3), 211–229.
intimacy, feeling valued, connected, and in control. Courtois, C. A., & Ford, J. D. (2009). Treating complex
Exploring how the survival behavior made sense in traumatic stress disorders: An evidence based guide.
the context of the traumatic abuse of childhood in New York: Guilford Press.
Finklehor, D. (2008). Childhood victimization: Violence,
the presence of an engaged, compassionate partner,
crime, and abuse in the lives of young people. Oxford,
helps heal the wounds of the traumatic event. So UK: Oxford University Press.
when Theresa, for example, talked about her step- Herman, J. (1992). Trauma and recovery. New York: Basic
father’s abuse and how powerless she was as a Books.
Messman-Moore, T., & Long, P. (2003). The role of child-
teenager, in front of Mattis, as the therapist guided
hood sexual abuse sequelae in the sexual
Mattis to witness without taking on Theresa’s anger revictimization of women: An empirical review and
or trying to fix Theresa’s hurt feelings, he is actu- theoretical reformulation. Clinical Psychology Review,
ally helping Theresa heal. Furthermore, Mattis is 23, 537–571.
Russell, D. (1986). The secret trauma: Incest in the lives of
calming his own nervous system down as well, a
girls and women. New York: Basic Books.
skill he can generalize outside the therapeutic Trepper, T., & Barrett, M. J. (1986). Treating incest:
encounter. A multiple systems perspective. New York: Routledge
New interactional cycles are then practiced. Press.
Trickett, P. K., Noll, J. G., & Putnam, F. W. (2011). The
These new patterns incorporate all parts of the
impact of sexual abuse on female development: Les-
brain and are practiced with intension. When sons from a multigenerational, longitudinal research
they are triggered, they can recognize their reac- study. Development and Psychopathology, 23(2),
tions from an engaged mindstate, and make deci- 453–476.
Valliancourt-Morel, M. P., Godbut, N., Sabourin, S., Brier,
sions about how they want to behave. In stage
J., Lussier, Y., & Runtz, M. (2016). Adult sexual out-
three, both partners have incorporated ways to comes of child sexual abuse vary according to relation-
support each other when one is triggered, pre- ship status. Journal of Marital and Family Therapy,
venting interactional cycles of survival, and pro- 42(2), 341–356.
viding each other a safe haven to cope with life’s
ongoing demands.
Affect in Couple and Family

Cross-References Therapy
▶ Attachment Injury Resolution Model in Emo- Andrew S. Brimhall and David M. Haralson
tionally Focused Therapy East Carolina University, Greenville, NC, USA
▶ Child Sexual Abuse in Couple and Family
Therapy
▶ Emotionally Focused Couple Therapy and Name of Concept
Trauma
▶ Vulnerability Cycle in Couple Therapy Affect
60 Affect in Couple and Family Therapy
Introduction sadness, or nervous. Because affect is a latent

variable (an intrapsychic experience), many
Affect, mood, and emotion are often used inter- people rely on emotions (the outward display
changeably. However, important distinctions of affect) in order to understand another per-
exist. Within modern psychology, affect is usually son’s affective experience. This outward display
represented as one of three interconnected of emotion is often described by the range, fluc-
domains: affect, behavior, and cognition tuation, intensity, appropriateness, and quality
(Duncan and Barrett 2007). Some theorists of the affect. When attempting to measure
believe that affect is a type of instinctual reaction affect, care should be taken when choosing an
to stimuli that occurs before cognition, while assessment. There are many self-report ques-
others believe that affective reactions happen tionnaires that can be used to measure affect,
both pre- and post-cognition. Although both emo- mood, and emotion (Ekkekakis, 2013). How-
tions and moods are generally considered affec- ever, since they are not exactly synonymous,
tive states, moods are distinguished by being more researchers and clinicians should be careful to
diffused, unfocused, and lasting much longer, choose a measure that theoretically fits with the
whereas emotions are typically elicited by some- concept being measured.
thing and include the individual assignment If a researcher chooses an instrument designed
meaning to that reaction (Batson et al. 1992). to measure a specific state/emotion, then global
inferences about a person’s mood would not be
appropriate. It is important to match the instru-
Theoretical Context for Concept ment with what is being assessed. For example,
the Differential Emotions Scale (DES) could be
Despite being one of three interconnected used reliably to divide an individual’s description
domains (affect, behavior, and cognition), the of specific emotional experiences into discrete
prominence placed on the role of affect varies by categories like enjoyment and interest, while the
theory. Theories who view affect as central to the Profile of Mood States (POMS) might be used to
change process (e.g., emotionally focused ther- assess more general mood states like anger/hostil-
apy) see affect as the window to change and ity, tension/anxiety, and friendliness. The most
intervene accordingly. Their belief is that behav- widely used scale for measuring individual affect
iors and cognitions change as emotional experi- is the Positive and Negative Affect Schedule
ences are reprocessed and reexperienced. Other Expanded (PANAS-X). These scales ask partici-
theories (i.e., behavioral, CBT) may see affect as pants to mark any of the feelings they have expe-
a supporting cast; something that changes as pro- rienced in the last few weeks and are aimed at
fessionals intervene to alter behaviors and cogni- measuring affective states.
tions. Irrespective of whether it is the primary
focus of intervention or not, most couple and
family theories see affect as one of the three Application of Concept in Couple and
domains that must change for individuals to Family Therapy
improve.
Because affect is an important part of human
relationships, most couple and family therapy
Description approaches are either centered upon or place
strong emphasis on increasing positive affect
Affect (both moods and emotions) is generally while simultaneously decreasing negative
divided into either positive or negative affect. Some professionals would go to the
experiences – positive affect being reserved for extent of arguing that this is a common factor
emotions such as happy, excited, and enthusias- that is unique to couple and family therapy
tic and negative affect for feelings such as anger, (Sprenkle et al. 2009). In fact, the literature on
Affective Reconstructive Approach to Couple Therapy 61
marital distress would suggest that distress is References

not a result of negative affect/conflict but rather
the abatement of positive. As a result, clinicians Batson, C. D., Shaw, L. L., & Oleson, K. C. (1992).
Differentiating affect, mood, and emotion: Toward A
should consider more interventions that help
functionally based conceptual distinctions. In M. S.
increase the positive affect of individuals within Clark (Ed.), Emotion (pp. 294–326). Thousand Oaks:
couples and families. Sage.
Duncan, S., & Barrett, L. F. (2007). Affect is a form of
cognition: A neurobiological analysis. Cognition &
Emotion, 21(6), 1184–1211. https://doi.org/10.1080/
Clinical Example 02699930701437931.
Ekkekakis, P. (2013). The measurement of affect, mood,
Joe and Sidney sought out therapy because they and emotion: A guide for health-behavioral research.
Cambridge, MA: Cambridge University.
felt disconnected. Working from an emotionally
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009).
focused approach, the therapist asked Sidney to Common factors in couple and family therapy: The
describe feeling “disconnected.” She explained overlooked foundation for effective practice.
that she felt “alone” and “unsupported” when New York: Guilford Press.
Joe was gone for long hours. The therapist then
asked Sidney to turn and tell Joe directly of her
feelings. Sidney turned to Joe and said I feel
“alone,” and “like a single parent.” Seeing Joe Affective Reconstructive
tense, the therapist asked Joe to describe what Approach to Couple Therapy
emotions were elicited as Sidney talked.
Looking down, Joe explained that he knew Sid- Molly F. Gasbarrini1 and Douglas K. Snyder2
1
ney felt alone and as such he “felt like a failure.” California School of Professional Psychology,
He began to cry and said, “I’m sorry. . .I wish Alliant International University, Los Angeles,
I could have been there for you, but I just CA, USA
2
couldn’t.” Noticing Sidney’s softened facial Texas A&M University, College Station,
expression (an emotional manifestation of TX, USA
inner affect), the therapist then asked Sidney to
tell Joe how that changed her experience. Sid-
ney responded that hearing Joe’s feelings helped Name of the Strategy or Intervention
her feel needed and important, something she
typically doesn’t feel (mood). Affective reconstruction.
In this scenario, the therapist was able to
create an environment that helped change the
couple’s overall affect. Sidney moved from feel- Introduction
ing disconnected and unimportant to feeling
closer to Joe. Joe moved from feeling like a Affective reconstruction (Snyder 1999) refers to
failure to feeling more supported. Learning to the interpretation of persistent maladaptive rela-
read affective displays (i.e., voice changes, tionship patterns having their source in previous
facial cues, etc.) helps therapists know how to developmental experiences. Affective reconstruc-
intervene when working with both positive and tion reflects an insight-oriented approach to cou-
negative affect. ple therapy and presumes that an important source
of couples’ current difficulties frequently includes
previous relationship injuries resulting in
Cross-References sustained interpersonal vulnerabilities and related
defensive strategies interfering with emotional
▶ Affect in Couple and Family Therapy intimacy. Hence, therapeutic approaches that fail
▶ Emotion in Couple and Family Therapy to address developmental experiences giving rise
62 Affective Reconstructive Approach to Couple Therapy
to these vulnerabilities and their associated reac- each partner consistencies in their interpersonal
tivities deprive individuals of a rich resource for conflicts and coping styles across relationships.
understanding both their own and their partner’s In addition, ways in which previous coping strat-
behaviors that could help them to depersonalize egies vital to prior relationships represent distor-
the hurtful aspects of the couple’s interactions and tions or inappropriate solutions for emotional
to adopt an empathic stance. intimacy and satisfaction in the current relation-
ship are articulated.
Theoretical Framework
Diverse approaches to examining maladaptive Rationale for the Strategy or

relationship patterns can be placed on a contin- Intervention
uum from traditional psychoanalytic techniques
rooted primarily in object relations theory to Affective reconstruction builds on strengths of
schema-based interventions derived from cogni- earlier relational models of individual psychother-
tive theory. These approaches vary in the extent to apy by capitalizing on features unique to conjoint
which they emphasize the unconscious nature of couple therapy. First, in couple therapy data
individuals’ relational patterns, the developmental reflecting current expression of persistent dys-
period during which these maladaptive patterns functional patterns of interpersonal relating are
are acquired, and the extent to which interpersonal not confined to the individual’s interactions with
anxieties derive from frustration of innate drives. the therapist but extend more visibly and impor-
However, these approaches all share the assump- tantly to in vivo observations of the individual and
tion that maladaptive relationship patterns are his or her significant other. Thus, core conflictual
likely to continue until they are understood in a relationship themes having greatest relevance to
developmental context. This new understanding each partner are more likely to be apparent than in
and exploration serve to reduce the couple’s atten- the context of individual therapy. Second, individ-
dant anxiety in current interactions and permit uals’ understanding of maladaptive relationship
them to develop alternative, healthier relationship themes and their reformulation of these in less
patterns. pejorative terms may extend beyond their own
Drawing on earlier psychodynamic formula- dynamics to a more benevolent reinterpretation
tions, Snyder and Wills (1989) articulated an of their partner’s more hurtful behaviors. That is,
insight-oriented approach to couple therapy both individuals can be helped to understand that,
emphasizing affective reconstruction of previous whereas certain relational coping strategies may
relationship injuries resulting in sustained inter- have been adaptive or even essential in previous
personal vulnerabilities and related defensive relationships, the same interpersonal strategies
strategies interfering with emotional intimacy. interfere with emotional intimacy and satisfaction
In affective reconstruction, developmental ori- in the present relationship. Finally, in couple ther-
gins of interpersonal themes and their manifesta- apy the “corrective emotional experience”
tion in a couple’s relationship are explored using (Alexander 1956) of disrupting previous patho-
techniques roughly akin to traditional interpre- genic interpersonal strategies and promoting more
tive strategies promoting insight, but emphasiz- functional relational patterns has an opportunity
ing interpersonal schemas and relationship to emerge not only between the individual and
dispositions rather than instinctual impulses or therapist, but between the individual and his or
drive derivatives (Snyder 1999; Snyder and her partner. Thus, interpretation of maladaptive
Mitchell 2008). Previous relationships, their interpersonal themes in the context of couple ther-
affective components, and strategies for emo- apy affords unique opportunities for affective
tional gratification and anxiety containment are reconstruction of these patterns in individuals’
reconstructed with a focus on identifying for primary emotional relationships.
Description of the Strategy or the couple’s ability to respond empathically to

Intervention feelings of vulnerability exposed by their partner,
and an introspective stance initially prompted by A
An essential prerequisite to affective reconstruc- examining dysfunctional relationship expectan-
tion of relational themes is a thorough knowledge cies and attributions residing at a more conscious
of each partner’s relational history. Critical infor- level.
mation includes not only the pattern of relation- In affective reconstruction, previous relation-
ships within the family of origin, but also ships are initially explored without explicit link-
relational themes in the family extending to prior age to current relational difficulties, in order to
generations. Beyond the family, intimate relation- reduce anxiety and resistance during this explora-
ships with significant others of both genders from tion phase. Often, individuals are readily able to
adolescence through the current time offer key formulate connections between prior relationships
information regarding such issues as perceived and current interpersonal struggles; when this
acceptance and valuation by others, trust and dis- occurs, it is typically useful for the therapist to
appointment, stability and resilience of relation- listen empathically, encouraging the individual to
ships to interpersonal injury, levels of attachment remain “intently curious” about their own rela-
and respect for autonomy, and similar relational tional history but to refrain from premature inter-
themes. Some of this information may be gleaned pretations that may be incorrect, incomplete, or
from earlier interventions linked to establishing excessively self-critical. Just as important is for
appropriate boundaries with families of origin, the individual’s partner to adopt an accepting,
discussion of partners’ expectancies regarding empathic tone during the other’s developmental
parenting responsibilities acquired during their exploration, encouraging self-disclosure in a sup-
own childhood and adolescence, or disclosures portive but noninterpretive manner.
of traumatic experiences with significant others Provided with relevant developmental history,
previous to the current relationship. Alternatively, the therapist encourages each partner to identify
in anticipating focused work on developmental significant relational themes, particularly with
issues, the therapy may adopt more structured respect to previous relationship disappointments
clinical or self-report techniques. and injuries. Gradually, as the couple continues to
For interpretation of maladaptive relationship explore tensions and unsatisfying patterns in their
themes to be effective with couples, the therapist own relationship, both partners can be encouraged
needs to attend carefully to both partners’ pre- to examine ways in which exaggerated emotional
paredness to examine their own enduring rela- responses to current situations have at least partial
tional dispositions. Unlike individual therapy in basis in affective dispositions and related coping
which clients often accept at least partial respon- styles acquired in the developmental context.
sibility for their own distress, persons entering Developing a shared formulation of core relation-
couple therapy often focus on their partner’s neg- ship themes is a critical antecedent to subsequent
ative behaviors and resist examining their own linkage of these themes to current relationship
contributions to relationship difficulties – particu- exchanges. Both individuals can be helped to
larly those linked to more enduring personality understand that, whereas certain relational coping
characteristics. Distressed couples often suffer strategies may have been adaptive or even essen-
from a long history of exchanging pejorative attri- tial in previous relationships, the same interper-
butions for each other’s behaviors, furthering their sonal strategies interfere with emotional intimacy
initial resistance to clinical interventions empha- and satisfaction in the present relationship.
sizing early maladaptive schemas underlying rela- In couple therapy, the therapist’s direct access
tionship distress. Consequently, examining to exchanges between partners affords a unique
developmental sources of relationship distress opportunity for linking enduring relationship
demands a prerequisite foundation of emotional themes to current relationship events. Rather
safety, partners’ trust in the therapeutic process, than interpreting transferential exchanges
between either partner and the therapist, the focus insufficient for reconstructing or modifying these
is on partners’ own exchanges in the immediate interpersonal patterns. The affective component
moment. Interpretations emphasize linking each of interpretation is seen in the reconstruction of
partner’s exaggerated affect and maladaptive these critical emotional experiences in the imme-
responses to his or her own relationship history, diate context; new understanding by both partners
emphasizing the repetition of relationship patterns often promotes more empathic responses toward
and their maintaining factors in the present con- both themselves and the other, facilitating more
text. Guidelines for examining cyclical maladap- satisfactory resolutions to conflict. Often the indi-
tive patterns in the context of individual therapy viduals must be encouraged to work through pre-
(Binder and Strupp 1991; Luborsky 1984) readily vious relationship injuries, grieving losses and
lend themselves to couples work. How does the unmet needs, expressing ambivalence or anger
immediate conflict between partners relate to core toward previous critical others in the safety of
relationship themes explored earlier in the ther- the conjoint therapy, and acquiring increased dif-
apy? What are each person’s feelings toward the ferentiation of prior relationships from the present
other and their desired response? What impact do one. Similar to individual therapy adopting a rela-
they wish to have on the other in this moment? tional model, the therapist serves as an auxiliary
How do their perceptions regarding their partner’s processor helping to “detoxify, manage, and
inner experience relate to their attitudes toward digest” the partners’ relationship themes in a man-
themselves? What fantasies do they have regard- ner that promotes interpersonal growth (Messer
ing their partner’s possible responses? What kinds and Warren 1995, p. 141).
of responses from their partner would they antic- Affective reconstruction makes possible but
ipate being helpful in modifying their core beliefs does not inevitably lead to changes in maladaptive
about their partner, themselves, and this relationship patterns. In addition to interpretive
relationship? strategies, interventions must promote partner
Specific therapeutic techniques relevant to interactions that counteract early maladaptive
examining core relationship themes in individual schemas. Thus, the couple therapist allows part-
therapy (Luborsky 1984; Strupp and Binder 1984) ners’ maladaptive patterns to be enacted within
apply to affective reconstruction in couple therapy limits, but then assists both partners in examining
as well. For example, it is essential that the ther- exaggerated affective components of their present
apist recognize each partner’s core relationship exchange. Partners’ exaggerated responses are
themes, that developmental interpretations link framed as acquired coping strategies that interfere
relational themes to a current relationship conflict, with higher relationship values. Interpretations of
and that therapy focuses on a few select relation- the developmental context underlying the current
ship themes until some degree of resolution and unsatisfactory exchange help both partners to
alternative interpersonal strategies are enabled. It depersonalize the noxious effects of the other’s
is also important that the extent and complexity of behavior, to feel less wounded, and consequently
interpretations take into account (a) the affective to be less reactive in a reciprocally negative
functioning of the individual and his or her ability manner.
to make constructive use of the interpretation, Both individuals are encouraged to be less
(b) the level of insight and how near the individual anxious and less condemning of both their own
is to being aware of the content of the proposed and their partner’s affect, and are helped to
interpretation, and (c) the level of relationship explore and then express their own affect in less
functioning and the extent to which developmen- aggressive or antagonistic fashion. Throughout
tal interpretations can be incorporated in a mutu- this process, each individual plays a critical ther-
ally supportive manner. apeutic role by learning to offer a secure context in
From a psychodynamic perspective, cognitive facilitating their partner’s affective self-
linkage of relational themes from early develop- disclosures in a softened, more vulnerable man-
ment to the current context is frequently ner. The couple therapist models empathic
understanding for both partners and encourages anticipated stresses from within or outside the
new patterns of responding that enhance relation- couple relationship that may challenge individual
ship intimacy. That is, by facilitating the non- or relationship functioning in the future. A
occurrence of expected traumatic experiences in
the couple’s relationship, both individuals are able Empirical Support for the Efficacy of Affective
to challenge assumptions and expectations com- Reconstruction
prising underlying maladaptive schemas. Thus, Snyder and Wills (1989) examined the effective-
therapeutic change results from the experiential ness of affective reconstruction as described here,
learning in which both partners encounter rela- in a study comparing this insight-oriented
tionship outcomes different from those expected approach with traditional behavioral therapy in a
or feared. In response, partners’ interactions controlled clinical trial involving 79 distressed
become more adaptive and flexible in matching couples. The behavioral condition emphasized
the objective reality of current conflicts and real- communication skills training and behavior
izing opportunities for satisfying more of each exchange techniques; the insight-oriented condi-
other’s needs. tion emphasized the interpretation and resolution
Although affective reconstruction seeks to proof conflictual emotional processes related to
mote new relationship schemas facilitating more developmental issues, collusive interactions, and
empathic and supportive interactions, couples maladaptive relationship patterns. At termination
sometimes need additional assistance in after approximately 20 sessions, couples in both
restructuring longstanding patterns of relating treatment modalities showed statistically and clin-
outside of therapy. In a pluralistic hierarchical ically significant gains in relationship satisfaction
model (Snyder 1999) in which structured inter- compared to a wait-list control group. Treatment
ventions for strengthening the relationship have effect sizes at termination for behavioral and
previously been pursued, couples already will insight-oriented conditions were 1.01 and 0.96,
have been exposed to communication and respectively, indicating that the average person
behavior-exchange techniques characterizing tra- receiving either couple therapy was better off at
ditional behavioral approaches. Consequently, termination than approximately 83% of individ-
alternative relationship behaviors can often be uals not receiving treatment. Moreover, treatment
negotiated more readily after schema-related anx- gains for couples in both therapy conditions were
ieties and resistance to changing enduring inter- substantially maintained at 6-month follow-up.
action patterns have been understood and at least However, at 4 years following treatment, 38%
partially resolved. of the behavioral couples had experienced
Termination of couple therapy proceeds when divorce, in contrast to only 3% of couples treated
the couple has resolved any initial crises poten- in the insight-oriented condition (Snyder et al.
tially precipitating treatment; when partners have 1991a). Based on these findings, Snyder and col-
acquired information and specific skills essential leagues suggested an important distinction
to maintaining individual as well as relational between acquisition of relationship skills through
health; and when partners understand and resolve instruction or rehearsal versus interference with
individual dynamics previously contributing to implementation of these skills on a motivational
exaggerated emotional reactivity, and substan- or affective basis. They argued that partners’
tially reduce or eliminate distorted responses to views toward each other’s behavior “are modified
their own as well as each other’s dynamics. As to a greater degree and in a more persistent man-
evidence of these goals being met evolves, the ner once individuals come to understand and
therapist may suggest terminating or “thinning resolve emotional conflicts they bring to the mar-
out” the frequency of sessions – with remaining riage from their own family and relationship his-
interventions emphasizing an integrative review tories” (Snyder et al. 1991b, p. 148).
and consolidation of therapeutic work that has Finally, Snyder (1999) has argued that affec-
been accomplished, and preparation for tive reconstruction comprises a critical
component of couple therapy from a pluralistic tolerate even his modest expressions of frustra-
perspective. Whereas some couples demonstrate a tion or unhappiness. When Bob expressed dis-
capacity to implement and maintain important content with Sharon or their marriage, she felt
relationship changes without undertaking such deeply wounded and unloved, retreating for
reconstructive work, others will remain signifi- days into minimal interactions. By contrast,
cantly if not permanently mired in recurrent mal- Bob’s family was characterized by recurring
adaptive interactions until they understand and high conflict and a dominant, emotionally abu-
resolve the developmental origins of exaggerated sive father. Bob had grown up often feeling
or distorted emotional responses to their own con- marginalized and powerless, with little opportu-
cerns or those of their partner. For some couples, nity to express his own feelings and needs.
affective reconstruction yields rapid and dramatic Sharon’s withdrawal in response to his com-
breakthroughs and resolution of longstanding plaints felt punitive.
dysfunctional patterns of interrelating. For others, Exploring these dynamics in couple therapy
insights are more gradual and the gains more helped each partner to alter their interpretation of
circumscribed. Affective reconstruction becomes the other’s behaviors, and these new understand-
critical to couple therapy when partners’ difficul- ings helped them to resist their respective tenden-
ties arise in part from previous relationship inju- cies to withdraw or escalate. Sharon worked hard
ries resulting in sustained interpersonal to expand her tolerance for Bob’s occasional
vulnerabilities and related defensive strategies expressions of discontent and he, in turn, worked
interfering with emotional intimacy. Partners’ to regulate more effectively when and how he
ability to benefit from insight into these vulnera- communicated his concerns or frustrations to Sha-
bilities and defensive strategies may be optimized ron. Understanding Sharon’s retreat as a reflection
when affective reconstruction is embedded within of her own anxieties rather than a ploy to punish
a broader, comprehensive therapeutic strategy him helped Bob to tolerate her needs to suspend
building upon structural, behavioral, and cogni- difficult discussions until they could both adopt
tive interventions earlier in the therapeutic softened perspectives on their differences and
sequence. engage these in a less defensive or antagonistic
manner. Sharon came to understand the intensity
of Bob’s feelings as reflecting deep needs for
Case Example closeness and his own anxious response to her
withdrawal, rather than as a rejection or punish-
Bob and Sharon entered couple therapy after ment of her.
15 years of marriage, reporting increasing emo- Bob’s and Sharon’s enduring dispositions to
tional detachment and brief but hurtful arguments lapse into escalation or withdrawal persisted, but
when either partner felt misunderstood or at a much lower frequency and intensity than
unappreciated by the other. The couple had two before the couple therapy. Moreover, their new
daughters, ages 13 and 11, to whom Sharon felt understanding of this interactional pattern helped
quite close but Bob often felt estranged. Both them to recognize it earlier in the cycle to dampen
partners were successful professionals in the its escalation, and to recover more quickly and
healthcare field and described effective communi- engage in corrective strategies when old patterns
cation strategies with coworkers. In their mar- resurfaced.
riage, however, a pronounced demand-withdraw
pattern undermined their efforts to engage and
resolve relationship issues. Cross-References
In discussing their families of origin, Sharon
reported a family that was emotionally close but ▶ Behavioral Couple Therapy
highly avoidant of conflict. Tensions with Bob ▶ Insight-Oriented Couple Therapy
felt threatening to her, and she was unable to ▶ Snyder, Doug
African Americans in Couple and Family Therapy 67
References Introduction
Alexander, F. (1956). Psychoanalysis and psychotherapy. African Americans, unlike most ethnic groups
New York: Norton. A
who immigrated to America in search of freedom
Binder, J. L., & Strupp, H. H. (1991). The Vanderbilt
approach to time-limited dynamic psychotherapy. In and equality, arrived involuntarily as slaves. Liv-
P. Crits-Christoph & J. P. Barber (Eds.), Handbook of ing in the shadow of slavery economically, polit-
short-term dynamic psychotherapy (pp. 137–165). ically, socially, and psychologically, African
New York: Basic Books.
Americans often are misunderstood, stigmatized,
Luborsky, L. (1984). Principles of psychoanalytic psycho-
therapy: A manual for supportive-expressive treatment. and racially stereotyped as inferior. Due to a his-
New York: Basic Books. tory of racism, discrimination, and lack of cultural
Messer, S. B., & Warren, C. S. (1995). Models of brief understanding, African Americans are wary and
psychodynamic therapy: A comparative approach.
underutilize mental health services. Also, dispa-
New York: Guilford Press.
Snyder, D. K. (1999). Affective reconstruction in the con- rate and inadequate treatment of African Ameri-
text of a pluralistic approach to couple therapy. Clinical cans has resulted in a culture of mistrust. As such,
Psychology: Science and Practice, 6, 348–365. it is critically important that couple and family
Snyder, D. K., & Mitchell, A. E. (2008). Affective-
therapists develop knowledge of African Ameri-
reconstructive couple therapy: A pluralistic, develop-
mental approach. In A. S. Gurman (Ed.), Clinical hand- can history and culture.
book of couple therapy (4th ed., pp. 353–382). Failure to consider the historical trauma of
New York: Guilford Press. slavery and the impact of race in African Ameri-
Snyder, D. K., & Wills, R. M. (1989). Behavioral versus
can clients’ experiences and presenting problems
insight-oriented marital therapy: Effects on individual
and interspousal functioning. Journal of Consulting may cause couple and family therapists to con-
and Clinical Psychology, 57, 39–46. ceptualize cases from the default perspective of
Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991a). the dominant white culture. While accredited cou-
Long-term effectiveness of behavioral versus insight-
ple and family therapy training programs are
oriented marital therapy: A four-year follow-up study.
Journal of Consulting and Clinical Psychology, 59, tasked to attend to context, race continues to be
138–141. an afterthought. Moreover, the advent of
Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991b). evidence-based models as best practice in couple
Risks and challenges of long-term psychotherapy out-
and family therapy may have the unintended con-
come research: Reply to Jacobson. Journal of Consult-
ing and Clinical Psychology, 59, 146–149. sequence of minimizing or negating the signifi-
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a cance of race.
new key: A guide to time-limited dynamic psychother-
apy. New York: Basic Books.
Description
African Americans in Couple The term African American refers to the descen-
and Family Therapy dants of those black Africans who were enslaved
in the United States of America. According to
Marlene F. Watson Billingsley (1992), the African American family
Drexel University, Philadelphia, PA, USA often is viewed too narrowly, which, out of the
context of black* communities and the larger
society, can fuel stereotypical thinking and be
Name of Family Form counterproductive. Frequently, theoreticians,
researchers, and clinicians focus exclusively on
African Americans in Couple and Family Therapy single-parent families, the lower class or problem
children and youth, falling into the trap of seeing
Synonyms these phenomena as characteristic of African
American families. Billingsley proposes a broader
Black and more complex definition of the African
68 African Americans in Couple and Family Therapy
American family as “an intimate association of black* Americans as docile, passive, and eager to
persons of African descent who are related to please – Uncle Tom-ish. Civil rights leaders and
one another by a variety of means, including organizations, such as Stokely Carmichael of the
blood, marriage, formal adoption, informal adop- Student Nonviolent Coordinating Committee, the
tion, or by appropriation; sustained by a history of Black Muslims, and Black Panthers, rallied
common residence in America; and deeply behind the term Black (Smith 1992). Also,
embedded in a network of social structures both acclaimed singer James Brown made a record in
internal to and external to itself” (p. 28). 1968 that became akin to a black* national
Throughout history and the changing sociopo- anthem, “Say it Loud—I’m Black and I’m
litical landscape, the name associated with black* Proud,” helping to solidify Black as the new iden-
Americans has been fluid, evolving across time tity. Black now stood for racial pride and
periods. A word or name contains power and action – empowerment. Black communicated
conveys persuasive ideas that can enlighten or African Americans’ rejection of second-class cit-
erode people’s minds. In reality, imposing, pro- izenship and the status quo (Smith 1992).
posing, accepting, or rejecting names can be used The word Black, though not accepted by all,
as a political tool. By the end of the first third of remained unchallenged until 1988 when
the nineteenth century, the N-word, which can be renowned civil rights leader Jesse Jackson
traced to the Latin word niger meaning black, was declared that members of the black* race pre-
firmly entrenched in the American psyche. During ferred the term African American. Seeking parity
slavery blacks* largely were referred to as the with white ethnic groups, the African American
N-word, conjuring up powerful imagery of label was fashioned to express cultural integrity
black* people as ugly, promiscuous, dangerous, and put black* Americans in the proper historical
immoral, and animal-like. Thus the imposition of context (Smith 1992).
the N-word onto black* Americans was political, African American and Black* often are used
dehumanizing blacks* and humanizing whites. interchangeably. However racial labels can arouse
The word Colored to describe black* Ameri- strong emotions. For example, Zilber and Niven
cans rose to dominance in the mid to late nine- (1995) found that whites, particularly liberal
teenth century. The rape of black female slaves by whites, view the label African American nega-
white masters resulted in mulatto children, a new tively in comparison to Black. African American
group of black* Americans with mixed ancestry was thought to be indicative of concern with the
that needed classification. Colored was regarded specific group, not society. Moreover, black*
as more encompassing and inclusive (Smith Americans’ concern about racial identity was
1992). seen as insignificant.
Negro replaced the word Colored in the late African Americans are not a monolithic group,
nineteenth century. Notables such as Booker and therefore therapists should not assume that all
T. Washington and W.E.B. Dubois pioneered the embrace a single term. Therapists may be able to
movement to trade Colored for Negro. The media, facilitate an understanding of the terms Black and
both black* and white, helped the word Negro to African American by helping clients to distinguish
gain acceptance and become the standard through between racial and ethnic identities. Approaching
its use of the term (Smith 1992), documenting the identity from a both-and rather than an either-or
role of the media in shaping public discourse and perspective, black* Americans can accept Black
politics. as their racial identity and African American as
The Civil Rights Movement ushered in the their ethnic identity.
word Black. The late 1950s to early 1960s called Slavery. Fully comprehending African Amer-
into question the word Negro to define black* ican couples and families requires understand-
Americans. A critique of the word Negro found ing slavery. Slavery began in 1619 with the
it outdated and reflective of the past and slavery. arrival of a Dutch ship in Jamestown, Virginia
Negro was thought to stir the white imagination of carrying 20 black Africans. Millions of blacks,
including royalty, were stolen from their Afri- their clothing, with potential buyers and
can homes, brought to America in chains, and strangers touching their most private parts to
sold into slavery for the specific purpose of determine if they were worth the price, the A
white economic prosperity. Slavery, as a legal slaves’ destinies as sexual beings were changed
practice, ended with the Emancipation Procla- on the auction block (Wyatt 1997).
mation by President Abraham Lincoln follow- Slaves experienced a brutal attack on their
ing the Civil War in 1865 (Meltzer 1984). bodies and minds. They had no real ability to
Blacks* were enslaved in the United States of nurture, care, protect, and support one another as
America for over 200 years. intimate partners and parents. Slave men and
African people and cultures were rich and women were forced to silently endure the degra-
diverse (Meltzer 1984). Slaves were forced into dation and humiliation of the other and to inter-
one mass identity, stripped of their rightful names, nalize the shame that comes from fear,
country, tribal identities, language, religion, cus- powerlessness, defeat, and/or emasculation.
toms, and the right to read or write. As chattel, Race and Racism. Race is a socially
they were worked, raped, bred, whipped, and sold constructed concept, which preserves the myth
according to the master’s needs and desires of white superiority and black inferiority
(Watson 2013). Perceived as a better fit because (Watson 2013). The institutionalized belief of
their black skin made them more durable, slaves, white superiority and black inferiority is funda-
including infants, were guinea pigs in medical and mental to the African American experience.
scientific experimentation (DeGruy 2005; Wyatt According to Walton and Smith (2008), American
1997). Slavery thus violated the most basic and founding father and author of the Constitution
core sense of self that, as Africans, the slaves had Thomas Jefferson stated in his Notes on Virginia
known. that blacks were “inferior by nature, not condi-
Slaves were denied the right to marry and tion” (p. 7).
forced to become studs and breeders. Slavery The white/black bifurcation functions to
first established patterns of no marriage, out of uphold the purity, privilege, beauty, goodness,
wedlock children, teenage pregnancy, and absen- and moral authority granted to whites at birth.
tee fathers. “The white man was the original By contrast, black* is targeted as inherently
abandoning father in this country” flawed, deficient, and undeserving, paving the
(Pinderhughes 1998, p. 187). He fathered children way for social discrimination and bias. African
with slaves, denied paternity, and rebuffed his Americans thus are likely to experience injustice,
children. criminalization, devaluation, depression, anxiety,
Slavery dismantled the black* family. The relational fractures, attachment ruptures, identity
African sense of “we” was disturbed because crises, trauma, high blood pressure, and more
slaves could be torn apart at any time. Couple based on the socially imagined but life-shaping
and parenting relationships were fragile at best, construct of race.
and group solidarity was difficult to sustain. Walton and Smith (2008) use Carmichael and
Direct support from or for the group was virtually Hamilton’s definition to describe racism as “the
nonexistent because of the perils of doing so predication of decisions and policies on consid-
(Wyatt 1997). erations of race for the purpose of subordinating
Sexuality was altered for the slaves and their a racial group and maintaining control over it”
descendants, beginning with the rape and (p. 5). Regardless of one’s ideology or rationale,
impregnation of black* females by white men any policy that has the intent or effect to subor-
aboard the slave ship (Wyatt 1997). Most female dinate a racial group is decidedly racism. For
slaves were sexually assaulted by white men by racism to be successful, a group or individual
their 16th birthday (Russell et al. 1992). Mar- must have the relative power to impose its will
riage and sex were valued and respected as a onto another group or individual through
sacred part of life’s plan in Africa. Deprived of policies.
Relevant Research About Family Life particularly black* men and white women. Also,
race mixing made it more difficult to justify slav-
Black* family research primarily has emanated ery on the basis of white morality and black
from three perspectives: (1) ethnocentric, (2) cul- immorality. Additionally, the widespread rape of
tural relative, and (3) class. The ethnocentric view female slaves by white masters presented a prob-
compares African Americans to Eurocentric lem, namely, whether mixed race children should
values, norms, attitudes, and behaviors, resulting take on the free status of the white father or the
in pathology of any deviation. Congressman Dan- black slave mother. Departing from traditional
iel P. Moynihan is responsible for decades of English law, Virginia enacted legislation, necessi-
research that approached black* families as path- tating children to have the same status as the
ological, affirming that the social is political. The mother (Russell et al. 1992).
infamous Moynihan Report entitled The Negro The rising number of mulattoes required racial
Family: The Case for National Action in 1965 classification. The “one drop” rule was decided by
resulted from President Lyndon B. Johnson’s legislators to address the problem of race mixing
request to understand social unrest and poverty and to maintain the social order. Anyone with a
in the black* community (Billingsley 1992). drop of black blood was by definition black*.
Blaming the victims, the Moynihan Report Mulattoes were forced into the black box no mat-
attributed problems in education, employment, ter how white looking their skin, hair, and fea-
and politics to internal black* family weaknesses. tures, giving birth to a color caste system
Rather than placing racism and injustice at the (colorism) that is evident today. Colorism posi-
center, Moynihan placed the dysfunctional tively affects those with lighter skin and nega-
black* family at the center; reinforcing the policy tively impacts those with darker skin,
perspective that society did not need to change influencing power and privilege. Hence skin
and downplaying the need for civil rights legisla- color may be the undercurrent in family strife or
tion and affirmative action (Billingsley 1992). the basis for mate selection (Russell et al. 1992;
Emphasized as weak were the matriarchal black* Watson 2013).
family structure and the absence of black* males Whiteness as the ideal marker of beauty, edu-
as heads of household, not the mandated invisi- cation, success, and wealth is the backdrop against
bility of black men, such as that in 1662 requiring which African Americans develop identity, con-
black children to take on the status (slave or free tributing to divisiveness in the African American
black) and name of their mothers regardless of the community. For instance, this author’s light-
condition of the father (Russell et al. 1992). skinned client Joe and his family considered
The cultural relativist perspective ascended in themselves to be “exceptional” blacks*. Joe railed
opposition to comparative studies of black* at worthless black* men and decried being a
Americans to white Americans, espousing an black* man. Yet everyday he went into his For-
Afrocentric worldview (Sudarkasa 2007). For tune 500 company, he felt less than all of his white
instance, African American couples tend to have peers, leaving him disconnected from self, other
more egalitarian relationships, which reflect Afri- blacks* and white coworkers. As a result, Joe
can values of unity, harmony, cooperation, and suffered from severe anxiety and depression
interdependence, not the Eurocentric value of (Watson 2013).
head of household. The class perspective The Nigrescence model of black* identity
de-emphasizes race, seeking to understand the (Cross 1991) comprises five developmental
specific needs and concerns of African Americans stages: (1) pre-encounter, (2) encounter,
according to socioeconomic status. (3) immersion-emersion, (4) internalization, and
Black Identity. Black slaves and white inden- (5) internalization-commitment. The pre-encounter
tured servants worked together in early America, stage starts with where the person is – the present
developing friendships and romantic relation- identity that needs to be changed. Pre-encounter
ships. Race mixing became a major concern, racial attitudes vary from low salience to neutral to
rejecting. Low salience refers to individuals who integration outlook think it is incumbent upon
accept being black* but do not see blackness as a African Americans to fit into white spaces and
factor in their daily lives. Some however feel com- structures, not those structures changing to be A
pelled to defend themselves against blackness as a more racially inclusive (Cross 1991).
social stigma, having little knowledge of black* A person’s identity is shaped by early experi-
history or culture. Neutrality denotes persons who ences in family and society. Once formed, identity
believe they have evolved beyond race. An exam- is difficult to change, no matter the stage. Incom-
ple of which may be an actress who does not see ing experiences are expected to match a person’s
herself as a black* actress but rather an actress who understanding of self and the world. An encounter
happens to be black*. Antiblack African Ameri- must occur that is strong enough to shake a per-
cans blame other blacks*, uphold racist stereo- son’s current identity, thrusting the individual
types, and affirm white culture (Cross 1991). toward needed change. The encounter can be a
Underlying causes of pre-encounter attitudes sudden event, such as the murder of nine black*
may be “miseducation, a Eurocentric cultural people in a church in Charleston, South Carolina
frame of reference, spotlight or “race-image” anx- by a self-proclaimed white supremacist or the
iety, a race-conflict resolution model that stresses mass incarceration of blacks* (Cross 1991).
assimilation-integration objectives, and a value The encounter can be positive (e.g., reading the
system that gives preference to other than Afro- Autobiography of Malcolm X) or negative (e.g.,
centric priorities” (Cross 1991, p. 192). Given that racial profiling) and involves two steps:
the American educational system has not focused experiencing and personalizing. Witnessing a dra-
on Africa’s role in civilization and the role of matic event does not necessarily mean that one is
blacks* in the making of America, blacks* gener- changed by it. For a person’s worldview to be
ally have a distorted view of their own cultural affected, the encounter must be personalized.
history as well as other histories besides white Feelings of confusion, guilt, anger, anxiety, and
western history. According to Cross (1991), poor depression likely are experienced in this stage,
mental health is not necessarily the most damag- which may be motivational (Cross 1991).
ing outcome of miseducation but a learned world In the immersion-emersion stage, an individual
view that inhibits knowledge and weakens the is committed to developing a new identity but
capacity to advocate for one’s best interests. more familiar with the old identity. Persons in
Through miseducation, blacks* are socialized this stage exhibit first-order change, such as wear-
to have a greater appreciation of all things white, ing natural hairstyles and/or African clothing.
leading to a Eurocentric cultural perspective. Thus Also, either-or thinking is manifested in this
blacks* in the pre-encounter stage may enjoy stage wherein the old attitude of white is superior
black* music and/or art but may see it as counter and black is inferior is reversed to black is supe-
to being accepted into the white mainstream. The rior and white is inferior. During the immersion
problem for blacks* is not appreciating white phase, an individual is consumed with
culture but seeing it as a measure of “correctness” blackness – a self-liberating experience from
(Cross 1991). Spotlight or race image anxiety whiteness – and tends to be judgmental about
speaks to African Americans being overly sensi- others’ blackness, which can become divisive.
tive to white people’s belief in negative racial Anyone who becomes stuck at the immersion
stereotypes, triggering worry about the behavior level has a pseudo-black* identity because of
of other blacks*. On the positive side, spotlight being more concerned with negating whites than
anxiety can lead to a heightened awareness of affirming blacks* and dismantling racism (Cross
prejudice and discrimination. However self- 1991).
hating blacks* are beyond race image. Antiblack Emersion signals the emergence from over-
blacks* embody their disdain for black skin and simplified dichotomous thinking and reactivity.
see blackness as an imposition that must be An individual in the emersion phase is better
discarded. Blacks* with an assimilation- positioned to develop a black* identity because
there is a balance between emotion and intellect. The cognitive dissonance or discomfort
Realizing that the commitment to black* issues between black* men and women may be due to
does not require white hatred or negation, the the residual effects of slavery and ongoing racism
individual is ready to move toward internalizing (Watson 2013). Surviving the horrors of slavery,
a new identity. However it should be remembered slaves disconnected emotionally. While emo-
that individuals at the immersion-emersion stage tional disconnection was a protective factor in
might regress because of the warring old and slavery, it may be limiting black* marriage
emerging new identities; fixate on white hatred today. Living with the realities of racism may
because of pain, anger, and guilt; or become over- cause feelings of shame and helplessness in Afri-
whelmed and give up (Cross 1991). can American men and women that each may try
The internalization stage “seems to perform to avoid by disconnecting or projecting onto the
three dynamic functions in a person’s everyday other. Finger pointing, African Americans attempt
life: (1) to defend and protect the person from to justify rather than heal from the trauma of
psychological insults that stem from having to slavery.
live in a racist society; (2) to provide a sense of The devaluation of black* womanhood and
belonging and social anchorage; and (3) to pro- manhood began in slavery with sexual victimiza-
vide a foundation or point of departure for carry- tion, objectification, and marginalization. Black*
ing out transactions with people, cultures, and women were seen as hypersexual, and black* men
situations beyond the world of blackness” (Cross were praised for their sexual prowess. The sexual
1991, p. 210). Second-order change occurs at the objectification and victimization of black* men
internalized stage of black* identity development. and women severed intimate bonds and created
An individual is concerned with standards of suspicion and distrust. Slavery and its racist after-
blackness, not outward physical appearances of math taught black* women two important lessons:
blackness or black* rhetoric. Uncontrolled anger black* women were not deserving of the same
is redirected away from white people toward racist protections as white women; and black* men
systems and injustice; and black* pride replaces could not be counted on to protect and provide.
rigidity and a holier-than-thou black* attitude. A prevailing message of the strong black* woman
Nonetheless, individuals at the end of this stage thus was born as black* men struggled with the
could develop a monocultural (black nationalist), “boy” complex from slavery (Watson 2013).
bicultural (black and American), or multicultural Black Mass Incarceration. The mass incarcer-
(multiple cultural interests and saliences) orienta- ation of black people functions as the new Jim
tion. Internalization-commitment, the final stage Crow, upholding the legacies of slavery in the
of the Nigrescence model, is mainly distinguished present day. Imprisonment is profitable and, like
from internalization by a sustained interest and slavery, requires bodies to secure the business
commitment to black issues (Cross 1991). interests of those that capitalize and benefit from
Black Male-Female Relationships. Marriage is it. Incarceration therefore has become the
desired and valued by African Americans. Prior to response to problems of addition, poverty, adoles-
the twentieth century, marriage was quite prevalent cence, and mental health issues. Blacks* are dis-
among African Americans. Currently, marriage is proportionately incarcerated and tend to receive
lower among black* Americans than any other higher sentences, generating racial disparities in
racial or ethnic group. As well, African Americans the criminal justice system that likely are steeped
have the highest rate of divorce and never married. in myths about black inferiority and white superi-
Social scientist bell hooks (1981) posits that black* ority originating from slavery (Stevenson 2015).
men adopted a view of black* women as controlling According to Stevenson (2015), the four insti-
and emasculating from Moynihan’s unfavorable tutions that have determined the American
report about the matriarchal black* family. Like- approach to race and justice are (1) slavery,
wise, black* women may have accepted a view of (2) the reign of terror following slavery, (3) Jim
black* men as inadequate. Crow, and (4) mass incarceration. The end of
slavery announced the beginning of terror for functioning of African American families around
black* people by the police, KKK, or any white interdependence, unity, mutual responsibility, rec-
person. Black* families were constantly in fear of onciliation, cooperation, and religion/spirituality. A
lynching, bombing, and overall racial violence. Dr. Maulana Karenga solidified and, to a great
Also, blacks* were subject to conviction for non- extent, codified the cultural connection between
sensical offenses that then allowed them to be Africa and African Americans when he founded
leased (convict leasing) to businesses, effectively Kwanzaa in 1966. Kwanzaa, an American holiday
forcing them back into slave labor. Jim Crow, that commemorates the African cultural heritage
which legalized segregation and denied blacks* of blacks*, is celebrated from December 26 to
basic rights, had real consequences for daily psy- January 1 and is based on seven fundamental
chological functioning of African American fam- principles known as the Nguzo Saba. These
ilies. Similarly, modern-day racial profiling has seven principles are (1) Unity (Umoja), (2) Self-
many of the same characteristics and negative determination (Kujichagulia), (3) Collective
consequences for black* families. On a daily Work and Responsibility (Ujima), (4) Cooperative
basis, blacks*, regardless of class, experience a Economics (Ujamaa), (5) Purpose (Nia), (6) Crea-
variety of indignations and humiliations, whether tivity (Kuumba), and (7) Faith (Imani) (McClester
followed in a store, profiled by the police, or 1994).
mistaken for the help. Mass incarceration is a The cumulative effects of race have resulted in
weakening burden borne by African American historical trauma or post-traumatic slave syn-
families and communities. Targeted prosecution drome for African Americans as a people
and draconian laws for drug crimes in poor black* (DeGruy 2005). Absorbing the myth of white
neighborhoods and the collateral damage (e.g., superiority and black inferiority has created lies
voter disenfranchisement and barriers to reentry) and difficulties that manifest themselves today in
to African American families operate within the multiple ways, including racial identity, black*
American legacy of race relations (Stevenson marriage, and mass incarceration. Couple and
2015). family therapists must confront myths of racial
differences and challenge racial injustice to work
effectively with African American clients. Couple
Special Considerations for Couple and and family therapy should be a place where both
Family Therapy therapists and African American clients can com-
mit to a process of truth, honesty, and healing.
African Americans, unlike other ethnic groups, Racial indignations and microaggressions accrue
are sometimes seen as having no history and cul- daily for African Americans, taking a serious toll
ture to safeguard or defend. Social scientist on the mind, body, and spirit. As a result, couple
E. Franklin Frazier believed that the African cul- and family therapists may be scratching only the
ture was obliterated by the experience of slavery. surface with African American clients without a
Scholars Melville Herskovits and W.E. B. Du deeper conversation around slavery, race, and
Bois opposed Frazier’s view, asserting that impor- racism.
tant vestiges of African culture survived slavery African Americans have shown tremendous
and that black* family life in the United States is strength and resilience in the face of adversity.
an extension of African heritage (Billingsley Hope and faith have been two major sustaining
1992). factors, allowing African Americans to achieve,
Although ties to African heritage were broken accomplish, contribute, and survive despite slav-
and distorted in slavery, there remain African ery and racism. Nonetheless, if true healing is to
American cultural values that are submerged in come, African Americans must face the grief,
African values. The intergenerational transmis- losses, and trauma of their own history. Couple
sion of African values from slavery to the present and family therapists must be prepared to help
can be seen in the behavioral and psychological African Americans do so by seeing (own and
that of client), not avoiding, race. Otherwise, cou- Cross-References

ple and family therapists risk perpetuating racism
and oppression in the lives of African American ▶ Black Men in Couples and Families
clients. As a cautionary note, couple and family ▶ Black Women in Couples and Families
therapists must do their own person of the thera- ▶ Boyd-Franklin, Nancy
pist work, including uncovering racial biases, in ▶ Cultural Competency in Couple and Family
order to be able to hold the intensity of engaging Therapy
in meaningful conversations about race while ▶ Cultural Values in Couples and Families
staying emotionally present and connected in ▶ Culture in Couple and Family Therapy
therapy. ▶ Ethnic Minorities in Couple and Family
However the growing interest in evidence- Therapy
based models of treatment may deter couple ▶ Ethnicity in Couples and Families
and family therapists from attending to race as ▶ Hardy, Kenneth V.
a crucial dimension of inquiry in therapy. Fun- ▶ Intercultural Couples and Families in Couple
damentally, evidence-based models tend to and Family Therapy
neglect broader social influences that impinge ▶ McGoldrick, Monica
on black* families daily. Personally, this author
believes that evidence-based models may
unwittingly distort or mystify race and its References
impact on black* families. Denying, relabeling,
or reframing race could be detrimental to Afri- Billingsley, A. (1992). Climbing Jacob’s ladder: The
enduring legacy of African American families.
can American clients because it basically robs
New York: Simon & Schuster.
them of their racial experiences and feelings, Cross, W. E. (1991). Shades of black: Diversity in African-
which might contribute to the development of American identity. Philadelphia: Temple University
a false self. Self-inauthenticity for African Press.
DeGruy, J. (2005). Post traumatic slave syndrome:
Americans, in turn, could reinforce feelings of
America’s legacy of enduring injury and healing.
internalized racism and black inferiority. Portland: Joy DeGruy Publications.
Admittedly, evidence-based models, such as hooks, b. (1981). Ain’t I a woman? Black women and
emotionally focused therapy (EFT) and feminism. Boston: South End Press.
McClester, C. (1994). Kwanzaa: Everything you always
attachment-based family therapy (ABFT), have
wanted to know but didn’t know where to ask.
not researched their applicability for clients of New York: Gumbs & Thomas.
culturally and racially diverse backgrounds. How- Meltzer, M. (1984). A history in their own words: The
ever, they maintain a universality of human emo- black Americans. New York: HarperCollins.
Pinderhughes, E. (1998). Black genealogy revisited:
tions, such as attachment. Nevertheless,
Restorying. In M. McGoldrick (Ed.), Re-visioning fam-
attachment in families can be affected by outside ily therapy: Race, culture, and gender in clinical prac-
social forces, which is well documented by tice (pp. 179–199). New York: Guilford.
slavery. Russell, K., Wilson, M., & Hall, R. (1992). The color
complex: The politics of skin color among African
Despite research demonstrating the effective-
Americans. New York: Anchor Books.
ness of evidence-based models across racial and Smith, T. W. (1992). Changing racial labels: From “Col-
cultural lines, the question of racial equality and ored” to “Negro” to “Black” to “African American”.
healing from slavery and racism remains for Afri- Public Opinion Quarterly, 56(4), 496–514.
Stevenson, B. (2015). Just mercy. New York: Spiegel &
can Americans. Families are affected by politics.
Grau.
The early pioneers in the field of couple and Sudarkasa, N. (2007). Interpreting the African heritage in
family therapy began a revolution that trans- African American family organization. In H. P.
formed mental health and changed the view of McAdoo (Ed.), Black families (pp. 29–47). Thousand
Oaks: Sage.
families from adversaries to supporters. Will the
Walton, H., & Smith, R. C. (2008). American politics and
field again rise to the occasion and take an active the African American quest for Universal freedom.
stance against racism and oppression? New York: Pearson Longman.
Ahrons, Constance 75
Watson, M. F. (2013). Facing the black shadow. Author. Among her awards are: Distinguished
Wyatt, G. E. (1997). Stolen women: Reclaiming our sexu- Research Award, Association of Family and
ality, taking back our lives. New York: Wiley.
Zilber, J., & Niven, D. (1995). “Black” versus “African Conciliation Courts; Fellow, Radcliffe Institute A
American:” Are whites’ political attitudes influenced for Advanced Study, Harvard University; and
by the choice of racial labels? Social Science Quarterly, Distinguished Cumulative Contrtibution to
76(3), 655–664. Family Therapy Research, American Family
Therapy Academy. She is a Fellow of the Amer-
ican Association for Marriage and Family Ther-
apy and the American Orthopsychiatric
Ahrons, Constance Association.
Roy H. Rodgers
Professor Emeritus, University of British Contributions to Profession
Columbia, Vancouver, BC, Canada
Based on her pioneering 5 year longitudinal study
of 98 postdivorce couples and her 20 year follow-
Name up of over 90% of the children of those divorces,
she introduced the concepts of “binuclear family”
Constance R. Ahrons, Ph.D. and “the good divorce.” Over thirty articles, book
chapters, and three books have resulted in the
widespread use of these concepts in the theoretical
Introduction and research literature on the structure and behav-
ior of divorced families, as well as in clinical
Constance R. Ahrons has been a leading scholar practice.
with her contributions to the theory and research By normalizing divorce and its transitions
on divorced families. She has been a major influ- and removing it from a purely pathological
ence in family therapy education and practice. view, her work has served to change the culture
of divorce in practice, scholarly theory and
research, and in public perceptions. Her work
Career has provided a new language for the structural
and behavioral dynamics in the family from
Ahrons received her Ph.D. from the University of childless couples, to families with children, to
Wisconsin in 1973. She held positions as Assis- postchild and aging couples.
tant and Associate Professor in the School of A major contribution to the field has been her
Social Work at Wisconsin (1974–1984) and numerous presentations nationally and interna-
Cofounder and Therapist, Wisconsin Family tionally to professional and lay audiences. These
Studies Institute, Madison, Wisconsin appearances have served to stimulate scholarly
(1979–1984). activity in the field and to invigorate public think-
The major portion of her career was spent at ing about the changes in families during the
the University of Southern California as an divorce experience.
Associate Professor in the School of Social Within the profession Ahrons has been active
Work and Associate Professor and Professor of in bringing her experience to a broad range of
Sociology (1986–2001). In the latter positions, organizations. These include:
she was heavily involved in the training of fam-
ily therapists as the Associate Director and Cofounder, first Chair, and Board Member of the
Director of the Marriage and Family Therapy Council on Contemporary Families
Program. She retired as Professor Emerita Guest Editor, Family Process, Special issue on
in 2001. Divorce and Remarriage
76 Ainsworth, Mary
Editorial Boards: Journal of Divorce and Introduction

Remarriage; Psychotherapy and the Family;
Family Process Mary Dinsmore Salter Ainsworth was a develop-
American Family Therapy Association: Charter mental psychologist whose vanguard empirical
Member, Executive Board (elected), Member methodology and theoretical formulations validated
of Research Committee, Chair of the Clinical the basic tenets of attachment theory while contrib-
Research Conference uting to the theory itself. Her conscientious,
American Association for Marriage and Family nurturing approach shaped numerous students and
Therapy: Fellow, Approved Supervisor, Com- colleagues whose work forms much of the sub-
mission on Supervision Research Committee stance of contemporary developmental psychology.
American Psychological Association, Member Ainsworth was born in 1913 in Ohio, to Mary
International Academy of Collaborative Profes- and Charles Salter. The family moved to Toronto,
sionals, Member Canada, in 1918 when Charles was transferred
International Family Therapy Association. and the family adopted Canadian citizenship.
Member Academic achievement was prized in the Ains-
National Conference on Family Relations, Mem- worth family, and Mary was precocious; she
ber, Publications Committee learned to read at three. At 16, Ainsworth began
honor psychology courses at the University of
Toronto. Despite her father’s initial suggestion
that she become a stenographer before she mar-
References ried, Ainsworth earned a doctorate in develop-
mental psychology at the University of Toronto
Ahrons, C. R. (1979). The binuclear family: Two house- in 1939 (Ainsworth 1983).
holds, one family. Alternative Lifestyles, 2, 499–515.
Ahrons, C. R. (1994). The good divorce: Keeping your
family together when your marriage comes apart.
New York: Harper Collins Publishers. Career
Ahrons, C. (1996). Making divorce work. Video: San
Francisco: Psychotherapy.net. Ainsworth’s first postgraduation appointment, as
Ahrons, C. R. (1998). Divorce: An unscheduled life cycle
a lecturer at the University of Toronto, was
transition. In B. Carter & M. McGoldrick (Eds.), The
family life cycle. New York: Allyn and Bacon. circumvented by World War II. She joined the
Ahrons, C. R. (2004). We’re still family: What grown Canadian Women’s Army Corps in 1942,
children have to say about their parents’ divorce. conducting assessments and counseling, and was
New York: Harper Collins Publishers.
promoted to the rank of major within the year.
Ahrons, C. R., & Rodgers, R. H. (1987). Divorced fami-
lies: A multidisciplinary developmental view. After V-Day, Ainsworth was invited to an admin-
New York: Norton. istrative position as superintendent of Women’s
Rehabilitation in the Department of Veteran’s
Affairs. Within a year, she had developed a multi-
disciplinary clinical vantage, deemed she had
Ainsworth, Mary accomplished what she could, and had tired of
administrative work (Ainsworth 1983).
Mary A. Fisher Returning to the University of Toronto, she
Mary Fisher Psychotherapy, PLLC, Salt Lake married Leonard Ainsworth, a veteran who was
City, UT, USA finishing his master’s degree. Concerned about
how it might feel to continue a Ph.D. in the
department where she had a faculty assignment,
Name the couple moved to London when Leonard
continued as a doctoral student at University
Ainsworth, Mary College, even though Mary had no work
Ainsworth, Mary 77
arranged for herself. In the interim, she controversy. Nonetheless, her work began to
co-authored a book on the Rorschach with validate Bowlby’s initial suspicions: Infants
Bruno Klopfer, Walter Klopfer (1954). are genetically predisposed to seek and maintain A
It was at a research position at the Tavistock proximity to adult caregivers, even before they
Clinic, directed by John Bowlby, that she began to are able to ambulate, by crying, vocalizing, and
formulate the research methodology that she reaching. Optimally, adult caregivers respond
would later employ in her cardinal works. Study- with complementary behaviors involving pro-
ing the effect of maternal separation on personal- tection and care. This ethological view pro-
ity development with James Robertson, she was posed that infants become attached to the
intrigued by his use of direct, naturalistic obser- caregivers who most reliably and substantially
vations followed by basic descriptive statistics. As relate with them and is its own motivational
well, Ainsworth’s collaborations with Bowlby, system distinct from feeding (Bretherton 1992).
during the early genesis of attachment theory Ainsworth’s second cardinal project began
itself, would change the course of her career with a theme that persisted throughout her married
(Bretherton 1992). Bowlby proposed that the pro- life: Leonard found an appointment, and Mary
cesses of social bonding in infancy were less followed, having made no arrangements for herself,
congruent with both psychoanalytic theory and though she asserted that career differences were not
social learning theory, and more specifically with at the root of their ultimate divorce in 1960
biology and ethology, in particular Lorenz’ con- (Ainsworth 1983). The couple settled in Baltimore.
cept of imprinting. Ainsworth remained skeptical, Johns Hopkins University eventually created a
influenced, as much of psychology was, by the position for her; responsibilities included providing
operant conditioning zeitgeist (Ainsworth 1983). psychological services, teaching, and the supervi-
When her husband finished his doctorate and sion of clinical students. Ainsworth soon found
applied for a position at the East African Insti- that her clinical appointment left scant time for
tute of Social Research at Kampala, Uganda, research, and thus she was released to pursue
Ainsworth, again, accompanied him with no what she would later write “drew together all the
work arranged for herself, though she was able threads of my professional career” (Ainsworth
to cobble together funds for a simple, anthropo- 1983, p. 213). Her Baltimore study combined nat-
logical, observational study. At the same time, uralistic observation in the homes of middle-class
she called for empirical validation of Bowlby’s families with a laboratory procedure she and Wittig
ethological views. Her motivation gave birth to (1969) named the Strange Situation. The Strange
one of two cardinal studies in Ainsworth’s Situation, the first of its kind, standardized a means
career. From 1954 to 1955, Ainsworth’s field of assessing how infants organize proximity-
study paid particular attention to “the onset of seeking behavior with attachment figures, illumi-
proximity-promoting signals and behaviors, nating normative patterns for how secure and inse-
noting carefully when these signals and behav- cure infants respond to stress. Early criticism of
iors became preferentially directed toward the Ainsworth’s interpretations of infant behavior in
mother” (Bretherton 1992, p. 7). Significantly, the Strange Situation was countered by the fact
Ainsworth found that secure infants cried less that classifications were extensively validated
and explored more, while insecure infants cried against home observations (Bretherton 1992). For
more and explored less, and that maternal sen- example, some critics viewed what Ainsworth clas-
sitivity to infants’ communications was corre- sified as avoidant behavior rather as independence.
lated with infant security. She also found that it However, her data showed that those babies had a
was not breastfeeding, per se, but rather the less congenial relationship with their mothers at
mother’s enjoyment of breastfeeding that is home than did the secure infants. Alan Sroufe and
salient to infant security (Ainsworth 1967). Everett Waters later further validated Ainsworth’s
These findings contradicted prevailing behav- classification with their psychophysiological
ioral notions and resulted in criticism and study revealing that the unperturbed demeanor of
78 Ainsworth, Mary
avoidant infants upon separation from caregivers baby who cries less. Because of her scientifically
belied their distress, as evidenced by increases rigorous nurturance, the field of attachment
in cortisol and heart rate (A. Sroufe, March 30, theory continues today, with conceptualizations
2018, personal communication). of attachment across the lifespan, psychopathol-
Collegial collaboration and connection were ogy, cross-cultural studies, and public policy
vital to Ainsworth, in part evidenced by her (Bretherton 1992).
vibrant correspondence and collaboration with
John Bowlby until his death, and the numerous
graduate students who were enriched by her men-
Cross-References
torship, including Mary Main, co-developer of the
Adult Attachment Interview, Robert Marvin, one
▶ Adult Attachment Interview
of the originators of the Circle of Security. In
▶ Attachment Disorders in Couple and Family
1975, when developmental psychologists were
Therapy
scant at Johns Hopkins, she accepted a position
▶ Attachment Theory
at the University of Virginia and continued her
▶ Attachment-Based Family Therapy
collaborative efforts. In 1978, along with Blehar,
▶ Bowlby, John
Waters, and Wall, she published Patterns of
▶ Children in Couple and Family Therapy
Attachment: A Psychological Study of the Strange
▶ Circle of Security
Situation, which is a report of the methodology
▶ Circle of Security Parenting Enrichment
and results of her Baltimore study.
Program
Ainsworth’s contributions and achievements
▶ Circle of Security: “Understanding Attachment
were lauded: the American Psychological Asso-
in Couples and Families”
ciation bestowed her with the G. Stanley Hall
▶ Development in Couples and Families
Award in 1984, the Award for Distinguished
▶ Fathers in Families
Contributions to Child Development in 1985,
▶ Mentalization in Couple and Family Therapy
and the Distinguished Scientific Contribution
▶ Mothers in Families
Award in 1989. She was elected a Fellow of
▶ Parenting in Families
the American Academy of Arts and Sciences
▶ Research in Relational Science
in 1992.
▶ Tavistock Clinic
Contributions to Profession of Couple

References
and Family Therapy
Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant
It is unlikely there exists a singular clinician in the care and the growth of love. Baltimore: The Johns
field of couple and family therapy who is unaware Hopkins Press.
of attachment theory, which is the result of a joint Ainsworth, M. D. S. (1969). Object relations, dependency,
and attachment: A theoretical review of infant-mother
effort between both Bowlby and Ainsworth. relationship. Child Development, 40, 969–1025.
Bowlby’s contributions were entirely theoretical Ainsworth, M. D. S. (1983). Mary D. Salter Ainsworth. In
and would not have had the impact and longevity A. N. O’Connell & N. F. Russo (Eds.), Models of
without Ainsworth’s empirically validating con- achievement (pp. 200–219). New York: Columbia Uni-
versity Press.
tributions (A. Sroufe, March 30, 2018, personal Ainsworth, M. D. S., & Wittig, B. A. (1969). Attachment
communication). Her work contributed to a more and the exploratory behavior of one-year-olds in a
accurate understanding of infant behavior and strange situation. In B. M. Foss (Ed.), Determinants
emotion, as well as what infants need for security. of infant behavior (Vol. 4, pp. 113–136). London:
Methuen.
Because of her work, clinicians may confidently Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S.
help struggling parents understand that picking (1978). Patterns of attachment: A psychological study
up a crying baby will ultimately result in a of the strange situation. Hillsdale: Erlbaum.
Alcohol Use Disorders in Couple and Family Therapy 79
Bretherton, I. (1992). The origins of attachment theory: have on relationship functioning, it is crucial to
John Bowlby and Mary Ainsworth. Developmental understand AUDs in the context of couple and
Psychology, 28, 759–775.
Klopfer, B., Ainsworth, M. D., & Klopfer, W. F. (1954). family therapy. A
Developments in the Rorschach Technique, vol. 1:
Technique and theory. Yonkers-on-Hudson: World
Book Company. Theoretical Context for Concept
Consequences associated with alcohol-related

problems can contribute to relationship distress,
Alcohol Use Disorders
which in turn can serve as a cue for further alcohol
in Couple and Family Therapy
use (Kelly 2009). Within couples, AUDs are asso-
ciated with relationship conflict, an increased risk
Autumn Rae Florimbio, Meagan J. Brem and
for partner violence, reduced intimacy, financial
Gregory L. Stuart
difficulties, and emotional health problems in one
University of Tennessee-Knoxville, Knoxville,
or both partners. When working with couples and
TN, USA
families, it is important to explore the dynamics of
the couple or family from a systemic view. In
other words, rather than focusing solely on one
Synonyms
individual, the focus should include all members
of the family system and the interactions that
Hazardous alcohol use; Problematic alcohol use
occur among them. Exploring relationships from
a systemic view provides information about each
Introduction individual within the system and how interactions
between individuals contribute to relationship
Alcohol is one of the most commonly used sub- functioning. This notion holds true when
stances. While some individuals can use alcohol addressing AUDs in the context of couple and
safely, others’ patterns of use result in signifi- family therapy. That is, the focus should not be
cant impairment in functioning across various limited to only the individual with the AUD diag-
life areas. Such impairment typically occurs nosis but should include all members of the family
when alcohol is used frequently, excessively, system and the interactions that occur among
and hazardously. Recurrent use of alcohol in members as well.
this manner that is accompanied by significant In regard to AUDs, individual and systemic
impairment is recognized as a disorder in the factors have been identified that may contribute
Diagnostic and Statistical Manual of Mental to a partner’s alcohol use and, in turn, affect rela-
Disorders (5th ed.; DSM-5; American Psychiat- tionship functioning. One area to consider is indi-
ric Association [APA] 2013). Alcohol use dis- vidual attitudes and beliefs regarding alcohol use
order (AUD) is characterized by a combination and AUDs. Individuals may hold certain beliefs
of features, including loss of control over one’s about the origins and explanations of alcohol use
alcohol use and physiological symptoms. More- and related disorders. For example, one partner
over, AUD is associated with a host of short- may hold the belief that using alcohol is a choice
and long-term consequences such as alcohol- and abstaining from alcohol use is just another
related accidents, physical and mental health choice that should not be difficult. This belief
problems, and disturbances in social, occupa- could impact how the partners address alcohol-
tional, and/or familial functioning. Although a related problems and how they interact with one
diagnosis of AUD occurs at the individual level, another. Additionally, this belief could interfere
the consequences associated with AUDs extend with treatment. A clinician aware of such beliefs
beyond the individual, affecting partners and could provide psychoeducation about current
family members. Given the impact AUDs can explanations of alcohol use and the intricacies of
80 Alcohol Use Disorders in Couple and Family Therapy
repeated alcohol use on biopsychosocial function- consists of treatment using substance- and
ing (Lander et al. 2013). relationship-focused methods in conjunction,
The various functions of alcohol use within the although substance-focused methods are typi-
relationship should also be considered. There is cally employed first. Substance-focused methods
evidence suggesting that alcohol use can facilitate in BCT include a daily recovery discussion or
intimacy and warmth among couples and may be contract around the sobriety of the partner with
viewed as a positive component within the rela- the AUD. Each day, the partner states their intent
tionship (Leonard and Eiden 2007). However, of sobriety for the week and plans for their recov-
there are often situations in which the function ery, such as attending self-help meetings. The
of alcohol within the relationship is not apparent other partner is encouraged to support their
to partners. In some cases, alcohol may be used as partner’s goals for sobriety and maintaining
a way to cope with relationship distress. One abstinence. Other substance-focused methods
partner may use alcohol as a way to cope with include identifying and reviewing high-risk situ-
day-to-day arguments occurring within the rela- ations that may trigger an urge to use alcohol and
tionship and be unaware that the arguments are a discussing with both partners the role of relapse
result of consequences related to the alcohol use in recovery. Relationship-focused methods
(e.g., financial difficulties, not fulfilling responsi- include increasing positive activities and com-
bilities around the home). This emphasizes the munication within the relationship. A similar
importance of understanding alcohol’s function approach is alcohol behavioral couples therapy
within a couple and/or family system. (ABCT), which aims to include both partners in
Another factor to consider is exploring the the treatment process and encourage change
interaction between partners’ behaviors and how within both partners. Goals of ABCT include
behaviors may reinforce an individual’s problem- (a) involving both partners in the treatment pro-
atic alcohol use. For example, when one partner cess, (b) reducing or discontinuing alcohol use,
has an AUD, the other partner may engage in (c) helping both partners develop effective cop-
enabling behaviors, behaviors they perceive as ing skills and responses to apply to drinking
caring and helpful, such as making excuses for a situations, (d) increasing relationship satisfac-
partner missing work, when the behaviors may tion, and (e) maintaining improvements
actually maintain problematic alcohol use by established in therapy (Kelly 2009; McCrady
reinforcing properties of alcohol use or eliminat- 2012). Both BCT and ABCT have demonstrated
ing negative consequences (Klostermann and favorable outcomes in terms of reduced drinking
O’Farrell 2013; McCrady 2012; Rotunda and better relationship functioning (McCrady
et al. 2004). It is important to note that such 2012; O’Farrell and Schein 2011).
behaviors may be a partner’s method of coping
with their partner’s alcohol use. Identifying
reinforcing properties of behavior among couples Application of Concept in Couple
and families is important to understand the recip- and Family Therapy
rocal relationship between AUDs and relationship
functioning. Couples and families may present to treatment
already having identified alcohol use as the pri-
mary problem. However, there may be situations
Description in which couples and families present to treatment
for problems associated with alcohol use such as
Different treatment modalities exist for treating financial difficulties, domestic violence, or
AUDs in couple and family therapy. Behavioral decreased relationship satisfaction. In other
couples therapy (BCT) is one approach to words, rather than identifying alcohol use as a
treating AUDs and other risky substance use in culprit for problems within the relationship or
couples (O’Farrell and Schein 2011). BCT family, alcohol-related consequences may be the
Alcohol Use Disorders in Couple and Family Therapy 81
reason for presenting to treatment (Cox discord. The therapist further assessed the role of
et al. 2013). As such, it is critical to routinely alcohol in their relationship.
assess alcohol use at the onset of treatment, even After becoming unemployed, Jane applied to A
when it is not the presenting problem. several jobs yet was unable to secure employment.
In addition to a thorough assessment, therapists This was discouraging to Jane and her evening glass
should clarify the impact and function of alcohol of wine seemed to help with handling her current
use within the couple or family. The impact of situation. Her evening glass of wine gradually
having a parent with an AUD on children and increased to three to four glasses, and eventually
adolescents, as well as how AUDs among adoles- she was drinking nearly two and a half bottles of
cents can impact the family system, should be wine daily. Despite having more time to fulfill obli-
considered. When a parent or guardian has an gations at home, Jane’s drinking interfered with her
AUD, children may develop reversed roles in ability to meet her obligations. Bill agreed and indi-
which they begin to take on a parental or caregiver cated that there were several occasions in which he
role. Taking on a role before it is developmentally had come home from work to find that Jane did not
appropriate is associated with difficulties setting follow through on tasks she said she would com-
interpersonal boundaries and regulating emotions plete (e.g., running errands, grocery shopping, laun-
(Lander et al. 2013). Children and adolescents dry, etc.). At first, Bill would complete the tasks for
with parents who have an AUD are at an increased her; however, Bill had become frustrated with Jane
risk for the later development of psychological and he began to argue with her about her drinking.
disorders, including alcohol and substance use Bill admitted that he had become increasingly over-
disorders. Adolescents with an AUD can impact whelmed as a result of working more hours to
the family system as well, and treatment should support their family. Jane’s increased alcohol use
focus on increasing familial support for absti- was negatively impacting her relationship with
nence, improving communication, and restoring Bill. As the turmoil in their relationship increased,
the family environment and functioning. When Jane’s desire to drink increased as a means to cope
working with couples and families in which one with the stress.
or more members have an AUD, it is important to Following the assessment sessions, the therapist
convey that the disorder does not solely affect the provided feedback based on the information the
diagnosed individual, but both members of the couple had provided during the assessment. Jane’s
couple or members of the entire family system. use of alcohol functioned as a coping mechanism for
Similarly, it should be communicated that behav- negative emotions and relationship distress. Her use
ior change of one partner or family member that also impaired her ability to fulfill responsibilities at
will occur during the course of therapy will affect home, which contributed to Bill’s stress. Bill’s
other members (Lander et al. 2013). response (e.g., taking care of her, completing tasks
for her) reinforced Jane’s alcohol use, as it removed
negative consequences associated with her drinking.
Clinical Example While acknowledging that treatment would be chal-
lenging, Bill and Jane were both motivated for
Bill and Jane presented for couple therapy after treatment to increase satisfaction within their rela-
experiencing increased arguments, problems with tionship and work toward Jane’s goal of achieving
communication, decreased intimacy, and overall abstinence from alcohol.
relationship dissatisfaction. The couple had been The beginning of therapy focused on reducing
married for 7 years with one child, a 4-year-old Jane’s alcohol use. One strategy utilized was for the
daughter. The couple described their relationship couple to engage in a daily conversation that Jane
as “good” up until 1 year ago when Jane was let go initiated in which she stated her intentions for sobri-
from her job. The couple revealed that Jane’s ety that day. The discussion also included Jane’s
alcohol use had escalated significantly since then intent for attending self-help and support groups,
and seemed to relate to much of their relationship such as Alcoholics Anonymous. Bill was
82 Alcoholics Anonymous, 12-Step Programs
encouraged to convey his support of Jane’s plan for Kelly, A. B. (2009). Behavioral couples therapy in the
sobriety. The couple practiced the discussion in ses- treatment of alcohol problems. In P. M. Miller (Ed.),
Evidence-based addiction treatment (1st ed.,
sion prior to trying it at home on their own. The pp. 233–247). Burlington: Elsevier/Academic.
therapist also provided psychoeducation on various Klostermann, K., & O’Farrell, T. J. (2013). Treating sub-
aspects of AUDs. Specific situations that elicited stance abuse: Partner and family approaches. Social
cravings for alcohol and/or triggered Jane’s alcohol Work in Public Health, 28, 234–247. https://doi.org/
10.1080/19371918.2013.759014.
use were assessed. Focusing on specific situations Lander, L., Howsare, J., & Byrne, M. (2013). The impact of
increased awareness for both partners regarding sit- substance use disorders on families and children: From
uations that would be particularly challenging for theory to practice. Social Work Public Health, 28,
Jane. Jane learned alternative, healthy ways to cope 194–205. https://doi.org/10.1080/19371918.2013.759005.
Leonard, K. E., & Eiden, R. D. (2007). Marital and family
with situations, and Bill learned skills to provide processes in the context of alcohol use and alcohol disor-
support for Jane in responding to situations that ders. Annual Review of Clinical Psychology, 3, 285–310.
might serve as a trigger for her. Eventually the https://doi.org/10.1146/annurev.clinpsy.3.022806.091424.
couple applied the positive coping skills they learned Marital.
McCrady, B. S. (2012). Treating alcohol problems with
to other areas of concern in their relationship (e.g., couple therapy. Journal of Clinical Psychology, 68(5),
communication problems, and reduced intimacy). 514–525. https://doi.org/10.1002/jclp.21854.
Bill and Jane practiced openness and honesty with O’Farrell, T. J., & Schein, A. Z. (2011). Behavioral couples
each other regarding their feelings on a daily basis. therapy for alcoholism and drug abuse. Journal of
Family Psychotherapy, 22(3), 193–215. https://doi.
They scheduled time together that did not involve org/10.1080/08975353.2011.602615.
alcohol and worked on increasing positive interac- Rotunda, R. J., West, L., & O’Farrell, T. J. (2004).
tions between them. They identified current prob- Enabling behavior in a clinical sample of alcohol-
lems (e.g., Jane’s unemployment, financial dependent clients and their partners. Journal of Sub-
stance Abuse Treatment, 26(4), 269–276. https://doi.
difficulties), and, with the help of the therapist, org/10.1016/j.jsat.2004.01.007.
they developed potential solutions to solve them.
Throughout the course of therapy, Jane decreased
her drinking and achieved abstinence from alcohol.
Bill and Jane were able to effectively communicate Alcoholics Anonymous,
with each other which reduced the amount of argu- 12-Step Programs
ments and increased their overall relationship
satisfaction. Shannon Cooper-Sadlo1 and Jessica L. Chou2
1
School of Social Work, Saint Louis University,
St. Louis, MO, USA
Cross-References 2
Queen of Peace Center, St. Louis, MO, USA
▶ Addictions in Couple and Family Therapy

▶ Behavioral Couple Therapy Synonyms
▶ Substance Use Disorders in Couple and Family
Therapy AA*
American Psychiatric Association. (2013). The diagnostic
and statistical manual of mental disorders (5th ed.). Over 17 million individuals suffer from alcohol
Washington, DC: Author. dependence or abuse, and millions more exhibit
Cox, R. B., Ketner, J. S., & Blow, A. J. (2013). Working with risky behaviors that have the potential to become
couples and substance abuse: Recommendations for an addiction (ncadd.org). In response to this public
clinical practice. The American Journal of Family Ther-
apy, 41, 160–172. https://doi.org/10.1080/01926187. health problem, Alcoholics Anonymous (AA)* was
2012.670608. created “. . . to carry the message of recovery to the
Alcoholics Anonymous, 12-Step Programs 83
person with alcoholism who is seeking help in members have the freedom to share personal nar-
achieving sobriety,” (Barnett 2003, p. 469). Since ratives that are the basis of the supportive nature
inception in 1935, AA supports individuals and their of mutual aid groups. There are three types of A
families in the recovery process through a 12-step meetings, and newcomers are encouraged to
program. Often times, various systems of a person’s attend 90 meetings in 90 days as well as obtaining
life are disrupted by alcohol use including social a sponsor. The three types of meetings include:
networks (friends, family, coworkers). Through Speaker meetings, Discussion meetings, and Step
AA a person can begin their journey to recovery meetings. Speaker meetings are personal addic-
and rebuilding their life. tion and recovery narratives by members who
have at least 90 days of sobriety. Discussion meet-
ings are open for members to share personal expe-
Location
riences but center around a specific topic. Step
meetings focus on the exploration and discussion
Alcoholics Anonymous is the oldest 12-step pro-
of a particular step and how members have used
gram and has more than 114,000 groups worldwide
that step in their recovery process. Speaker meet-
and a membership of two million individuals in the
ings are traditionally open to all who wish to
USA and Canada (Alcoholics Anonymous World
attend, while Discussion meetings and 12-Step
Services 2012). Groups are often held at churches,
meetings can be closed to anyone that is not a
community centers, and treatment facilities. Individ-
part of the fellowship (Alcoholics Anonymous
uals are encouraged to contact the regional chapter
2016; Fewell and Speigel 2014; Reiter 2015).
in order to locate meetings in the area. AA offers
groups that are specific to gender, age, demographic,
Ultimately, the 12-Steps were developed and are
as well as offering groups for members with
the guiding principles of AA and the other
co-occurring mental health issues.
12-Step programs that have developed utilizing
the prototype of AA.
Prominent Associated Figures The 12-Steps are:
Alcoholics Anonymous is a mutual aid group that 1. We admitted we were powerless over
was developed in 1935 by Bill Wilson and Dr. Bob alcohol – that our lives had become
Smith. AA was influenced by the Oxford Group, an unmanageable.
international religious movement in the 1920s and 2. Came to believe that a Power greater than
1930s, which incorporated the early teachings of ourselves could restore us to sanity.
Christianity and self-improvement that encouraged 3. Made a decision to turn our will and our lives
an examination of the lives of the members, admit- over to the care of God as we
ting wrongdoing, making amends, praying and understood Him.
meditation, and spreading the work of the group 4. Made a searching and fearless moral inven-
(Fewell and Speigel 2014; Reiter 2015). tory of ourselves.
5. Admitted to God, to ourselves, and to another
human being the exact nature of our wrongs.
Contributions (Including What It Is 6. Were entirely ready to have God remove all
Known for, Relevance to Couple these defects of character.
and Family Therapy, and Mission 7. Humbly asked Him to remove our
and Values, Though Not Presented shortcomings.
in Separate Sections) 8. Made a list of all persons we had harmed and
became willing to make amends to them all.
9. Made direct amends to such people wherever
AA Overview AA is a strictly peer-led program possible, except when to do so would injure
that requires anonymity in order to ensure that them or others.
84 Alcoholics Anonymous, 12-Step Programs
10. Continued to take personal inventory and members of the unit have experienced consequences
when we were wrong promptly admitted it. of alcohol dependence. Alcohol problems within a
11. Sought through prayer and meditation to couple or family can generate marital conflict and
improve our conscious contact with God as have a negative impact on children. As research
we understood Him, praying only for knowl- suggests that family and couple relationships are
edge of His will for us and the power to carry an integral part of the recovery process for those
that out. with alcohol addiction (Navarra 2007), AA can be
12. Having had a spiritual awakening as the result used as a counterpart to couple and family therapy to
of these steps, we tried to carry this message to treat the whole family system (Walsh 2003). Family
alcoholics and to practice these principles in all is encouraged to attend meetings and help partici-
our affairs. (Alcoholics Anonymous 2016). pate in the recovery process (Gurman 2008).
Values Bill W. wrote Alcoholics Anonymous Al-Anon Overview Al-Anon grew out of the
(Bill 1939/1976), which is often referred to as AA movement as a support for the families and
“The Big Book” as a guide to the recovery friends of the members of AA. Lois, the wife of
process. This text describes “The Promises” Bill W., was instrumental in the formalization of
which are statements that encourage members Al-Anon as a separate self-help group in 1951
to accept responsibility for recovery, engage in a (Fewell and Speigel 2014; Reiter 2015).
spiritual awakening, and use personal experi- Al-Anon remains the most recognizable and
ences to provide guidance and support to others. widespread support group for families
If members adhere to the 12 Steps, recovery and friends of loved one with alcohol addic-
from substance use is possible (Fewell and tions. According to a 2009 Al-Anon survey,
Speigel 2014). The goals of AA are maintained Al-Anon groups are found in the USA, Canada,
abstinence from substance use, a sober support and 130 countries worldwide (Al-Anon
community, as well as a guide for psychological Family Groups 2009; Fewell and Speigel 2014).
and spiritual well-being.
The majority of the participants in Al-Anon are
Relational Perspective of AA Many who suffer the female partner/spouse of men who have an
from alcohol addiction have severed personal and addiction (Fewell and Speigel 2014). The 2009
professional relationships leaving an individual survey of Al-Anon participants reports that 84 %
isolated to manage their disease. Each person of the members are women and 60 % are over the
participating in the 12-Step program is encourage of 56 (Al-Anon 2009). Of the respondents of
aged to utilize support by seeking out a sponsor. this survey, 94 % were still involved with the indi-
Sponsorship is described as a supportive one-on- vidual whether or not the loved one was sober
one relationship with a long-term member of AA (Al-Anon 2009).
(Fewell and Speigel 2014; Reiter 2015). Sponsor- Al-Anon utilizes the 12 steps of AA as the guid-
ship provides an individual in the program a per- ing principles with the exception of the final step in
son to turn to in times of question and hardship, as which the language is changed to include the edu-
well as someone who will celebrate recovery cation of others (Reiter 2014). The focus of
through shared experience. As alcoholism Al-Anon is to provide ongoing support and increase
impacts individuals and their families, a sponsor the coping skills for the families and friends of the
can assist an individual in exploring different person with the addiction. Al-anon addresses the
capacities for family involvement. issue of codependency through the slogan of the
three C’s: “I didn’t cause alcoholism, I can’t control
When one member of a family is experiencing it, and I can’t cure it” (Al-Anon Family Groups
alcohol addiction, there is a high likelihood other 2009). Participants can focus on their recovery
Alexander, James 85
needs rather than on the person with the addiction.

Furthermore the refocusing of attention to the self Alexander, James
provides the participant the opportunity to “detach A
with love” from the loved one’s behaviors while Douglas Kopp and Michael Robbins
maintaining a positive and loving relationship with Functional Family Therapy LLC, Seattle,
the person. WA, USA
Due to the increase of 12-Step groups that
address specific drugs, drug-specific and
age-specific family support groups have grown as Name
well. These groups are Nar-Anon and Alateen. The
groups offer an opportunity for peer support and James F. Alexander.
growth for those who have a loved one with an
addiction.
Introduction
Cross-References Alexander is the developer of Functional Family

Therapy (FFT), one of the most widely dissemi-
▶ Addictions in Couple and Family Therapy nated family therapy approaches for young per-
▶ Adult Child of Alcoholics (ACOA) sons with disruptive behavior problems. His
▶ Alcohol Use Disorders in Couple and Family contributions to the field span more than four
Therapy decades with over 100 publications demonstrating
▶ Family of Origin the impact of family therapy for one of the most
▶ Stages of Change in Couple and Family Therapy recalcitrant clinical populations. His work has
been recognized by the Centers for Disease Con-
trol, Office of Juvenile Justice and Delinquency
References Prevention, and the Surgeon General as one of the
most effective treatments for youth with behavior
Al-Anon Family Groups. (2009, Fall). Al-Anon member-
problems.
ship survey. Virginia Beach: Author. www.al-anon.org/
membership-2009-survey
Alcoholics Anonymous World Services. (2012). 2011
Membership survey. Retrieved July 26, 2016, from Career
http://www.aa.org
Alcoholics Anonymous. (2016). AA.org. Retrieved July
29, 2016, from http://www.aa.org Alexander received his Bachelor of Arts from
Barnett, M. A. (2003). All in the family: Resources and Duke University before attending graduate school
referrals for alcoholism. Journal of the American Acad- at the California State University and Michigan
emy of Nurse Practitioners, 10, 467–472.
State University, where he received his Ph.D. For
Fewell, C. H., & Speigel, B. R. (2014). 12-Step programs
as a treatment modality. In S. L. Straussner (Ed.), Clin- more than 40 years, Alexander was a Professor at
ical work with substance-abusing clients (3rd ed., pp. the University of Utah in Salt Lake City where he
275–300). New York: The Guilford Press. developed FFT. During this time, he served as
Gurman. A. (Ed.). Clinical handbook of couple therapy
principal or coprincipal investigator on numerous
(4th ed). New York: Guilford Press.
Navarra, R. (2007). Family response to adults and alcohol. clinical and research grants and contributed
Alcoholism Treatment Quarterly, 25, 84–104. numerous publications to the field of family ther-
Reiter, M. D. (2015). Substance abuse and the family. New apy. Alexander served as President of Division
York: Routledge Publishing.
43 of the American Psychological Association in
Walsh, F. (Ed.). (2003). Normal family processes: Growing
diversity and complexity (3rd ed.). New York: 1988. Alexander’s contributions to the field have
Guildford Press. been consistently recognized by his peers,
86 Alexander, James
including the American Psychological Association groups, and service providers with diverse back-
where he has received the Presidential Citation for grounds and training. Moreover, evidence sup-
Lifetime Contributions to Psychology, Family Psy- ports the effectiveness of FFT for siblings and
chologist of the Year, and Distinguished Contribu- parents of problem youth, and for the long-term
tion to Family Psychology Awards. effectiveness of the intervention.
Alexander’s efforts to develop, test, and
disseminate the FFT model has had a broad
Contributions to Profession impact on youth, families, and communities,
both nationally and internationally. FFT is being
Alexander began to create and research the core implemented systematically in more than
elements of Functional Family Therapy (FFT) in 350 accredited sites in USA, Europe, and the
1971 in collaboration with Drs. Cole Barton and Western Pacific/Asia. FFT LLC (www.fftllc.
Bruce Parsons. The development of the FFT com) trains and supervises/consults with 2000+
model has now spanned more than four decades therapists treating 40,000+ families per year, with
and represents one of the most rigorous and clini- session-by-session tracking for feedback and
cally compelling programs of research in the field of quality control. Thus, implementation in the real
evidence-based practice. Jim’s body of work has world has been characterized by rigorous evalua-
included core experimental family interaction tion, oversite, and accountability, which has been
research, in-session change mechanisms research, a hallmark of Alexander’s work for decades. The
developing and sequencing clinical model integrity of implementation has ensured that
elements, developing training formats, and approximately 500,000 troubled youth and their
conducting outcome research evaluating proximal, families have received the highest quality of care
intermediate, and long-term outcomes. over the past 15 years.
After the first two decades of research and FFT also represents a framework and implemen-
clinical development, primarily led by tation vehicle for programs providing treatment for
Dr. Alexander and colleagues at the University youth and families in diverse settings including
of Utah, the FFT model was designated by the mental health, school, child welfare, juvenile justice
Center for the Study and Prevention of Violence probation and/or parole, and integrated reentry/
as a “Blueprints Program.” FFT has received sim- reunification services. The findings from numerous
ilar designations as an Exemplary Program, Best independent research studies provide strong support
Practice, and Evidence-Based Effective program for the effectiveness of FFT across these settings.
(Center for Substance Abuse Prevention, Centers Newer specialized applications of the model are
for Disease Control, Office of Juvenile Justice and undergoing trials in child welfare settings and with
Delinquency Prevention, and the American Youth gang-involved youth.
Policy Forum) for the treatment of youth violence,
substance abuse, and related behavioral disorders.
FFT also has been designated one of only four Cross-References
Level 1 treatment programs in the 2001 US Sur-
geon General’s Report on Youth Violence (www. ▶ Functional Family Therapy
ncbi.nlm.gov/pubmed/20669622).
Over the past two decades, Alexander has
spearheaded efforts to move FFT from research References
to clinical practice settings. The FFT model is now
one of the most widely-disseminated family- Alexander, J. F., Barton, C., Schiavo, R. S., &
based intervention programs for adolescent vio- Parsons, B. V. (1976). Systems-behavioral intervention
with families of delinquents: Therapist characteristics,
lence, substance abuse, and related behavioral family behavior, and outcome. Journal of Consulting
disorders. The effectiveness of FFT has been rep- and Clinical Psychology, 44(4), 656–664. https://doi.
licated across sites, settings, ethnic cultural org/10.1037/0022-006X.44.4.656.
Alger, Ian 87
Alexander, J., & Parsons, B. V. (1982). Functional family Medicine in the United States. He mainly practiced
therapy (pp. 109–112). Monterey, CA: Brooks/Cole in the state of New York and pursued training in
Publishing Company.
Alexander, J. F., Waldron, H. B., Robbins, M. S., & psychoanalysis at the New York Medical College A
Neeb, A. A. (2013). Functional family therapy for after which he opened a private practice. Dr. Alger
adolescent behavior problems (p. 261). Washington, established a successful academic and clinical career
DC: American Psychological Association. holding esteemed appointments such as clinical pro-
fessor of psychiatry at the Albert Einstein College of
Medicine, adjunct professor of clinical psychiatry
and training and supervising analyst at the Psycho-
Alger, Ian analytic Institute within the department of psychia-
try at the New York Medical College, psychiatrist at
Sarah K. Samman the Rusk Institute of Rehabilitation Medicine in
Alliant International University, San Diego, New York, and chief psychiatrist at the New York
CA, USA Regional Respiratory Center, in addition to appoint-
ments at the Weill Medical College of Cornell, the
Letterman Army Hospital in San Francisco, and the
Name New York–Presbyterian Hospital. He was also the
president of the American Orthopsychiatric Associ-
Alger, Ian ation from 1979 until 1980 and was an advisory
editor for Family Process. His innovative therapeu-
tic interventions landed him a consulting position
Introduction for a public broadcasting show addressing issues on
mental health, titled The Thin Edge.
Ian E. Alger was born in Oshawa, Canada, in
1926. After earning his medical degree, he immi-
grated to the United States and pursued psychiatry Contributions to Profession
at Bellevue Hospital-New York University
(NYU) School of Medicine. He later trained as a Dr. Alger was one of the first psychoanalysts to
psychoanalyst and established innovative tech- pioneer the use of videotaping and playback into
niques for couples, families, and groups, primarily couple, family, and group therapy sessions. He
around the use of video recording in therapy and intentionally used videotaping with patients as a
its use as a catalyst for self-revelation. He was a therapeutic instrument to capture nonverbal cues
successful published author spanning four and gestures which Dr. Alger believed influenced
decades on various topics such as the treatment the therapeutic experience as strongly as spoken
of physical and mental illnesses within their social words. He often showed video recordings to patients
contexts; modern couple therapy, including roles, to point out nonverbal cues and bring them to
rules, and power in relationships; and the use of patients’ awareness such as nervous tapping and
technology in therapeutic treatment such as utiliz- its effect on other members. He believed this process
ing videos in therapy, engaging in virtual reality, increased patients’ self-awareness and resulted in
and telemedicine. Dr. Alger passed away in 2009 tangible insights leading to immediate and signifi-
in Manhattan, New York, at the age of 82. cant changes in sessions, particularly in family and
marital therapy. He also advocated for the use of
videos in therapy with children who present as
Career nonverbal or who have experienced trauma. He
proposed recording puppets on video and introduc-
Dr. Alger obtained his medical degree from the ing the recordings to young patients to support the
University of Toronto in 1949 and trained as a therapeutic experience when there are no opportu-
psychiatrist at Bellevue Hospital-NYU School of nities to use physical puppets in session.
88 Alliance in Family Relationships
Dr. Alger also advocated for the use of tele- Alger, I., & Hogan, P. (1969). Enduring effects of video-
therapy and virtual reality. Teletherapy involves tape playback experience on family and marital rela-
tionships. American Journal of Orthopsychiatry, 39(1),
communication with patients via videoconferencing 86–98.
as opposed to face-to-face in-session interactions. Alger, I., & Rusk, H. A. (1955). The rejection of help by
Virtual reality involves the inclusion of live interac- some disabled people. Archives of Physical Medicine
tion between the therapist and patients in a proposed and Rehabilitation, 36(5), 277–281.
virtual environment that reflects the patients’ reali-
ties. The therapist in this approach joins the interac-
tional process and provides in-session feedback with Alliance in Family
the goal to exact immediate change. This allows the Relationships
space for patients to co-create their realities and
enact change in their lives. Jody Russon1, Maliha Ibrahim2 and
Dr. Alger contributed dozens of publications Guy S. Diamond2
over the course of his 40-year career. Several book 1
Center for Family Intervention Science, Drexel
publications included Doctor/patient Communica- University, Philadelphia, PA, USA
tion and Technology, Marriage and Marital Prob- 2
Center for Family Intervention, Drexel
lems, Family Therapy: Full Length Case Studies University, Philadelphia, PA, USA
(co-author), Family Therapy: Models and Tech-
niques (co-author), and The Marriage Relationship:
Psychoanalytic Perspectives (co-author). Several Name of Concept
article titles include Continuing Education and
Training; Creative Media in Psychotherapy; Marital Alliance in family relationships
Therapy with Dual Career Couples; Puppetry as a
Therapeutic Tool for Hospitalized Children; Stimu-
lus Tapes on Attitudes, Supervision, and Stereo- Introduction
types; The Social Context in Virtual Realities;
Therapeutic Use of Videotape Playback; and Ther- Alliance refers to the factors that allow clients to
apy with Schizophrenic Patients. accept and engage in psychotherapy (Bordin
1979). This construct is the most robust predictor
of psychotherapy outcome and has been investi-
Cross-References gated for several decades (Barber et al. 2000).
▶ Emerging Technologies in Couple and Family

Therapy Theoretical Context for Concept
▶ Family Process (Journal)
▶ Psychoanalytic Couple and Family Therapy Early in the history of psychotherapy, Carl Rog-
▶ Recorded Supervision in Couple and Family ers’ (1951) emphasis on unconditional positive
Therapy regard made the relationship central to the
achievement of therapeutic gains. Building off of
Rogerian concepts, Bordin (1979) conceptualized
References alliance as consisting of three components.
Specifically, the client and therapist must
Alger, I. (1990). Managing the aggressive patient, plus (a) develop a trusting relationship (bond),
videotapes on schizophrenia and the homeless. Psychi- (b) establish agreement on what the client wants
atric Services, 41(8), 840–842. https://doi.org/10.1176/ to change (goals), and (c) obtain agreement on
ps.41.8.840.
Alger, I., & Hogan, P. (1967). The use of videotape record- how to go about changing (tasks). Bordin’s frame-
ings in conjoint marital therapy. American Journal of work served as the foundation for decades of
Psychiatry, 123(11), 1425–1430. theoretical and empirical work on alliance.
Alliance in Family Relationships 89
Description room while moving the family to agree on joint

goals and tasks (Bordin 1979; Pinsof and Catherall
Alliance in family relationships refers to a trusting 1986): A
relationship as well as agreement upon goals and
related tasks in therapy among various dyads (i.e., Case. A 15-year-old Caucasian adolescent,
family member to therapist, and family member to Sasha, and her father, Eric, were referred
family member, as well as entire system to from a local children’s hospital due to
therapist). Sasha’s intermittent, passive suicidal
thoughts (client names have been changed
to maintain confidentiality). In an assess-
Application of Concept in Couple and
ment, Sasha disclosed that she has been feel-
Family Therapy
ing “down” and had “lost her friends.” Eric
stated that Sasha’s paternal grandmother
Alliance research has focused on treatment out-
passed away a month ago and expressed his
comes and therapeutic change across a variety of
frustration about his daughter’s “inability to
treatment modalities and clinical issues. It is well
communicate.” He complains that Sasha is
established that alliance consistently predicts out-
“too sensitive” to have a mature
come above and beyond therapeutic techniques
conversation.
(Safran and Muran 2000). In the last three
Bond. The therapist begins the first session by
decades, couple and family therapy (CFT)
asking about individual and relational
researchers and practitioners have expanded the
strengths. Specifically, the therapist asks
definition of alliance by examining relationships
Sasha about her interests at school and,
within and between multiple family members and
thus, unearths her strengths. The therapist
the therapist. According to Pinsof and Catherall
then asks Eric to comment on these strengths
(1986), this meant accounting for multiple levels
(“Did you know your daughter was so good
of alliance. At the first level, each client’s alliance
at math?”). As Eric responds positively to his
with the therapist is determined (e.g., Does the
daughter’s attributes, the therapist then high-
father feel good about his work with the thera-
lights this interaction (“It sounds like you are
pist?). At the next level, each client’s perception
really proud of your daughter’s ability”). In
of other family members’ alliances with the ther-
this initial interaction, the therapist’s
apist is considered (e.g., Does the mother think
verbal and nonverbal communication
that the therapist had a good connection with the
emphasizes that she is interested in each fam-
reluctant father?). Finally, at the final level, each
ily member.
family members’ perception of the therapeutic
Goal. Once a bond is created, the therapist asks
relationship with the family system, at large, is
Sasha and her father to discuss why they
evaluated (e.g. Does the son think that the thera-
came to therapy. The therapist continuously
pist has a strong working relationship with his
reiterates that she wants to hear both Eric’s
family?).
and Sasha’s perspective on the issue. The
therapist notices that Sasha has a tendency
Clinical Example to disengage, while Eric does most of the
talking. In order to continue to build her alliance
The following clinical example illustrates one of with Sasha, the therapist respectfully blocks
many possible ways of joining with a family system. Eric’s interruptions while Sasha is talking
Strategies used to join with families vary according about her experience (e.g., “Hold on one sec-
to approach. In this example, the therapist uses an ond, I need to make sure I understand your
attachment-based family therapy (Diamond et al. daughter’s perspective too, so I know where
2014) framework to guide alliance-building. Specif- you both stand”). This intervention continues
ically, the therapist bonds with each individual in the to build the bond with Sasha, while the therapist
90 Alliance Repair in Couple and Family Therapy
gets an individual understanding of the prob- References

lems. Sasha explains that she has been feeling
sad and lonely. She has been missing her Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis,
L., & Siqueland, L. (2000). Alliance predicts patients’
grandma and doesn’t feel like her dad under-
outcome beyond in-treatment change in symptoms.
stands her. In fact, he keeps bothering her by Journal of Consulting and Clinical Psychology, 68(6),
always being “in my business.” Eric describes 1027.
how his daughter isn’t giving him the chance to Bordin, E. S. (1979). The generalizability of the psycho-
analytic concept of the working alliance. Psychother-
understand her. After helping father and daugh-
apy: Theory, Research & Practice, 16(3), 252.
ter each share their perspective and getting the Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014).
details, the therapist presents a relational con- Attachment-based family therapy for depressed adoles-
ceptualization of the problem to the family, one cents. Washington, DC: American Psychological Asso-
ciation Press.
that incorporates each individual’s perspective
Pinsof, W. M., & Catherall, D. R. (1986). The integrative
of the problem and the impact on the relation- psychotherapy alliance: Family, couple and individual
ship. In this case the therapist suggests that therapy scales. Journal of Marital and Family Therapy,
father and daughter want to have a supportive 12, 137–151.
Rogers, C. R. (1951). Client-centered therapy. Cambridge,
relationship (“Sasha, you want dad to under-
MA: Riverside Press.
stand you, and dad, you want your daughter to Safran, J. D., & Muran, J. C. (2000). Negotiating the
let you know what to do so you can help her”). therapeutic alliance: A relational treatment guide.
The therapist then states a potential goal for the New York: Guilford Press.
family: “Can we work on communicating in a
different way?”
Task. The therapist then gets the family’s feedback
on the treatment plan and provides structure and Alliance Repair in Couple and
information about how future sessions will work. Family Therapy
Specifically, she says “I’d like to work with you
on your communication by teaching you new Jacob Z. Goldsmith
ways of interacting with each other. This means The Family Institute at Northwestern University,
that, during each session, I will support you both Evanston, IL, USA
in talking about your experiences. As you talk,
I will help each of you listen and respond in a
new way. In order to work on our goal, we will Synonyms
need to meet all together each week. Does this
sound okay to you?” Therapeutic alliance repair; Working alliance
repair; Working relationship repair
In this case, the therapist developed a bond
with the family and got an agreement from each
individual on the desired goal of treatment as well Introduction
as on the process of achieving these goals. The
therapist made sure to incorporate all individual The working relationship between client(s) and
perspectives into her conceptualization of the rela- therapist, called the alliance, is one of the power-
tional problem. This therapist has set the ground- ful common factors in successful psychotherapy
work for maintaining a strong working alliance (Friedlander et al. 2006). Problems in the alliance,
with the individual clients and family system. called ruptures, are common and may occur for a
variety of reasons. The process of rectifying such
a rupture is called alliance repair. Repairs can take
Cross-References a variety of forms, depending on the rupture, but
should be executed quickly according to the gen-
▶ Attachment-Based Family Therapy eral guidelines described below.
Alliance Repair in Couple and Family Therapy 91
Theoretical Context differences in the process and goals of treatment.

With multiple clients comes the potential for
Psychotherapy alliance is the working relation- conflicting needs, goals, and interpersonal styles A
ship between client and therapist. Edward Bordin (Pinsof and Catherall 1986). As a result, in terms
(1979) defined alliance as agreement between cli- of both the theoretical conceptualization and the
ent and therapist on the tasks and goals of therapy, actual clinical practice, couple and family alliances
in addition to the presence of an interpersonal are more complex. In conjoint treatment alliances
bond. Agreement on tasks involves a shared exist between each client and the therapist, and each
understanding (between client(s) and therapist) client is aware not only of his or her own alliance but
of what is occurring in the therapy room (e.g., of the other alliances as well (Friedlander et al. 2006;
the choice of interventions or area of focus within Pinsof and Catherall 1986). Furthermore, working
a session), whereas agreement on goals involves a relationships exist between the clients themselves.
shared understanding of the overall objectives or Therefore, alliance in couple and family therapy
desired outcomes of the therapy. The bond aspect must not be thought of as a monolithic entity but
of alliance involves a felt sense of interpersonal rather as a system of interconnected relationships
connection. This varies greatly across different that must be balanced and that can each rupture and
types of therapy and therapist interpersonal style require repair.
but typically involves some felt sense of empathy, With the added conceptual complexity of mul-
warmth, or caring. Each different therapy requires tiple relationships in couple and family alliances
a somewhat different configuration of tasks, comes added difficulty in building and
goals, and bonds, but every therapy requires a maintaining those relationships. Maintaining all
strong enough alliance to be successful. Strong alliances at equal strength at all times is not
alliance is necessary for positive outcome in ther- always possible. Some temporary imbalance in
apy, and without an alliance therapy falters and the alliance is to be expected and does not neces-
cannot continue (Safran and Muran 2000). sarily constitute a rupture. A rupture is better
Some clients enter therapy with a strong alli- thought of as a break than an imbalance, wherein
ance and maintain it throughout treatment therapy cannot continue without a repair. For
(Goldsmith and Stiles 2010). Others experience example, a teenage daughter in family therapy
change in the quality of their alliance over the may experience temporary frustration when her
course of treatment. Many (if not most) clients father describes his side of a recent argument. This
will experience a brief precipitous drop in the is not necessarily a rupture. But if the therapist
quality of alliance, called a rupture (Safran et al. exclusively validated the father’s experience to
2011). Alliance ruptures are sudden decrements in the point where the daughter no longer felt bonded
an established alliance – in other words they are or invested in therapy, then a rupture has occurred
moments when an otherwise strong client- and would require repair.
therapist alliance falters. Alliance ruptures can
have many causes, including client defensiveness
or poor fit between clients’ and therapist’s goals, Description
but often involve a misstep by the therapist (e.g., a
failure of empathy, or decision to push a client too Alliance repair begins when the therapist recognizes
hard in a given situation). Alliance repair is the act a rupture and shifts the focus of therapy to explicitly
of fixing an alliance rupture, or restoring the alli- address the problem (Safran et al. 2011; Friedlander
ance to its original strength. et al. 2006). To make an effective repair, the thera-
The concepts of psychotherapy alliance, and pist must remain open and nondefensive throughout
rupture-repair, although initially developed in the the repair process. With the rupture identified and
context of individual therapy, may be applied to the focus of the session shifted, the therapist may
couple and family therapy with some basic changes implement a number of different repair strategies
to accommodate the additional clients and the including:
92 Alliance Repair in Couple and Family Therapy
• Clarifying the events of the rupture Application of Concept in CFT

• Therapist taking responsibility for any mis-
takes or missteps The first step in alliance repair is the timely iden-
• Eliciting emotions related to the rupture tification of a rupture. With multiple clients in the
• Empathically joining with the client room, the therapist must attend to multiple alli-
• Identifying necessary changes to the tasks or ances and to clients’ perceptions of each other’s
goals of therapy alliances. This can make identifying a rupture
• Connecting the rupture to underlying interper- difficult, simply due to the burden of having
sonal processes more moving parts to monitor at any one time.
• Connecting the rupture to ongoing relational Further complicating rupture identification, some
patterns in the client’s life imbalance between alliances is expected in couple
and family work and does not necessarily consti-
The choice of specific repair techniques tute a rupture. The task for the therapist then is to
depends on the content and process of the rupture. be aware of whether each interconnected part of
For example, if the therapist has made a clear the alliance system is strong enough to maintain
mistake (e.g., a lapse in empathy), he or she the work of therapy, or conversely whether one or
needs to take responsibility. If the client becomes more parts have become so weak that therapy
withdrawn or disengaged during the rupture, cannot continue without a repair.
eliciting emotions may be helpful. If the rupture When a rupture is identified, the therapist must
appears due to misunderstanding of the tasks and actively shift the focus of the session toward
goals of therapy, then explicit discussion of these repairing the rupture. In cases where only one
topics is necessary (including, perhaps, client ruptures, the process of repair requires
psychoeducation about the need to balance direct attention to that client’s needs, but still
conflicting needs within the system). demands consideration of the other clients. Mak-
Beyond the obvious goals of allowing the cli- ing a shift to address one client may alienate other
ent to work through negative feelings about the members of the system. Those clients in turn may
relationship and restoring a strong working alli- feel upset or defensive witnessing the repair pro-
ance, repair is an opportunity for client(s) and cess and may even object to the shift in focus. The
therapist to build insight into a client’s relational therapist must therefore be explicit and directive
style (or defenses). Repair is also a chance for the throughout this process, explaining his or her
therapist to model appropriate, nondefensive con- intentions to the group. It may also be necessary
flict resolution, and as a corollary the repair pro- to process client reactions to the repair process
cess can be a moment of experiential learning for after the fact.
all clients in the room. When multiple clients rupture at the same
Often, only a single client will experience a time, the therapist must still pause the ongoing
rupture at once. In that case, the therapist must work of therapy to focus on the repair. If all
accomplish the repair while still considering the clients rupture for the same reason (e.g., the
alliances of the other clients. At other times, therapist is at odds with the entire family about
multiple clients will rupture at once, sometimes the goals of therapy), the therapist can imple-
for the same reason and sometimes for different ment a single broad repair. If clients simulta-
reasons. In all of these cases, the generic repair neously rupture for different reasons, it may be
process is the same, with repair techniques cho- necessary to shift the focus of therapy from one
sen to fit the specific situation. However, client to the next to accomplish multiple sequen-
whether one client or every client ruptures, the tial repairs.
therapist must still consider the system as a Different repair techniques have different con-
whole during repair. sequences in a systemic context. Take for example
Alliance Repair in Couple and Family Therapy 93
a rupture caused by the therapist neglecting one Clinical Example

client’s viewpoint in family therapy. If the thera-
pist apologizes and gives that client a chance to Parents Alex and Nina seek therapy with A
express frustration, this could lead to the client 17-year-old son Sam to address Sam’s emo-
feeling a sense of pride or vindication. The client tional dysregulation and aggressive behavior.
is empowered through the rupture. On the other The therapist works with the family to concep-
hand, if the therapist takes the opportunity to push tualize Sam’s behavior as part of a broader sys-
deeper, eliciting underlying emotions or temic pattern involving Nina’s anxiety and
connecting the rupture to other instances of Alex’s work-related stress. Early alliance is
neglect or disempowerment in the clients’ life, strong. Sam and Nina both readily recognize
this could lead to a feeling of exposure – the their contributions to the ongoing issues. Alex
client’s personal vulnerabilities are now on generally appears engaged and nominally
display. agrees with the therapist’s assessment, but with-
With any repair technique, the therapist should draws somewhat when the focus turns to his role
consider the systemic context, including the in the family’s problems.
intersecting needs and goals, differing relational In the sixth session, feeling frustrated at
styles and areas of defensiveness, and potential Alex’s lack of ownership, the therapist makes
areas of high vulnerability, among all of the clients an overly directive push to get him to take
(not just the client who initially ruptured). responsibility, saying “Both your wife and son
Although repair is more complicated in cou- have shared what they feel they’ve contributed
ple and family work, it may also be especially to Sam’s problems. What do you think your role
meaningful in this context. Repairs are moments is here?” Alex scowls, physically turns himself
when clients’ interpersonal issues (defenses, away, and clenches his fist; he has never
areas of need or sensitivity, ways of being in exhibited this level of contempt in session
conflict) come into the spotlight in the therapy before.
room. If the goal of therapy is to improve the Sensing a rupture, the therapist begins by
quality of romantic or family relationships, then simply noticing out loud Alex’s change in
the insights gleaned from alliance repair are body language and facial expression. Alex
directly relevant to the overall work. Two repair responds “Of course I’m angry, you’re blaming
techniques in particular – connecting the rupture me for my son’s problems!” With this acknowl-
to existing interpersonal processes and to pat- edgement, the therapist begins the repair by
terns that manifest in relationships beyond the shifting the focus and eliciting information
alliance – may be particularly applicable to the about Alex’s experience:
ongoing work of conjoint therapy.
Therapists may also take particular advantage of Therapist: I think I did a bad job of saying
repairs as moments of experiential learning. The what I was trying to say. I’m sorry.
therapist can use the repair to demonstrate non- I don’t believe that you caused your
defensive, appropriate conflict resolution, which son’s problem. I see how that
again may be particularly relevant to couple and made you angry, and I want to
family work. Of course, in couple and family ther- understand what you’re feeling
apy, repairs happen in the presence of the other more clearly. I want to switch our
clients, allowing the group to observe and learn focus now and give you time to talk
from the resolution. For a spouses entrenched in this through. I know I’m asking
their own repetitive conflict cycles, the repair may you to take a risk here. Can you tell
be crucial evidence that a different way of me what you were feeling when
expressing anger or hurt is possible. you got angry?
94 Alliance Scales in Couple and Family Therapy
Alex: The thought that happens over and References

over again is “Its all your fault! It’s all
your fault!” Bordin, E. S. (1979). The generalizability of the psycho-
T: Sounds like you felt blamed. Did apy: Theory, research & practice, 16(3), 252.
feeling blamed by me remind you of Friedlander, M., Escudero, V., & Heatherington, L. (2006).
anything? Therapeutic alliances in couple and family therapy: An
A: It actually reminds me of things I’ve empirically informed guide to practice. Washington,
DC: APA Press.
said to my dad. I’ve worked so hard Pinsof, W. M., & Catherall, D. R. (1986). The integrative
not to be like him. And then you said psychotherapy alliance: Family, couple and individual
what you said and I just felt like ‘oh therapy scales*. Journal of Marital and Family Ther-
well, I guess he thinks I’m just like apy, 12, 137–151. https://doi.org/10.1111/j.1752-
0606.1986.tb01631.
my dad’. And I felt angry, but I also Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011).
felt really insulted. Repairing alliance ruptures. Psychotherapy, 48(1), 80–87.
T: Hurt? Safran, J. D., & Muran, J. C. (2000). Negotiating the
A: Yeah, Hurt! therapeutic alliance: A relational treatment guide.
New York: Guilford.
Stiles, W. B., & Goldsmith, J. Z. (2010). The alliance over
time. In J. Muran, J. P. Barber, J. Muran, & J. P. Barber
(Eds.), The therapeutic alliance: An evidence-based
The therapist empathically joins with him in guide to practice (pp. 44–62). New York: Guilford.
this hurt, reflecting and normalizing it. Alex
acknowledges feeling relief and connection
and, in this context, is able to begin to take
Alliance Scales in Couple and
responsibility for letting his work-life
Family Therapy
intrude into the home. As the repair process
concluded, the therapist began to reintegrate
Maliha Ibrahim1, Katherine Vaughan2 and
Nina and Sam into the work, both as additional
Guy S. Diamond1
sources of information to help Alex and also to 1
check in about both of their experiences of the
University, Philadelphia, PA, USA
repair. 2
Drexel University, Philadelphia, PA, USA
The repair process here accomplished three
main goals. First, it allowed Alex to work through
the pain of the rupture and open himself back up to
Synonyms
the therapy. Second, it provided insight into a part
of Alex that had been hidden throughout treat-
Individual, Couple and Family Therapy Alliance
ment. Finally, it provided a model for the whole
Scale (ITAS, CTAS and FTAS); System for
system to understand an appropriate discussion of
Observing Family Therapy Alliances (SOFTA);
personal responsibility, even in the face of
Vanderbilt Therapeutic Alliance Scale (VTAS);
unwanted emotions, that the therapist could refer
Working Alliance Inventory (WAI); Working
back to throughout the rest of the treatment.
Alliance Inventory (WAI-Co)
Cross-References Introduction
▶ Alliance in Family Relationships For the past 60 years, therapeutic alliance has been
▶ Alliance Scales in Couple and Family Therapy considered one of the most important common
▶ Split Alliance in Couple and Family Therapy factors in psychotherapy research. Early on, cou-
▶ Therapeutic Alliance in Couple and Family ple and family therapy (CFT) researchers joined
Therapy this area of research, wanting to better understand
Alliance Scales in Couple and Family Therapy 95
how therapeutic alliance could be examined client rates their view of their relationship with
within a family system (Pinsof and Catherall the therapist. In the family systems measurement
1986; Rait 2000). Previous measurement tools system, clients can rate not only their own view of A
were developed to evaluate the therapeutic alli- the alliance, but they might be asked to rate how
ance between an individual client and their thera- they think other family members are feeling
pist. CFT researchers questioned if these toward the therapist. For the therapist’s perspec-
measurement tools could assess the complexities tive, the therapist does not rate their own feelings
of a therapist attending to multiple family mem- of their alliance with the patient. Instead, the ther-
bers simultaneously. Consequently, family thera- apist rates how they think the client sees the alli-
pists sought to develop more complex, multilevel ance with them. Observer rating usually involves
models of alliance and the assessment tools to training raters (often undergraduate students) to
measure them. Two of the most widely used scales watch tapes of therapy. Raters can rate one client
for measuring alliance in individual therapy are or several (e.g., parent and child, husband and
reviewed. Additionally, three of the most widely wife). Usually one group of raters rates one family
used and psychometrically strong scales for mea- member. Interestingly, most studies suggest ther-
suring alliance in CFT are reviewed. All of these apist reports of alliance are not as good at pre-
measures have utility in the context of CFT dicting outcome as client self-report. Observer
research and practice. reports of alliance however are consistently the
Regardless of the measure used, differential most robust perspective for predicting outcome
alliance in family therapy has interesting clinical (Horvath 2001).
implications. One study with adolescents found
that therapist’s alliance with the adolescent pre- Working Alliance Inventory* (WAI; Horvath
dicted outcome but that therapist’s alliance with and Greenberg 1989)
the parents predicts treatment retention (Shelef Introduction. The WAI is the most widely used
and Diamond 2008). Paying attention to the alliance scale (Martin et al. 2000). Utilizing
impact of these kinds of split alliances in family Bordin’s theory of working alliance (Bordin
therapy may help illuminate some of the unique 1979), the WAI assesses three primary compo-
challenges faced by a family therapist. Addition- nents: tasks, goals, and bonds. Tasks refer to
ally, barriers in the development of the therapeutic what is done in therapy (e.g., CBT worksheets,
alliance such as client motivation and the therapy family therapy enactments, DBT mindfulness
environment may also influence alliance measure- exercises). Goals refer to whether the client and
ment. Cost, complexity, and transportability of therapist agree on what they are working on, or
alliance measures into clinical settings also need toward, in therapy. Bonds refer to the general
to be considered, as these factors will determine feeling of being liked or respected by the therapist.
the overall utilization of the measures in the years Developers. Adam O. Horvath and Leslie
to come. S. Greenberg developed the WAI. They first
Before considering which of these measures described it in a paper titled Development and
one might use for clinical or research purposes, Validation of the Working Alliance Inventory
one must consider a few methodological issues (Horvath and Greenberg 1989).
regarding different sources of data and when to Description of measure. The WAI has three
collect it. Alliance has been measured from the different versions: client, therapist, and observer.
client’s perspective, the therapist’s perspective, Each version contains 36 items and similar ques-
and from the perspective of trained objective tions, all using a 7-point Likert scale (1 =
raters. Client report is usually done with a short, “Never”; 7 = “Always”). Questions evaluate the
self-report questionnaire after the third or fourth agreement on task, goal, and the quality of the
session. This gives enough time for the alliance to strength of the therapist-client bond. The WAI-
form, but not so much time to be confounded by short version (WAI-S) reduces the number of
symptom reduction. In individual therapy, the items to 12, and there are still self-report and
therapist report types for this version. The scale Description of measure. The VTAS is an
items for this measure were selected through fac- observer scale only, containing 44 items. It uses
tor loading the 36 items on the WAI. A 7-point a 6-point Likert scale (0 = “none at all”, 5 = “a
Likert scale (1 = “Never”; 7 = “Always”; Busseri great deal”) to measure alliance via client contri-
and Tyler 2003) is also used on the WAI-S. bution (14 items), therapist contributions
Although less well known and used, there is a (18 items), and client-therapist interaction
WAI couples version (WAI-Co*; Symonds 1997). (12 items) (Horvath and Greenberg 1994). Client
Using the same 7-point Likert scale (1 = “Never”; contribution items are defined as patient resis-
7 = “Always”) and 68 items, this self-report scale is tance, patient motivation, patient responsibility,
made up of three sections. Section 1 asks the client and patient anxiety. Therapist contribution items
to rate their alliance with the therapist. Section 2 are defined as positive therapeutic climate and
asks the client to rate their partner’s alliance with the therapist intrusiveness. Questions are similar to
therapist. Section 3 asks the client to rate the cou- the WAI. For example, client items include “The
ple’s joint alliance with the therapist. client agreed to the therapist’s method or process,”
Psychometrics. WAI has strong reliability “He/she expressed feeling more positive since the
(r = 0.85–0.93) and has demonstrated predictive initiation of therapy (bond),” and “The therapist
validity in several outcome studies (Ardito and and patient together share a common viewpoint
Rabellino 2011; Elvins and Green 2008; Martin about the definition, causes, and alleviation of the
et al. 2000). Reliability for the WAI-Co was patient’s problems? (goal).”
observed for each partner at the third session and A shortened and revised version of the VTAS
was similar to the reliability found on the WAI (VTAS-R Short Form; Shelef and Diamond 2008)
(r = 0.95–0.97; Symonds and Horvath 2004). was developed due to the time-consuming nature of
Application. The WAI has been used in numer- the longer observer-rater scale that generated burden
ous research studies, exploring a range of treatment on staff implementing it (Fenton et al. 2001; Shelef
disorders and treatment modalities. With versions in et al. 2005). The scale is a 26-item self-report mea-
18 languages, it can be used with a diverse set of sure and is on a 5-point Likert scale.
clients (Ardito and Rabellino 2011; Elvins and Psychometrics. VTAS demonstrated adequate
Green 2008; Horvath and Greenberg 1989; Martin inter-rater reliability, based on interclass correlations
et al. 2000). The WAI-Co has been observed pri- as indicated by a coefficient a = 0.95 and internal
marily with couples described as heterosexual, Cau- consistency (0.96–0.82; Elvins and Green 2008).
casian, and married (Symonds and Horvath 2004). The scale also demonstrated adequate predictive
validity in the association between early treatment
alliance and outcome. The Vanderbilt scales also
Vanderbilt Therapeutic Alliance Scale* depicted the best convergent validity (r = 0.86)
(VTAS; Hartley and Strupp 1983) with other alliance scales (Elvins and Green 2008).
Application. VTAS scales have been used with
Introduction. The VTAS was developed from the children, adolescents, and adults with multiple
Vanderbilt Psychotherapy Process Scale (VPPS; mental health issues like substance use and
Gomes-Schwartz 1978; O’Malley et al. 1983). depression (Faw et al. 2005; Mayorga 2008).
Multiple theories influenced the VPPS, but
Bordin’s theory of working alliance (Bordin
1979) primarily influenced development of the Individual, Couple, and Family Therapy
VTAS (Martin et al. 2000). Alliance Scale* (ITAS, CTAS, and FTAS;
Developers. D. Hartley and H.H. Strupp devel- Pinsof and Catherall 1986)
oped the VTAS. They first described it in a paper
titled The therapeutic alliance: Its relationship Introduction. The Individual Therapeutic Alliance
to outcome in brief psychotherapy (Hartley and Scale (ITAS), Couple Therapeutic Alliance Scale
Strupp 1983). (CTAS), and Family Therapy Alliance Scale
Alliance Scales in Couple and Family Therapy 97
(FTAS) were developed to assess alliance in CFT System for Observing Family Therapy
research. These alliance scales were also Alliances* (SOFTA; Friedlander et al.
influenced by Bordin’s theory of working alliance 2006) A
(Bordin 1979; see WAI).
Developers. William M. Pinsof and Donald Introduction. The SOFTA scale was developed
R. Catherall developed the ITAS, CTAS, and for both self-report and observational rating.
FTAS. They first described it in a paper titled Using Bordin’s theory (Bordin 1979), the
The Integrative Psychotherapy Alliance: SOFTA scales reflect Bordin’s principles of
Family, Couple and Individual Therapy Scales tasks, bonds, and goals as well as systemic ele-
(Pinsof and Catherall 1986). They, more than ments unique to couple and family therapy
any other family therapy researchers, have tried (Bordin 1989, 1994; Pinsof and Catherall 1986;
to capture the complex nature of alliance in Pinsof 1999; Symonds and Horvath 2004). The
systemic therapies (Norcross 2011). scale assesses client’s trust in the therapy process
Description of measure. The ITAS, CTAS, and captures features in the therapeutic relation-
and FTAS are self-report measures for clients. ship that could be used to prevent treatment drop-
Using a 7-point Likert scale (i.e., 1 = out (SOFTA-o; Friedlander et al. 2001, 2004;
“Completely disagree” to 7 = “Completely SOFTA-s; Friedlander and Escudero 2002).
agree), the ITAS (26 items), CTAS (29 items), Developers. Myrna Friedlander and Valentin
and FTAS (29 items) all examine how each Escudero developed and published the SOFTA
participant views alliance based on Bordin’s in a manual (Friedlander et al. 2006).
tasks, goals, and bonds. While the ITAS evalu- Description of measure. The four major
ates alliance scores between the client and the dimensions on the scale are (1) engagement in
therapist, the CTAS and FTAS include an the therapeutic process, (2) emotional connection
evaluation of the client’s view of others’ alli- to the therapist, (3) safety within the therapeutic
ance with the therapist as well as the client’s system, and (4) shared sense of purpose within the
view of the whole groups’ (i.e., couple or family (Friedlander et al. 2006, p. 56).
family’s) combined alliance with the therapist. The engagement in the therapeutic process
The CTAS and FTAS measure alliance similarly scale measures the client’s view of how meaning-
to the WAI-Co (see WAI; Friedlander et al. ful treatment is to them and how well he or she and
2011). Examples of questions are: “The the therapist are working together on negotiated
therapist does not understand the relationship goals. Sample items include (a) client’s agreement
between my partner and myself” and “The ther- with therapy and (b) client expressing optimism
apist understands my goals in this therapy” that positive change is taking place. Reverse-
(Pinsof et al. 2008, p. 282). The ITAS-r, coded items include (a) the client feeling stuck or
CTAS-r, and FTAS-r were recently revised to (b) the client showing indifference to the tasks or
include more comprehensive questions (i.e., process of therapy (Friedlander et al. 2006, p. 62).
36, 40, 40; Hamilton and Carr 2016; Pinsof The safety within the therapeutic relationship
et al. 2008). scale measures the degree to which clients feel
Psychometrics. The ITAS, CTAS, and FTAS they can take risks and process new insights with
have adequate reliability (r = 0.72–0.83; Elvins their therapist. Sample items include (a) client
and Green 2008) and predictive validity showing vulnerability in session, (b) open and
(Heatherington and Friedlander 1990). relaxed body posture, and (c) encouraging other
Application. The ITAS, CTAS, and FTAS family members to speak up. Reverse-coded items
were the first alliance scales developed to include (a) reluctant to respond to the therapist or
assess alliance from a more systemic perspec- another family member and (b) anxiety toward
tive. They are frequently used in couple and camera (Friedlander et al. 2006, p. 62).
family therapy research (Friedlander The emotional connection with the therapist
et al. 2011). refers to the client feeling that the therapist has
genuine care and concern for them. Sample items Bordin, E. S. (1994). Theory and research on the therapeu-
include client sharing a light-hearted moment tic working alliance: New directions. In The working
alliance: Theory, research, and practice (pp. 13–37).
with the therapist. Reverse-coded items include Busseri, M. A., & Tyler, J. D. (2003). Interchangeability of the
(a) hostile or sarcastic interactions and (b) working alliance inventory and working alliance inven-
commenting on therapist’s lack of training or tory, short form. Psychological Assessment, 15(2), 193.
competency (Friedlander et al. 2006, p. 66). Elvins, R., & Green, J. (2008). The conceptualization and
measurement of therapeutic alliance: An empirical
The shared sense of purpose within the family review. Clinical Psychology Review, 28(7), 1167–1187.
implies that family members work collaboratively Faw, L., Hogue, A., Johnson, S., Diamond, G. M., & Liddle,
and value one another in therapy. Items include H. A. (2005). The Adolescent Therapeutic Alliance Scale
family members ask for each other’s perspectives (ATAS): Initial psychometrics and prediction of outcome
in family-based substance abuse prevention counseling.
and validate one another. Reverse-coded items Psychotherapy Research, 15(1–2), 141–154.
include (a) avoiding eye contact and Fenton, L. R., Cecero, J. J., Nich, C., Frankforter, T. L., &
(b) devaluing each other’s opinions and perspec- Carroll, K. M. (2001). Perspective is everything: The
tives (Friedlander et al. 2006, p. 68). predictive validity of six working alliance instruments.
The Journal of Psychotherapy Practice and Research,
Psychometrics. The SOFTA has been tested 10(4), 262.
psychometrically in a number of studies. In one Friedlander, M.L., & Escudero, V. (2002). Self-report ver-
study, the 44 items were ordered by 24 different sion of the System for Observing Family Therapy Alli-
MFT researchers across 3 countries to assess face ances. Unpublished instrument. Available from www.
softa-soatif. net. Retrieved 16 Nov 2016.
validity. High internal consistency of items was Friedlander, M.L., Escudero, V., & Heatherington, L. (2001).
found via kappa coefficients Ks = 0.81(English) SOFTA-o for clients. Unpublished instrument. Available
and Ks = 0.71 (Spanish). Client and therapist from www.softa-soatif.net. Retrieved 16 Nov 2016.
reports were then developed using the four con- Friedlander, M.L., Escudero, V., Heatherington, L., Deihl,
L., Field, N., Lehman, P., ..., Cutting, M. (2004). Sys-
ceptual SOFTA dimensions with 16 positive and tem for Observing Family Therapy Alliances
negative items on a 5-point Likert scale (SOFTA-o) training manual-revised. Unpublished
(Friedlander et al. 2006). manuscript. Available from www. softa-soatif. net.
Application. The SOFTA has been especially Friedlander, M. L., Escudero, V., & Heatherington, L.
(2006). Therapeutic alliances in couple and family
applicable in the training and supervision of nov- therapy: An empirically informed guide to practice.
ice CFT therapists, as they can observe a client’s Washington, DC: American Psychological
engagement in sessions, emotional connection Association.
with the therapist, and ability to work together Friedlander, M. L., Escudero, V., Heatherington, L., &
Diamond, G. M. (2011). Alliance in couple and family
with family members (Friedlander et al. 2006, therapy. Psychotherapy, 48(1), 25.
p. 44). Being an observational coding system, Gomes-Schwartz, B. (1978). Effective ingredients in psy-
the SOFTA can also identify moments of client chotherapy: Prediction of outcome from process vari-
alliance and resistance with the therapist ables. Journal of Consulting and Clinical Psychology,
46(5), 1023.
(Friedlander et al. 2006). Hamilton, E., & Carr, A. (2016). Systematic review of
self-report family assessment measures. Family pro-
cess, 55(1), 16–30.
Hartley, D. E., & Strupp, H. H. (1983). The therapeutic
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Bordin, E. S. (1989). Building therapeutic alliances: The Horvath, A. O., & Greenberg, L. S. (1989). Development
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Almeida, Rhea 99
Horvath, A. O., & Greenberg, L. S. (1994). The working Somerset, NJ, and a former faculty member
alliance: Theory, research, and practice (Vol. 173). of Rutgers University School of Social Work.
New York: Wiley.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Rela- Dr. Almeida is co-founder of the Liberation- A
tion of the therapeutic alliance with outcome and other Based Healing Conference (LBHC) held annually
variables: A meta-analytic review. Journal of Consult- in locations throughout the United States.
ing and Clinical Psychology, 68(3), 438. Almeida is an internationally renowned leader
Mayorga, C.C. (2008). Self-reported and observed cultural
competence and therapeutic alliance in family therapy. in decolonizing couple and family therapy and
Norcross, J. C. (Ed.). (2011). Psychotherapy relationships developed the cultural context model of family
that work: Evidence-based responsiveness. New York: therapy.
Oxford University Press.
O’Malley, S. S., Suh, C. S., & Strupp, H. H. (1983). The
Vanderbilt Psychotherapy Process Scale: A report on the
scale development and a process-outcome study. Journal
Career
of Consulting and Clinical Psychology, 51(4), 581.
Pinsof, W.M. (1999). Family therapy alliance scale-revised.
Unpublished document. Evanston: The Family Institute. Rhea Almeida was born and raised in Kampala,
Pinsof, W. M., & Catherall, D. R. (1986). The integrative Uganda. She moved to the United States to
psychotherapy alliance: Family, couple and individual
attend Florida State University in Tallahassee
therapy scales. Journal of Marital and Family Therapy,
12(2), 137–151. for her undergraduate studies. She earned a BA
Pinsof, W. M., Zinbarg, R., & Knobloch-Fedders, L. M. in social work and psychology at Florida State
(2008). Factorial and construct validity of the revised University and an MS in social work at Columbia
short form integrative psychotherapy alliance scales for
University in New York. Dr. Almeida completed
family, couple, and individual therapy. Family Process,
47(3), 281–301. her PhD in anthropology at Makerere University,
Rait, D. S. (2000). The therapeutic alliance in couples and in Kampala, Uganda.
family therapy. Journal of Clinical Psychology, 56(2), From 1980 to 1987, Dr. Almeida was on
211–224.
the faculty of Rutgers University School of
Shelef, K., & Diamond, G. M. (2008). Short form of the
revised Vanderbilt Therapeutic Alliance Scale: Devel- Social Work and completed her postgraduate
opment, reliability, and validity. Psychotherapy training at the Ackerman Institute in New York
Research, 18(4), 433–443. City. Almeida left her position at Rutgers when
Shelef, K., Diamond, G. M., Diamond, G. S., & Liddle, H. A.
it became clear to her that clinical social work
(2005). Adolescent and parent alliance and treatment
outcome in multidimensional family therapy. Journal of was focused primarily on the individual as the
Consulting and Clinical Psychology, 73(4), 689. therapeutic location for change efforts. She felt
Symonds, D. (1997). The working alliance inventory for there was no systemic analysis of change for
couples. Retrieved from http://wai.profhorvath.com/
practice or the institutions that provided social
sites/default/files/upload/waiCo.doc
Symonds, D., & Horvath, A. O. (2004). Optimizing the alli- work services. In 1993 she published
ance in couple therapy. Family Process, 43(4), 443–455. “Unexamined Assumptions and Service Deliv-
ery Systems.”
Dr. Almeida established the Institute of Family
Almeida, Rhea Services in 1890 where she began to investigate
theories of social and political change and resis-
Willie Tolliver tance. She found many of these ideas more useful
Silberman School of Social Work at Hunter to oppressed peoples than the narrow theories of
College, New York, NY, USA psychology promoted by social work educators.
She and her colleagues developed the cultural
context model that sought to bring critical con-
Introduction sciousness to client journeys weaving in threads
of empowerment and accountability. Connecting
Rhea Almeida, MS, PhD, is the founder and people and their context was the focus for thera-
director of the Institute of Family Services in peutic change.
100 Ambiguous Loss in Couple and Family Therapy
Contributions to the Profession individuals, their families, their context, and

their healing spaces. Liberation-based healing
Throughout her career, Dr. Almeida has evidenced encompasses the multiplicity of personal and
commitment to decolonizing theory and practice social institutional locations that frame identities
that sustain and reproduce coloniality in couples within historic, economic, and political life.
and family therapy. In 1997, Almeida was named Almeida is the author of several books
as one of ten innovative healers in the nation (The and numerous journal articles. Her upcoming
UTNE Reader – “Cultural Healers: Ten Innovative book, Liberation Based Healing Practices, is due
Therapists Who Do More Than Just Talk,” features to be released soon! Almeida is also an AAMFT
Rhea Almeida, February 1997). Her commitment to approved supervisor.
decolonization extended to pointing out to editorial
boards of journals how their processes for selecting
Cross-References
articles for publication sustained the status quo.
In 1998, she negotiated with the Journal of
▶ Decolonizing Couples and Family Therapy:
Feminist Therapy to provide a section in the
Social Justice Praxis in Liberatory Healing
journal that would not be subject to the “blind
Community Practice
process” of review that frequently vanished
publications from authors on the margin. This pro-
vided the opportunity to many authors outside of
References
whitestream to submit and get published.
After 25 years of knowledge building, Almeida, R. (1993). Unexamined assumptions and
training, and practice in the Institute for Family service delivery systems: Feminist theory and
Services (IFS), in 2005 Almeida was honored racial exclusions. Journal of Feminist Family Therapy,
by the American Family Therapy Academy 5, 3–23.
Almeida, R. (2013). Cultural equity and displacement of
with an Award for Innovative Contributions to othering. Article ID: acrefmrw-9780199975839-e-889.
Family Therapy. Therapeutic approaches at IFS https://doi.org/10.1093/acrefmrw/9780199975839.013.
incorporate an analysis of power, privilege, oppres- 889.
sion, and intersectionality into its therapeutic Almeida, R. (in press). Liberation based healing practices.
Somerset: Institute for Family Services.
approaches to a wide range of problems presented Almeida, R.V., Melendez, D., & Paéz, J. (2015).
by couples, families, children, and youth who Liberation-based healing. Encyclopedia of Social
engage in violence. The programs also encourage Work. Online Publication Date: December 2015.
healing by embracing life-affirming choices, based Hernández, P., Siegel, A., & Almeida, R. (2009). How does
the cultural context model facilitate therapeutic change?
on a strong foundation of empowerment and Journal of Marital and Family Therapy, 35(1), 97–110.
accountability. Mindful of the resilience embodied
by those who struggle, the therapeutic process
anchors the problems presented within a system of
support, care, and action strategies. Ambiguous Loss in Couple
Dr. Almeida co-founded the Liberation-Based and Family Therapy
Healing Conference in 2005. Currently, in its
13th year, the LBHC travels the country and Janet Yeats
Canada hosted by organizations and universities. LMFT LLC, Minneapolis, MN, USA
The vision for the Liberation-Based Healing
Conference is embedded within strategies
of decoloniality. Strategies of decoloniality call Introduction
for changing the paradigm, the lens, the language,
and the historical journey that upholds the Ambiguous loss theory was created by Pauline
myth of healing through diagnostic codes, indi- Boss, PhD in the 1970s, from initial research
vidual structures and the rigid bifurcation of conducted with indigenous women and wives of
Ambiguous Loss in Couple and Family Therapy 101
Navy pilots missing in action Boss (2000). Type 1: Leaving Without Goodbye: Physical
Dr. Boss continued her research with families of absence with psychological presence. Although
missing persons and with families living with a the loved one is not physically present, their A
loved one with a dementia diagnosis. Researchers presence is felt in ways that reflect their ongoing
and clinicians continue Dr. Boss’s work in ambig- psychological connection to family and friends.
uous loss by applying the theory to adoption, Examples of this type of loss include
GLBTQ communities, hoarding disorder, refugee persons who have disappeared or missing in
populations, bereavement, military families, action. More commonly experienced examples
divorce, among many other diagnoses and of this type are divorce, adoption, and
populations. immigration.
Type 2: Goodbye Without Leaving: Psycholog-
ical absence with physical presence. In this type
Theoretical Context for Concept of loss, loved ones remain physically present to
family and friends but absent in their emotional
Dr. Boss began her research first in boundary and psychological connections. Examples of this
ambiguity in families. As she continued her type of loss include persons with a dementia diag-
work, she noted that what she was finding went nosis, depression, and hoarding disorder. More
beyond boundary ambiguity to a lack of identify- commonly experienced examples of this type are
ing and naming loss. Clinicians and researchers loss of a dream, or loss of a way of life, e.g., loss of
continuing Dr. Boss’s work in ambiguous loss identity due to career transition.
have applied the theory to a variety of individual Ambiguous losses create complicated grief
and family losses. Ambiguous loss theory fills a because the losses have not been identified as
gap in marriage and family theories and therapies such. Lack of understanding that the ambiguous
by providing an understanding for how to address situation is indeed a loss does not give permission
grief that lacks definition and defies cultural to begin the grief process. Without permission to
understandings of how loss is typically identified. grieve, coping can be blocked and grief gets stuck.
Grief and loss work in the therapy context encour- Friends and family do not understand the loss as it
ages the opportunity for clients to tell their story as lacks definition, and questions are raised as to
a way to begin to understand their loss and how to appropriate responses. This lack of understanding
move into their lives while holding their grief in is often not intentional, but rather due to misun-
healthy ways. derstanding ambiguity.
The stress of living with ambiguous loss may
affect individuals with a variety of emotions such
Description as:
Ambiguous loss is a psychological or physical • Depression, anxiety, guilt, shame

loss that is unclear and lacks definition. Lack of • Neglect or lack of self-care
definition creates difficulty in obtaining support • Somatic illnesses
and movement through the grief process. When • Abuse: substance and other
the goal of addressing ambiguous loss is to • Distress and traumatization
resolve the loss and solve the “problem,” indi-
viduals may get stuck in the search for a right or The unknowing that accompanies ambigu-
wrong decision. Application of ambiguous loss ous loss can become overwhelming and leave
theory does not provide a solution to a the individual feeling as though they have no
“problem” but rather assists with helping indi- way to control the events that are taking place
viduals and families to live well with their expe- around them, as well as the sense that they are
riences of ambiguity. There are two types of alone and misunderstood. Helping the individ-
ambiguous loss: ual identify their psychological family,
information, community, and spiritual support

is important, as well as encouraging the indi-
Finding
vidual to reach for those experiences, people, Meaning
and recreation activities that encourage self-
care and much-needed respite.
Reaching for a solution to resolve the ambigu- Discovering Tempering
Hope Mastery
ous loss does not work and is not helpful to the
individual or family. How, then, do we provide the
best help and resources to those living with
ambiguous loss?
Revising Reconstructing
Attachment Identity
Family Therapy: Guidelines for
Normalizing
Resilience Ambivalence
The therapeutic goal of ambiguous loss theory is

to help the individual live well with ambiguity.
Living well with ambiguity involves a response
of learning to flow with the ambiguity rather Finding Meaning: How do I make sense of my
than fighting it and demanding solutions. losses? The ability to name a loss “ambiguous”
Ambiguous losses are not problems to be helps to make sense of that which does not make
solved, but life situations to be explored and sense. Therapy that applies ambiguous loss the-
lived with. Often there is a belief that closure ory to individuals and families living with ambi-
is possible and individuals living with ambigu- guity focuses on a both/and approach rather than
ity are encouraged to seek that closure to their either/or. Both/and approaches allow for para-
situation; however, closure is a myth. Attempts doxical thinking that helps foster resilience in
to reach closure in ambiguous losses lead to ambiguity. Spirituality, forgiveness, reshaping
feelings of shame, worthlessness, and failure. family rituals are also helpful resources.
These attempts are not a reflection on the indi- Anger, the desire for revenge, and secret-
vidual, but rather a reflection of the situation of keeping hinder one’s capacity for living well
ambiguity. Ambiguous loss is difficult and hard with their loss.
to hold. Ambiguous losses are irrational, and Tempering Mastery: How do I learn to accept
rational attempts to address them will not suc- what I cannot control? Recognizing that the
ceed nor provide healthy coping strategies for world is not always fair helps to address the feel-
living with ambiguity. ings of being out of control that can accompany
The Guidelines for Resilience provide a frame- ambiguous losses. Other actions that assist accep-
work for understanding what works and what tance are: externalizing blame, decreasing self-
does not work in addressing ambiguous loss. blame, and mastering one’s internal self by the
The guidelines are not linear and are best under- use of meditation, prayer, etc. Perceptions such
stood as elements that work together to better live as believing that bad things only happen to bad
with ambiguity. The chart below introduces the people, and the harder you work, the more you
six guidelines and provides details related to each avoid suffering, only increase the belief that
guideline (Boss and Yeats 2014; Sampson et al. solving the ambiguity “problem” is the best
2012). solution.
Ambiguous Loss in Couple and Family Therapy 103
Reconstructing Identity: How can I know who lightens the heaviness. However, insisting that
I am now? Accepting that ambiguous losses will the suffering end or looking for closure to the
change the way in which individuals view them- ambiguity will create more pain, not less Boss A
selves, redefining couple/family boundaries can (2006).
be helpful. Such redefining helps to clarify who
is “in” and who is “out,” as well as who plays what
roles in this new way of life. Connections with Clinical Example
new acquaintances as well as old friends help with
the feelings of sadness. Isolation and Ambiguous losses can create stress in family
disconnecting from social interactions hinders systems and complicate relationships, due to
the move to resilience. the fact that ambiguity is difficult to live with.
Normalizing Ambivalence: What can I do with Relationships become immobilized and impact
the anger and guilt? Many feelings that are often the capacity to make decisions that can create
identified as “negative” are actually normal and to conflict between family members. Therapy may
be expected in living with ambiguous loss. Deny- involve family mediation and helping family
ing that these ambivalent feelings exist about who members (and other systems involved with the
or what has been lost gets in the way of a healthy couple or family) understand how ambiguous
life. Understanding and normalizing these con- loss impacts each individual and system
flicted feelings are helpful, with the caution that involved Boss (2011).
the harmful actions that may occur with the feel- A family who came to me for help in
ings need to be redirected. Talking with trusted responding to their growing concerns related to
friends and colleagues or mental health profes- decision-making. Al, 80 years of age, had been
sionals can also be helpful. diagnosed with Alzheimer’s a year earlier. His
Revising Attachment: How can I let go without social ease had masked symptoms for quite some
the certainty of loss? The uncertainty in an ambig- time, and the family was surprised to learn just
uous loss situation can lead to freezing and lack of how diminished his cognitive capacity had
decision-making. Forcing oneself to make a deci- become. Al requested that his family keep his
sion without knowing the true outcome of this diagnosis a secret and that everyone act as though
type of loss puts the individual in an impossible nothing was wrong. The family complied for a
situation of expecting clarity and closure. Instead, year, and came to me after reporting that the adult
recognizing the paradox of what or who is ambig- children and Al’s wife, Jean, were concerned
uously lost can be both here and gone can help the about their inability to come to agreement as to
individual live with resilience. Finding new Al’s treatment moving forward.
human connections can also be helpful. I met with Jean and her adult children. Al’s
Discovering Hope: How can I find new hope health had significantly declined, he was living at
when my loss remains ambiguous? Although it home with Jean who was his primary caregiver.
may be hard to imagine, it is possible to discover Jean reported that she was exhausted and felt
hope in the situation of ambiguity. Developing guilty for saying so. Jean did not like to ask for
the capacity to become comfortable with ambi- help from her children and grandchildren as they
guity requires an individual or family to “float” were “busy with their own lives.” Al and Jean’s
with the situation. Becoming comfortable does son, Jeff managed his parents’ finances and was
not mean pretending or acting as though all is ok, self-employed with a business that did not allow
but rather comfort is not fighting the ambiguity. him to spend much time with his parents. Jeff and
Finding or exploring existing spirituality, justice, his wife, Susan, lived about 15 min from Al and
and forgiveness can help this process. The ability Jean. Daughter Diane and her son lived approxi-
to find the humor in the absurdity of the situation mately 3 h from the rest of the family. Diane
visited her parents once each month for a few diagnosis, as Alzheimer’s is a progressive disease,
hours and believed that the family needed to but by acknowledging their ambiguous losses,
move Al to a memory care unit because Jean they are more able to address those challenges in
needed relief and she (Diane) was unable to healthy and connected ways.
help. Jeff disagreed with his sister and believed
that the family needed to stick to their promise,
regardless of the fact that Al no longer had capac- Conclusion
ity to remember his request.
At our first family meeting, the tension in my Ambiguous losses are difficult and painful; how-
office was palpable, and it was also clear that ever, individuals and families can live well with
this family cared about each other, felt guilty the ambiguity. The process is not easy and is best
about what to do, and did not feel they had managed with support from mental health pro-
permission to make decisions. After listening fessionals, friends, and family. Ambiguous loss
to each family member, also clear to me was is a relational condition, and a therapeutic goal is
that none of the family members had grieved to encourage and support resilience. Paradoxical
the losses they had faced and were facing. thinking can be used to increase coping: both/
Because Al had not yet died, the family was and approaches (harmony with) rather than
not sure they had anything to grieve. either/or approaches (mastery over) help to min-
I introduced the concept of ambiguous loss to imize suffering in the midst of the loss. Sup-
the family, and we discussed what the losses porters can be most helpful when they keep in
were that this family had been facing. With mind that the person experiencing ambiguity is
this understanding, the family could look at normal, it is the situation that is abnormal (Boss,
decision-making through a different lens that personal communication 3/17/12). Understand-
allowed them to know that the choices they ing how to live well with ambiguous loss will
were making were in Al’s best interest and for help to create meaning and significance within
the good of Jean’s health. In two additional the loss.
family meetings, we discussed how having free-
dom of choice, based on loss, not only helped
the family make decisions but also gave them Cross-References
the opportunity to grieve what had happened
and what was currently happening. Finally, ▶ Boss, Pauline
using the Guidelines for Resilience allowed us ▶ Externalizing in Narrative Therapy with Cou-
together to reframe the guilt and shame Jeff and ples and Families
Diane were experiencing related to their limited ▶ Family Therapy
capacity to help their parents and gave Jean a ▶ Feminism in Couple and Family Therapy
new way to understand that she could still be ▶ Loss in Couples and Families
taking good care of her husband by making use ▶ Resilience in Couples and Families
of trained professionals to help. ▶ Theory of Resilience and Relational Load
At the end of our sessions, the family decided
to move Al to a memory care unit close in prox-
imity to Jean’s home so she could visit her hus- References
band frequently. He received excellent care, Jean
was able to sleep through the night and saw a Boss, P. (2000). Ambiguous loss: Learning how to live with
reduction in her stress symptoms. Jeff, Susan, unresolved grief. Cambridge, MA: Harvard University.
and Diane committed to working out a plan Boss, P. (2006). Loss, Trauma and Resilience: Therapeutic
work with ambiguous loss. New York: WW Norton.
amongst themselves to provide more support for Boss, P. (2011). Loving someone who has dementia: How
Jean as the primary caregiver. This family will to find hope while coping with stress and grief.
continue to have challenges related to Al’s New York: Jossey-Bass.
American Academy of Couple and Family Psychology 105
Boss, P., & Yeats, J. (2014). Ambiguous loss: definition, education, training, competencies, and
A complicated type of grief when loved ones disappear. the examination process leading to being a board
Bereavement Care, 33(2), 63–69.
Sampson, J. M., Yeats, J. R., & Harris, S. M. (2012). An certified specialist (i.e., a diplomate) in couple and A
evaluation of an ambiguous loss based psychoedu- family psychology. The Academy of Family Psy-
cational support group for family members of people chology has evolved into the AACFP, an indepen-
who hoard: A pilot study. Contemporary Family Ther- dent nonprofit professional corporation. The
apy, 34(4), 566–581.
purpose of the AACFP is to advance family psy-
chology as a science, advocate on behalf of family
psychologists, and to ensure adequate training for
American Academy of Couple those practicing couple and family therapy and
and Family Psychology family assessment. In 2002, the APA’s Council
for the Recognition of Specialties and Profi-
Bob Geffner ciencies in Professional Psychology (CRSPPP)
Institute on Violence, Abuse, and Trauma, San approved family psychology as a specialty. The
Diego, CA, USA AACFP promotes this specialty certification and
works to encourage and mentor family psycholo-
gists in this certification process.
Introduction The AACFP has developed and enhanced its
infrastructure in recent years, improved and
The American Academy of Couple and Family refined its governance, added new board mem-
Psychology (AACFP) is the specialty organiza- bers, including early career psychologists for sus-
tion for family psychologists that works with the tainability and mentoring, and has encouraged
American Board of Professional Psychology early career psychologists and graduate students
(ABPP) with respect to the diplomate process to become involved even before obtaining their
and board certification in the specialization of own diplomates. Couple and family psychology
family psychology. The actual group that issues also represents a comprehensive application of the
certifications and diplomates in family psychol- science and profession of family psychology with
ogy is the American Board of Couple and Family assessment, treatment, and consultation for indi-
Psychology (ABCFP). The AACFP works closely viduals, families, and family subsystems. Couple
with the ABCFP as well as the Society for Couple and family psychologists stress the centrality of
and Family Psychology, a division of the Ameri- understanding and constructively changing the
can Psychological Association. This report family unit or subsystems, as well as facilitating
focuses on the AACFP, its origins, structure, and change within the individual.
goals with respect to family psychologists.
In the late 1950s at the American Psychologi-
cal Association (APA), the Academy of Psychol- Prominent Associated Figures
ogists in Marriage Counseling was formed. The
1960s and 1970s saw the growth of theoretical Robert Geffner
orientations and training institutes in couple and Chris Tobey
family therapy. In 1984, APA added the Division Andy Benjamin
of Family Psychology (Division 43), now the Christen Carson
Society of Couple and Family Psychology noted Karen Prager
above. In 1990, the ABPP recognized family psy- Rachael Silverman
chology as a specialty, and the American Board of Anthony Chambers
Family Psychology (ABFamP) and the Academy Allison Waterworth
of Family Psychology were created. Currently, Florence Kaslow
ABFamP is now called the ABCFP. It is respon- Terry SooHoo
sible for establishing criteria related to the Lenore Walker
106 American Association for Marriage and Family Therapy (AAMFT)
Michel Harway forensic ones, are indeed trained in family psychol-

John Thoburn ogy and identify as such. The academy wants to
Terry Patterson help ensure that such training and identification is
Mark Stanton more widely recognized so that psychologists and
others untrained in these areas would not be chosen
to do this type of treatment or evaluation. This raises
Contributions ethical concerns, especially about mental health pro-
fessionals working in forensic arenas with situations
The AACFP coordinates efforts and works coop- that involve couples and families but who are not
eratively with the ABCFP and APA’s Division trained nor have expertise in couple or family psy-
43 to promote the profession of couple and family chology. This has been most relevant in family
psychology nationally and internationally. The courts with respect to child custody evaluations
AACFP has developed and conducted advanced and the role and expertise required to do such family
training workshops in conjunction with other con- evaluations. There is also a controversy that
ferences, developed an excellent newsletter that is revolves around ethics and appropriate roles and
disseminated to academy members and others, responsibilities of therapists who happen to have a
enhanced the mentoring program to help those client or family involved with a court and whether
seeking to become diplomates in couple and fam- the therapist should be trained and follow forensic
ily psychology, enhanced its website, and devel- guidelines rather than therapeutic or family psychol-
oped a fellows program for active members. How ogy ones. These issues will be addressed by AACFP
professionals identify themselves is a key to in the future in order to set appropriate policies.
enhancing and uniting the field. Part of this is
ensuring that they understand the dynamics of
dysfunctional, abusive, traumatized, or conflicted
family members and are able to conduct appropri- American Association for
ate assessments and treatment. Marriage and Family Therapy
Thus, the AACFP promotes and works to ensure (AAMFT)
that family psychologists are able to work with such
varied situations as marriage therapy, family ther- Christopher M. Habben
apy, child abuse, intimate partner abuse, divorce, Friends University, Overland Park, KS, USA
parenting, and so forth and are trained in all of
these areas. For example, many of the above situa-
tions involve trauma, child psychology, family Name of Organization
dynamics, family violence, couples’ interactions,
attachment, adverse childhood experiences, and American Association for Marriage and Family
possibly forensic issues if they end up in some Therapy
court. Thus, identifying as a family psychologist if
one is working in some area of this specialty is
important, as is obtaining the needed training and Introduction
expertise. It is hoped that these issues will be clari-
fied and emphasized in the coming years, with the Founded in 1942, the American Association for
AACFP playing a key role. Marriage and Family Therapy (AAMFT) is the
Many training programs that focus on marital oldest and largest professional association pro-
therapy, or clinical psychology with a family moting the common professional interests of mar-
emphasis, do not necessarily identify themselves riage and family therapists and the field of
as family psychology. It is also important to ensure marriage and family therapy as a whole (Nichols
that those psychologists who do evaluate or treat 1992; AAMFT 2017). Multiple pathways exist for
family members in a variety of settings, including membership in AAMFT with variant categories of
American Association for Marriage and Family Therapy (AAMFT) 107
membership and related benefits. Membership is AAMFT promotes the public trust of marriage
open to those licensed or pursuing licensure as a and family therapists by developing high stan-
marriage and family therapist as well as students dards for ethical and professional behavior as A
enrolled in a graduate marriage and family therapy outlined in the AAMFT Code of Ethics and the
program. In addition, AAMFT extends member- formal processes for addressing complaints of
ship to professionals holding or pursuing profes- ethical misconduct (AAMFT 2015).
sional licenses in related mental health fields The Commission on Accreditation for Marriage
authorized to provide services to individuals, cou- and Family Therapy Education (COAMFTE),
ples, or families and to students enrolled in accept- established by AAMFT, furthers the profession of
able alternative graduate mental health programs. marriage and family therapy by developing and
Membership is also available to those profes- reviewing rigorous standards of education for mar-
sionals in fields related to marriage and family riage and family therapy and by promoting best
therapy (AAMFT 2017). practices for training (COAMFTE 2016).
With a goal to identify and improve the quality
of service delivered by all marriage and family
Location therapists, AAMFT commissioned a task force to
define core competencies articulating the knowl-
112 S. Alfred Street edge and requisite skills necessary for the compe-
Alexandria, VA 22314 tent practice of marriage and family therapy
(AAMFT 2004). The development of the core
competencies further delineates the overlap and
Prominent Associated Figures distinctiveness of marriage and family therapy
relative to other mental health disciplines. The
Dr. Tracy Todd, Chief Executive Officer core competencies of AAMFT also pose learning
objectives for educational and training programs.
The AAMFT Approved Supervisor designa-
Contributions tion is another example of the dedication of
AAMFT to ensure a high standard of practice.
The primary mission of the AAMFT is the advance- AAMFT Approved Supervisors must meet strin-
ment of both the profession and the practice of gent education and training requirements and
marriage and family therapy (AAMFT 2017). The renewal criteria. These high standards of training
contributions of AAMFT to couple and family ther- and practice assure that supervisees are equipped
apy have shaped the development and maturation of with the latest innovations and skills for compe-
the marriage and family therapy profession. tent practice (AAMFT 2014).
AAMFT has long endeavored to represent the pro- Another contribution to the advancement of
fessional interests of marriage and family therapy the profession of marriage and family therapy is
before government and corporate policymakers the AAMFT Research and Education Foundation
regarding matters such as licensure, the equitable which endeavors to fund systemic and relational
reimbursement of practitioners, and evidence of the research, scholarship, and education. The
efficacy of systemic and relational therapies. Research and Education Foundation supports the
The profession and practice of marriage and next generation of scholars and clinicians through
family therapy is enhanced through its profes- grants, awards, and a minority fellowship pro-
sional journal, the Journal of Marital and Family gram [http://www.aamftfoundation.org/].
Therapy (JMFT). The peer-reviewed JMFT is Amid the efforts to advance the profession,
published quarterly and has earned international AAMFT is equally cognizant of marriage and
respect as a family therapy journal [http:// family therapy practitioners’ needs. AAMFT
onlinelibrary.wiley.com/journal/10.1111/(ISSN) offers multiple services, publications, and prod-
17520606/homepage/ProductInformation.html]. ucts to members to improve their clinical practices
108 American Board of Couple and Family Psychology
and efficacy of client care. The Family Therapy http://networks.aamft.org/viewdocument/aamft-bylaws-

Magazine, continuing education (in-person and effective-january-2012
Commission on Accreditation for Marriage and Family
online), interest networking, an employment Therapy. (2016). Accreditation manual: Policies and
search engine, and various practice tools are a procedures. Alexandria: Commission on Accreditation
few of the options for members. for Marriage and Family Therapy.
Legislative advocacy in provinces, states, Nichols, W. C. (1992). The AAMFT: Fifty years of marital
and family therapy. Washington, DC: American Asso-
and federal levels, policy advocacy with policy ciation for Marriage and Family Therapy.
and research entities, meaningful publications,
educational support, professional standards,
research opportunities, and the products and
services of AAMFT all advance the profession
of marriage and family therapy. A vibrant and American Board of Couple and
flourishing association attentive to the relevant Family Psychology
needs of a diverse membership in turn provides
various resources for the continual advance- Allison Waterworth
ment of the field. To that end, AAMFT consis- American Board of Professional Psychology,
tently pursues high standards of care and Chapel Hill, NC, USA
innovation in all of the association efforts to
promote systemic and relational therapies in
general and marriage and family therapy in par- Introduction
ticular. The diversity of association member-
ship and the collective possibilities members The American Board of Couple and Family Psy-
provide to the field of marriage and family ther- chology (ABCFP) is a specialty credentialing
apy are a precious resource. AAMFT has long board for the American Board of Professional
served the profession and practice of marriage Psychology (ABPP). A specialty is a defined
and family therapy and remains a vivid cham- area in the practice of psychology that connotes
pion for the interests of all marriage and family special competency acquired through an orga-
therapists. nized sequence of formal education, training,
and experience. In order to qualify as a specialty
affiliated with the ABPP, a stable examining
Cross-References board, national in scope, must reflect the current
development of the specialty.
▶ Journal of Marital and Family Therapy As a constituent specialty group of ABPP,
ABCFP offers certification to psychologists who
present the requisite training and experience in
References couple and family work. One of the most impor-
tant missions of ABCFP is to increase consumer
American Association for Marriage and Family Therapy.
(2004). Marriage and family therapy core competen-
protection. Board certification assures the public
cies. Retrieved from http://www.aamft.org/imis15/doc that specialists designated by ABPP have success-
uments/mft_core_competencie.pdf fully completed the educational, training, and
American Association for Marriage and Family Therapy. experience requirements of the specialty, includ-
(2014). Approved supervisor designation: Standards
ing an examination designed to assess the compe-
handbook. Alexandria: American Association for Mar-
riage and Family Therapy. tencies required to provide the highest degree of
American Association for Marriage and Family Therapy. service. Additionally, board certification through
(2015). Code of ethics. Retrieved from http://www. ABPP provides psychologists with increased
aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_
of_Ethics.aspx
opportunities for career growth, including
American Association for Marriage and Family Therapy. employability, mobility, and financial
(2017). AAMFT bylaws: January 2017. Retrieved from compensation.
American Counseling Association (ACA) 109
Candidates for board certification in couple

and family psychology complete an application, American Counseling
submit credentials, provide a work sample, and sit Association (ACA) A
for an oral examination administered by the
ABCFP. Candidates who successfully complete Thelma Duffey
the process earn board certification. University of Texas at San Antonio, San Antonio,
Couple and Family Psychology (CFP) is a TX, USA
broad specialty in professional psychology that
is founded on a systemic epistemology. It rep-
resents a paradigm shift from contemporary Name of Organization or Institution
individualistic psychology and incorporates an
understanding of human behavior, psychologi- American Counseling Association (ACA)
cal assessment, and intervention based on a sys-
temic perspective and model. The specialty of
Couple and Family Psychology conceptualizes Synonyms
human behavior in a matrix of reciprocal inter-
action among intrapersonal, interpersonal, envi- ACA
ronmental, and macro-systemic factors.
ABCFP-certified psychologists use their aware-
ness of context, diversity, and developmental Introduction
perspectives to understand, assess, and treat
the comprehensive issues of psychological The American Counseling Association is the larg-
health and pathology. These issues include est professional membership organization for coun-
affective, cognitive, behavioral, and dynamic selors in the world. With a membership of over
factors among individuals, couples, families, 55,000, ACA serves counselors working in diverse
and larger social systems. ABCFP-certified psy- settings and across specialties. ACA is dedicated to
chologists depend upon a body of knowledge strengthening professional identity and unity
and evidence-based interventions that require within the counseling profession, promoting clarity
specialty competence (Stanton and Welsh within the public about the counseling profession,
2011). and advocating for legislation serving the interests
The ABCFP Board was affiliated in 1990. of counselors and their clients. ACA also supports
Before its inception, the only organization the professional development of counseling stu-
representing the interests of psychologists in the dents and promotes research in counseling. These
family field was the Academy of Psychologists in goals are grounded in ACA’s mission to promote
Marital, Sex, and Family Therapy. In 1983, the respect for human dignity and diversity.
academy changed its name to the Academy of
Family Psychology, and in 1984, it officially
became the Division of Family Psychology of Location
the American Psychological Association. Foun-
ders of the ABCFP included Florence Kaslow, ACA is headquartered in Alexandria, Virginia, and
Michael Gottlieb, S. Richard Sauber, Gerald serves counselors in the United States, Latin Amer-
Weeks, and George Nixon, Jr. ica, Europe, the Philippines, and the Virgin Islands.
There are 4 ACA regions (Midwest, North Atlantic,
Southern, and Western) and 56 state- and territory-
References
level branches of the ACA which support the goals
Stanton, M., & Welsh, R. (2011). Specialty competencies of the ACA and address issues particular to each
in couple and family psychology (1st ed.). Oxford: geographical area. The ACA also maintains a
Oxford University Press. website: www.counseling.org.
110 American Counseling Association (ACA)
Prominent Associated Figures American Mental Health Counselors Association

(AMHCA); American Rehabilitation Counseling
ACA is a community of professional counselors Association (ARCA); American School Coun-
across specializations, and its growth and foci have selor Association (ASCA); Association for Spiri-
been developed through the work of countless tual, Ethical, and Religious Values in Counseling
members. There are a number of notable figures (ASERVIC); Association for Specialists in Group
within ACA, including Thelma T. Daley, Work (ASGW); Counselors for Social Justice
1975–1976 president of the American Personnel (CSJ); International Association of Addictions
and Guidance Association (APGA) – which would and Offender Counselors (IAAOC); International
later become the ACA. Daley has been a Association of Marriage and Family Counselors
pioneering leader and mentor for many within the (IAMFC); Military and Government Counseling
profession and beyond. Daley was the first African Association (MGCA); National Career Develop-
American president of the American School Coun- ment Association (NCDA); and National
selor Association in 1971 and the first African Employment Counseling Association (NECA).
American and third female president of APGA; ACA traces its development to 1952, when the
Samuel T. Gladding continues to be a leading fig- National Vocational Guidance Association
ure within the ACA. He has written a myriad of (NVGA), the National Association of Guidance
textbooks within the field of counseling and served and Counselor Trainers (NAGCT), the Student
as ACA president in 2004–2005. Patricia Personnel Association for Teacher Education
Arredondo, well known for her work on multicul- (SPATE), and the American College Personnel
tural competencies, served as president in Association gathered in Los Angeles, California,
2005–2006. Loretta Bradley, ACA president in to create the American Personnel and Guidance
1998–1999 has made seminal contributions in the Association (APGA). The APGA was renamed
area of marriage and family counseling and is a the American Association of Counseling and
board member for the Texas State Board of Exam- Development in 1983 and became the American
iners of Professional Counselors. These leaders, Counseling Association in 1992, a name which
and others like them, have contributed to ACA’s best reflected its goals for professional unity.
growth and the professionalization of counseling. Through the strategic efforts of ACA and its
organizational partners and predecessors, the
identity and standing of the counseling profession
Contributions has strengthened steadily over time. Among the
recent historical milestones for the profession are
ACA is structured to include 20 divisions/associ- the adoption of a unified definition of professional
ations which address distinct areas of specializa- counseling by ACA in 1997, the legal recognition
tion in practice or orientation within the of counselors as mental health specialists within
counseling profession. Among these are: the the Veterans Affairs health care system in 2006,
Association for Adult Development and Aging the enactment of counselor licensure in all
(AADA); Association for Assessment and 50 states in 2009, when California adopted licen-
Research in Counseling (AARC); Association sure legislation, and the promulgation of a con-
for Child and Adolescent Counseling (ACAC); sensus definition of counseling by ACA delegates
Association for Creativity in Counseling (ACC); and 30 other professional organizations in 2010.
American College Counseling Association Other milestones include the passing of the
(ACCA); Association for Counselor Education 2015–2016 ACA Governing Council’s policy to
and Supervision (ACES); Association for endorse the Council for Accreditation of Counsel-
Humanistic Counseling (AHC); Association for ing and Related Educational Programs
Lesbian, Gay, Bisexual and Transgender Issues (CACREP) as the accrediting body for coun-
in Counseling (ALGBTIC); Association for Mul- selors, and the 2015–2016 ACA Governing
ticultural Counseling and Development (AMCD); Council’s passage of the ACA Licensure
American Counseling Association (ACA) 111
Portability Model. ACA continues its advocacy The ACA Code of Ethics (2014) provides a
for counselors through this model. framework for ethical conduct and decision-
ACA was instrumental in supporting state- making for professional counselors. It is struc- A
level efforts to secure licensing laws for coun- tured around the core values of the counseling
selors in all 50 states and continues to advocate profession and the fundamental ethical principles
that licensed counselors be included in govern- of autonomy, nonmaleficence, beneficence, jus-
mental insurance systems. In addition, with licen- tice, fidelity, and veracity. The ACA Code of
sure legislation in place in all 50 states, licensure Ethics has nine sections dealing with the counsel-
portability across states has become a primary ing relationship; confidentiality and privacy; pro-
concern for the ACA. Currently, counselors mov- fessional responsibility; relationships with other
ing across state lines must satisfy the licensure professionals; evaluation, assessment and inter-
requirements of the new state in which they intend pretation; supervision, training, and teaching;
to practice, regardless of their experience and research publication; distance counseling, tech-
record. The long and idiosyncratic history of nology, and social media; and resolving ethical
state legislation of counselor licensure inadver- issues.
tently created a significant burden to the counselor The ACA Code of Ethics is a living document.
moving across state lines. The 2015–2016 ACA Since the approval of the first Code of Ethics in
Governing Council made significant strides in 1961, the code has undergone numerous revisions
addressing educational standards and policies on to stay up-to-date with current thinking and
portability to address these burdens. The council’s emerging issues. The most recent ACA Code of
position on CACREP as the accrediting body for Ethics was issued in 2014 with a number of
counselors, and its passage of the ACA Licensure updates, including but not limited to the ethics of
Portability Model, both serve the vision of a uni- social media for counselors, clearer language
fied and standardized counseling license. The around client referral based on counselor compe-
ACA Licensure Portability Model provides that tence rather than personal values, the need to use a
fully licensed counselors without disciplinary decision-making model when considering ethical
records would be eligible for licensure without dilemmas, and the need to rely on relevant laws in
additional requirements after taking a jurispru- deciding whether to disclose a client’s status as a
dence exam in any state or US territory. carrier of a life-threatening communicable disease
ACA is dedicated to legislative advocacy at to a person at risk.
state and federal levels. Its efforts have two foci: ACA holds an annual conference which serves
advocacy for the professional interests of coun- to bring together members for collaboration and
selors and advocacy for the mission of the ACA. continuing education. Presenters and participants
These involve enhancing the quality of life in at the conference travel from all over the world to
society and promoting human respect and dig- learn from each other. The conference features
nity. The ACA offers training on legislative keynote speakers, group discussions, plenary ses-
advocacy to its members and also employs a sions, and research presentations. It also provides
Director of Government affairs and legislative opportunities for counselors to connect with col-
representatives that work on Capitol Hill to rep- leagues and engage in growth-fostering network-
resent the interests of counselors and their cli- ing. The conference serves as a forum for the
ents. ACA also continues to advocate for expression of a unified professional identity for
counselors’ inclusion as mental health providers counselors.
within various governmental systems. For exam- Continuing education is a common licensure
ple, since 2010, licensed professional counselors requirement, and it is also important for coun-
who meet standards set by the VA health care selors’ professional advancement. ACA provides
system qualify to work as licensed professional continuing education courses online and offers
mental health counselors for the VA health care webinars and podcasts for professional develop-
system. ment. ACA is approved by the National Board of
112 American Family Therapy Academy (AFTA)
Certified Counselors, the Association for Play

Therapy, the Association for Addiction Profes- American Family Therapy
sionals, and other related associations and licen- Academy (AFTA)
sure boards as a provider of continuing education
units. Kiran Arora
The Journal of Counseling & Development is Long Island University, Brooklyn, NY, USA
the flagship journal of ACA and published quar-
terly. Research studies published in the Journal of
Counseling & Development span many topics and Introduction
include both quantitative and qualitative studies,
as well as pieces on practice and theory. A number The American Family Therapy Academy was
of ACA divisions also have their own peer- founded in 1978. It is an interdisciplinary commu-
reviewed journals. In addition, Counseling nity of family therapy and allied-field mental health
Today is the monthly newsletter of ACA, professionals, researchers, academics, students, pol-
published since 1958. It includes news, feature icy makers, and program directors. AFTA studies
stories, and other related information on profes- the interaction between psychological, relational,
sional issues in counseling. ACA also publishes biological, and sociocultural dimensions that con-
books electronically and in print in partnership tribute to mental health and well-being (AFTA
with John Wiley & Sons publishing company on 2016). Members are informed of topics of concern
topics including creativity in counseling, coun- to those in the mental health field. AFTA holds a
selor supervision and education, counseling chil- core commitment to justice and social responsibility
dren and adolescents, ethical and legal issues in while providing acute attention to underserved
counseling, multiculturalism and diversity in groups. Emerging leaders in the field are supported
counseling, counselors’ professional develop- through a variety of initiatives.
ment, school counseling, and substance abuse
and addictions counseling.
Location
ACA emphasizes the importance of develop-
ing a strong research base within the counseling
The AFTA office is located in Haverhill,
profession. Because empirical work in counseling
Massachusetts.
may be framed to explore some of the issues of
particular interest to counselors, including
strengths-based work, multiculturalism, innova- Prominent Associated Figures
tive and creative practice, and preventive mental
health, the ACA sees counseling research as indis- Murray Bowen
pensable to the growth of the profession. James L. Framo
Kitty La Perriere
Lyman C. Wynne
Carol M. Anderson
Cross-References
Rachel T. Hare-Mustin
Froma Walsh
▶ Training Counselors in Couple and Family
Richard Chasin
Therapy
Evan Imber-Black
Donald A. Bloch
Celia J. Falicov
References
Janine Roberts
American Counseling Association. (2005). ACA code of Lois Braverman
ethics: As approved by the ACA Governing Council, Paulette Moore Hines
2005. Alexandria: American Counseling Association. John S. Rolland
American Psychiatric Association 113
John Sargent members and holds two annual meetings every

Hinda Winawer year: the Annual Meeting of the APA in May
Gonzalo Bacigalupe each year and the Institute of Psychiatric Services A
Volker Thomas in October. The APA also owns and operates a
Kiran S. K. Arora publishing company that publishes and markets
books and journals on a variety of mental
healthcare topics. The American Psychiatric
Contributions Association Publishing Company also publishes
the APA’s Diagnostic and Statistical Manual
AFTA envisions a just world by transforming (DSM) which provides information on diagnostic
social contexts that promote health, safety, and criteria for and descriptions of all psychiatric diag-
well-being of all families and communities. noses. The fifth edition (DSM-V) was published
AFTA’s mission is developing, researching, teach- in 2013, was several years in creation, and is the
ing, and disseminating progressive, just family standard used for diagnosis and coding for mental
therapy, and family-centered practices and poli- health treatment in the United States and is widely
cies. An annual conference is held for members used internationally.
and nonmembers where practitioners, educators, The American Psychiatric Association was
and researchers share contributions to the field. formed in 1844. It was formed by 13 superinten-
Interest groups include online communities that dents of psychiatric hospitals and was called the
provide AFTA members with opportunities to Association of Superintendents of American Insti-
discuss areas of interest, generate new ideas, and tutions for the Insane. Throughout the nineteenth
develop community. The AFTA Springer Briefs in century, the organization was primarily concerned
Family Therapy, produced in partnership with with the funding, building, and operation of long-
Springer Science is an official publication of the term care institutions for those with mental illness.
American Family Therapy Academy. AFTA Over the first 50 years of its existence, the orga-
releases position statements and provides recom- nization was primarily concerned with ensuring
mendations to current social issues that are rele- adequate care for those in institutions and defining
vant to the well-being of families. procedures and indications for admission as well
as criteria for a legal definition of insanity.
As the twentieth century began, the organiza-
References
tion expanded and diversified its focus to outpa-
American Family Therapy Academy (2016). Retrieved tient care and appropriate and effective treatments
from https://afta.org/. 1 Aug 2016. for a range of mental health problems including
those that did not require institutional treatment.
The name of the organization was officially
changed to the American Psychiatric Association
American Psychiatric in 1921. Through the twentieth century, the orga-
Association nization embraced new forms of treatment includ-
ing psychoanalysis, group therapy, family
John Sargent therapy, cognitive therapy, and psychopharmacol-
Tufts Medical Center, Boston, MA, USA ogy. One particularly noteworthy event was
removing homosexuality from the diagnostic
manual in 1973, thus depathologizing that sexual
Description and Contributions orientation.
The scope of attention of the APA currently has
The American Psychiatric Association (APA) is expanded to include advocacy, communication –
the professional organization of psychiatrists in especially with patients, families, and the
the United States. The APA has over 36,000 public – diversity in membership, and leadership
114 Andersen, Tom
and research into the causes of and treatments for Association and the International Family Therapy
mental illness. The organization has grown to Association. He was a Board member of the Taos
include 76 district branches across the country Institute.
and councils addressing major topics in psychia-
try. The APA views itself as the professional home
for all subspecialties of psychiatry although each Career
subspecialty may have its own focused organiza-
tion as well (e.g., the American Academy of Child Tom Andersen started as a psychiatrist, but he was
and Adolescent Psychiatry for child and adoles- attracted to the ideas of Family Therapy that were
cent psychiatrists). Of particular note to marriage critical of orthodox psychiatry. He disliked labels
and family therapists is the APA component, the and to treat people as such. He and his colleagues
Association of Family Psychiatrists, composed of were influenced by the ideas of Gregory Bateson,
psychiatrists with a strong interest in the treatment the physiotherapist Aadel Bülow-Hansen, Jay
of couples and families. DSM-V, while steadfastly Haley, Salvador Minuchin, Paul Watzlawick
only diagnosing individuals with a formal diag- from the MRI in Palo Alto, Peggy Penn from
nosis, does include a section covering “other con- The Ackermann Institute, Luigi Boscolo and
ditions that may be a focus of clinical attention” Giancarlo Cecchin from the Milan Model of Fam-
including family problems, relational problems, ily Therapy, Phillippa Seligman, and Brian Cade,
and problems related to interpersonal violence Harlene Anderson and Harry Goolishan, Lynn
including child maltreatment. These, indeed, are Hoffman, and the Chilean biologist Humberto
the focus of couple and family therapy. Maturana and FranciscoVarela, among other the-
orists and practitioners. He was invited around the
world to teach his RT, he appreciated the different
milieu of human behaviors and the gift of the
Andersen, Tom human spirit to grasp and surmount adversity.
Tom dedicated himself to traveling to developing
Elena Fernández countries where he taught many of his colleagues,
Grupo Campos Elíseos, Mexico City, Mexico donating his time and getting funds and training
for therapists in these countries.
Name
Contribution to the Profession
Tom Andersen Ph.D. (1936–2007)
Andersen’s innovative manner of working was
originally proposed as a therapeutic space
Introduction consisting of three parts: (1) An interview of one
or more therapists with one or more consultants
Tom Andersen was a Norwegian psychiatrist, Pro- during the first 30–40 min, while a team of several
fessor of Social Psychiatry at the Institute of Com- therapists listen quietly, (2) A reflective conversa-
munity Medicine, University of Tromsø, Norway, tion about the ideas and thoughts that arose during
and he is recognized worldwide for the contribu- the time of listening to the interview (the RT
tion that, with his colleagues, led him to the devel- maintains this conversation with each other for
opment of the Reflecting Team (RT). The RT is an about 10/15 min not including the consultants,
approach that offers to the consultant a pluralistic who are in a posture of listening), and (3) A final
view of meaning by inviting numerous interpreta- conversation between the team and the consultant
tions rather than a correct view of what is happen- about his/her/their reflections on the reflections of
ing to them. Tom Andersen was an inspiration the RT. Andersen (Andersen 1987) underscored
both for the Norwegian Family Therapy the tentative way in which members of the team
Anderson, Carol 115
should present their ideas once they give back References

their reflections to the clients: As a general rule,
everything that is said should be speculative: “I Andersen, T. (1987). The reflecting team: Dialogue and
A
meta-dialogue in clinical work. Family Process, 26,
am not sure, “It occurred to me,” “Maybe,” “I had
415–428.
the feeling that, “Maybe this is not appropriate, http://www.newtherapist.com/andersen5.html. Retrieved
but,” and so forth. The reflections must have the 31 July 2017.
quality of tentative offerings, not pronounce-
ments, interpretations, or supervisory remarks References
(p. 419). The RT continues developing around Andersen, T. (Ed.). (1991). The reflecting team, dialogues
and dialogues about the dialogues. London: Norton.
the world.
Andersen, T. (1987). The reflecting team: Dialogue and
The weight of his work is better explained in meta-dialogue in clinical work. Family Process, 26,
his own words: 415–428.
Andersen, T. (1989). Back and forth and beyond.
I see two kinds of therapy, the first gives priority to Australian and New Zealand Journal of Family Ther-
the philosophy of ontology and the second gives apy, 10, 75–76.
priority to the philosophy of ethics. Ontology is Andersen, T. (1992a). Reflections on reflecting with fam-
occupied with questions like: What is it? For ilies. In S. McNamee & K. J. Gergen (Eds.), Therapy as
instance, what is a human being? Or what is the a social construction (pp. 54–68). Newbury Park:
problem? One could say questions that call on Sage.
explanations and understanding of something, Andersen, T. (1992b). Relationship, language and pre-
“out there”. Ethics are carried by what connects understanding in the reflecting processes. Australian
people; that which is between us, for instance, and New Zealand Journal of Family Therapy, 13,
language and conversations. http://www. 87–91.
newtherapist.com/andersen5.html Andersen, T. (1993). See and hear, and be seen and heard.
In S. Friedman (Ed.), The new language of change:
Andersen’s main contribution, The Reflection
Constructive collaboration in psychotherapy
Team, characterizes a transformation in the (pp. 303–322). New York: Guildford Press.
means of delivering ideas to the clients and on
“expert knowledge.” When several specialists
offer their views tentatively and horizontally, the
position of the specialists changes and enhances Anderson, Carol
the relationship with the client. Reflection teams
are used in many countries and in a variety of Britney Acquaire, Justine Encinas and
contexts: clinical, educational, and organizational Christiana I. Awosan
and with different objectives: therapeutic, super- Seton Hall University, South Orange, NJ, USA
vision, or training.
Name
Cross-References
Carol Anderson (11/1/1939–11/20/2014).
▶ Anderson, Harlene
▶ Collaborative and Dialogic Therapy with Cou-
ples and Families Introduction
▶ Dialogical Practice in Couple and Family
Therapy Carol Anderson is most well known for her revo-
▶ Milan Associates lutionary approach to the treatment of schizophre-
▶ Open Dialogue Family Therapy nia. Family psychoeducation is an empirically
▶ Postmodernism in Couple and Family Therapy supported family therapy model that aims to
▶ Social Constructionism in Couple and Family decrease symptoms of schizophrenia and increase
Therapy social involvement in schizophrenic patients.
▶ Talk as Action in Couple and Family Therapy Carol Anderson proposed that families can
116 Anderson, Carol
support their loved ones with schizophrenia if did not blame families for the development of
they are given the knowledge to understand the mental illness. In the 1970s, her approach to
illness and the skills to care for their family mem- treatment was controversial and revolutionary
ber effectively. because she accepted the families’ view of the
symptom bearer as the identified patient and
advocated for the use of medication in conjunc-
Career (Includes Education, Professional tion with family therapy.
Training, Positions) The goal of family psychoeducation is to help
families manage symptoms of schizophrenia,
Carol Anderson attended the University of Min- cope with the illness, and help the identified
nesota where she received a Bachelor’s Degree in patient achieve their highest potential for social
Child Development and Psychology in 1961 and engagement. The family psychoeducation model
a Master’s Degree in Social Work in 1964. She is divided into five stages of treatment. During
earned her Ph.D. in Interpersonal Communica- the beginning stages, therapists provide informa-
tion from the University of Pittsburg in 1981. tion to families about schizophrenia. Topics
Early in her career, Carol Anderson served as include: symptoms and causes of schizophrenia,
Chief Psychiatric Social Worker at Yale medication treatment and side effects, brain
University’s Psychiatry Department. Carol functioning of a schizophrenic, and the social
Anderson joined the faculty at the University of response to schizophrenia. During the middle
Pittsburg Medical Center (UPMD) in 1973, stages of treatment, families use their new
where she worked as a Professor of psychiatry knowledge in the context of their everyday
and social work. She was granted Professor lives in order to help the identified patients suc-
Emerita status in 2010. During her time at cessfully return to life in the community. During
UPMD, Carol Anderson helped develop the the last stage of treatment, therapists address
Family Therapy Clinic at the Western Psychiatric general family functioning issues that are
Institute and Clinic (WPIC). Over the span of her unrelated to the mental illness.
career, Carol Anderson also served as Director of Outcome studies endorsed by the American
the Family Therapy Institute and Clinic, Director Psychiatric Association support the use of Carol
of Family Research, Director of Brief Treatment Anderson’s family psychoeducation model in the
Center for Children and Families, Director of treatment of families struggling with schizophre-
Child and Adolescent Outpatient Services, and nia. In conjunction with medication, family
Director of Family Studies and Social Work. psychoeducation significantly reduces relapse
Carol Anderson was the administrator of WPIC and unemployment for the individual with
from 1989 to 1994 and then became Vice Presi- schizophrenia.
dent for Patient and Family Psychiatric Services Carol Anderson’s research interests also
at UPMD. Carol Anderson served as the Presi- include: access to mental healthcare, barriers to
dent of the American Family Therapy Academy mental health services, and engaging low-income
(AFTA) from 1988 to 1989. She was Editor of mothers in mental health treatment.
the Family Process journal from 1999 to 2003. Throughout her career, Carol Anderson wrote
and coauthored more than 40 research articles and
published several books: Mastering Resistance:
Contributions to Profession A Practical Guide to Family Therapy, Families
and Schizophrenia, Schizophrenia and the Fam-
Carol Anderson developed family psycho- ily: A Practitioner’s Guide to Psychoeducation
education, an empirically validated family ther- and Management, Flying Solo: Single Women in
apy model used to treat schizophrenia. Midlife, and Women in Families.
Developed in 1978, family psychoeducation Carol Anderson received multiple acknowl-
was among the first family therapy models that edgement for her contributions to the field. In
Anderson, Harlene 117
1992, Anderson was named a Distinguished coedited Appreciative Organizations, Collabora-

Daughter in the State of Pennsylvania, an tive Therapy: Relationships and Conversations
award grated to renowned individuals affiliated that Make a Difference and Innovations in the A
with Pennsylvania who have achieved profes- Reflecting Process.
sional excellence. She was also granted two
Distinguished Contribution to Family Therapy
awards from AFTA in 1985 and AAMFT Career
in 1987.
Harlene Anderson holds a doctorate in psychol-
ogy and is a licensed professional counselor and
Cross-References family therapist. She is an advisor for the Taos
Institute Doctoral Programs and a member of Sil-
▶ Family Psychoeducational Treatments for ver Fox Advisors. She received the 2008 Ameri-
Schizophrenia in Family Therapy can Academy of Family Therapy Award for
Distinguished Contribution to Family Therapy
Theory and Practice, the 2000 American Associ-
References ation for Marriage and Family Therapy award for
Outstanding Contributions to Marriage and Fam-
Barlow, K. K. (2014, December 4). Obituary: Carol
M. Anderson. University Times. http://www.utimes.
ily Therapy, and the 1997 Texas Association for
pitt.edu/?p=33431. Marriage and Family Therapy award for Lifetime
Carpeter, M. (2014, November 21). Obituary: Carol Anderson Achievement.
/ Psychiatrist social worker helped to develop cutting-edge
therapy for children. Pittsburg Post-Gazette. http://www.
post-gazette.com/news/obituaries/2014/11/21/Psychiatric-
social-worker-helped-to-develop-cutting-edge-therapy- Contribution to the Profession
for-children/stories/20141121008.
Singer, J. B. (Host). (2007, October 24). Family In collaboration with Harold Goolishian, Ph.D.,
psychoeducation: Interview with Carol Anderson, Ph.D.
[Episode 27]. Social Work Podcast. Podcast retrieved
she is the creator of postmodern collaborative and
3 Aug 2016, from http://socialworkpodcast.com/2007/ dialogic practices, also known as collaborative
10/family-psychoeducation-interview-with.html. language systems approach to therapy. The
collaborative-dialogic approach draws from post-
modern, social construction and hermeneutic tra-
ditions of thought to emphasize conversation,
Anderson, Harlene collaboration, and language as the main principles
to promote transformations and generate
Sylvia London possibilities.
Grupo Campos Elíseos, Mexico City, Mexico Dr. Anderson is a cofounder and board mem-
ber of the Taos Institute, Houston Galveston Insti-
tute, and Access Success International; she is the
Introduction founding editor of the International Journal of
Collaborative Practices and cofounder of the
Harlene Anderson is recognized internationally as International Certificate in Collaborative Practices
a leader in the development of a postmodern program.
collaborative-dialogic approach to psychotherapy, A sought-after speaker, consultant, and trainer,
which she has applied to work in organizations, she uses her tools – her insights, her keen interest,
communities, education, research, and consulta- her engaging conversational style, and her leader-
tion. Her books, translated into several languages, ship skills – to help and inspire individuals and
include Conversations, Language and Possibili- organizations to achieve clarity, focus, renewed
ties: A Postmodern approach to Therapy; she energy, and often surprising results.
118 Andolfi, Maurizio
References creativity and humanity as the best way to build an

alliance and work with a family in crisis. Andolfi
Anderson, H. (1997). Conversation, language and possi- has been published widely in English, Italian, and
bilities: A postmodern approach to therapy. New York:
several other languages.
Basic Books.
Anderson, H. (2007). The heart and spirit of collaborative
therapy: A way of being. In H. Anderson & D. Gehart
(Eds.), Collaborative therapy: Relationships and con- Career
versations that make a difference. New York: Taylor &
Francis Group 4.
Anderson, H. (2009). Collaborative practice: Relationships After graduating and specializing as child psychi-
and conversations that make a difference. In J. Bray & atrist with Giovanni Bollea, in the early 1970s
M. Stanton (Eds.), The Wiley handbook of family psychol- Andolfi moved to New York, where he stayed
ogy (pp. 300–313). Malden: Blackwell Publishing Ltd.
for a few years and where he established close
Anderson, H., & Gehart, D. (2007). Collaborative therapy:
Relationships and conversations that make a differ- professional relationships with the most important
ence. New York: Taylor & Francis Group. family therapists, such as Salvador Minuchin,
Anderson, H., & Goolishian, H. (1988). Human systems as Carl Whitaker, James Framo, and Murray
linguistic systems: Preliminary and evolving ideas
Bowen. He learnt family therapy by personally
about the implications for clinical theory. Family Pro-
cess, 27(4), 371–393. observing master therapists at work and absorbing
Anderson, H., Goolishian, H., Pulliam, G., & Winderman, their skills and knowledge. Back in Italy, he was
L. (1986). The Galveston Family Institute: A personal Professor in Clinical Psychology at the University
and historical perspective. In D. Efron (Ed.), Journeys:
La Sapienza, Rome, and cofounder of the
Expansions of the strategic-systemic therapies
(pp. 97–124). New York: Brunner/Mazel. European Family Therapy Association. Andolfi
Anderson, H., Goolishian, H., & Winderman, L. (1986). is currently Director of the Accademia di
Problem determined systems: Towards transformation Psicoterapia della Famiglia of Rome and is editor
in family therapy. Journal of Strategic and Systemic
of Journal Terapia familiare.
Therapies, 5, 1–13.
Throughout his career he received several
awards, among which the AAMFT Award for his
Significant Contribution to Marriage and Family
Therapy and the Life Achievement award from
Andolfi, Maurizio the American Family Therapy Academy (AFTA).
Anna Mascellani
Accademia di Psicoterapia della Famiglia, Rome, Contributions to Profession
Italy
The Multigenerational Family Therapy devel-
oped by Andolfi reveals the limits of the medical
Name model in treating mental and relational problems.
It instead provides a toolkit for therapists, observ-
Maurizio Andolfi, M.D. (1942). ing family functioning over the last three genera-
tions to explore the developmental history of the
family, in order to discover links between past
Introduction trauma and broken emotional bonds and current
problems experienced by family members.
Maurizio Andolfi is a world-renowned family Andolfi’s model considers both the structural
therapist due to his remarkable scientific and dimension (Minuchin 1974) and the historical and
methodological contribution to the contemporary developmental dimension with which the thera-
family therapy. Over the last 45 years, he devel- pist interacts.
oped the Multigenerational Family Therapy, an In the observation of the family spanning sev-
experiential model of intervention that centers on eral generations, an important role is given to the
Andolfi, Maurizio 119
subsystem of the children, who are engaged in gestures, and postures that are more eloquent than
therapy as significant relational bridges in the words, and to appreciate pauses and silences rich in
dialogue of clash between generations. This active relational meanings. A
role of children and adolescents in therapy, espe- The therapist described by Andolfi should be
cially when they are the bearers of symptomatic free from cultural stereotypes and institutional
behaviors, is without doubt the most original routines, to be able to use himself, his affective
aspect of Andolfi’s clinical experience and of the resonance and the therapeutic space in an active
model he proposes. Having noticed the limitations way, approaching and establishing physical con-
and often the damage caused by the widespread tact with this or that family member, facilitating
pharmacological treatment of many types of child new connections, and mending the emotional dis-
and adolescent psychopathology, over time, he connections of the past. His physical and internal
developed the conviction that the family is the presence, besides the professional one, is the most
best medicine. The cure, therefore, consists of effective therapeutic instrument to make direct
revisiting together the family’s developmental and authentic contact with each person, by
history, stitching up still open wounds and healing attuning to the pain and desperation expressed
broken emotional bonds. The presenting problem by many families in therapy, as well as to the
becomes an access door to the family’s world and implicit aspects of vitality and hope, in order to
the identified patient a privileged guide in the transform them into elements of strength and
exploration of family ties. change.
The first concrete result of this therapeutic
approach will be the gradual disappearance of
symptoms in the person for whom intervention Cross-References
was required, but even more significant, will be
to observe the affective and relational transforma- ▶ Children in Couple and Family Therapy
tions between family members, both on the couple ▶ European Family Therapy Association
dimension and on the intergenerational relation- ▶ Multigenerational Households
ships. The family will thus move from a passive ▶ Parenting in Families
position of delegating to the expert, typical of a ▶ Terapia Familiare (Journal)
medical model, to a leading role in its own des-
tiny, within the kind of therapy that helps it to
discover its own resources rather than highlight- References
ing its failures.
For this to happen, it is necessary for the therapist Minuchin, S. (1974). Families and family therapy. Cam-
to keep in mind a multigenerational map of the bridge, MA: Harvard University Press.
family that he meets in therapy, a kind of “living
genogram,” where he can access active resources References
and open healing pathways. The therapist needs to Andolfi, M. (2017). Multi-generational family therapy.
Tools and resources for the therapist. New York:
adopt the curiosity of an explorer who enters into the Routledge.
private world of each family, while remaining cen- Andolfi, M., & Haber, R. (Eds.). (1994). Please help me
tered. His professional toolkit consists of multiple with this family: Using consultants as resources in
instruments designed to promote a trusting and family therapy. New York: Brunner/Mazel.
Andolfi, M., & Mascellani, A. (2013). Teen voices. Tales
cooperative therapeutic relationship with each fam- from family therapy. San Diego: Wisdom Moon
ily member. It is necessary to develop a creative Publishing.
repertoire of relational questions and to listen atten- Andolfi, M., Angelo, C., Menghi, P., & Nicolò-Corigliano,
tively to each person’s voice, honoring adults as A. (1983). Behind the family mask: Therapeutic change
in rigid family systems. New York: Brunner/Mazel.
well as children. At the same time, it is important Andolfi, M., Angelo, C., & De Nichilo, M. (1987). The
during the session to be able to gasp those nonverbal myth of atlas: Families and the therapeutic story.
signals transmitted by the body, the eyes, by New York: Brunnel/Mazel.
120 Anxiety Disorders in Couple and Family Therapy
symptoms and relationship discord in treatment

Anxiety Disorders in Couple is important, due to the potential for each to main-
and Family Therapy tain and promote the other. Research suggests that
couple-based interventions are effective in
Lindsay T. Labrecque, Margaret Tobias and treating posttraumatic stress disorder (PTSD)
Mark A. Whisman and obsessive compulsive disorder (OCD),
Department of Psychology and Neuroscience, which were both included in the anxiety disorder
University of Colorado Boulder, Boulder, category in previous editions of the DSM. To date,
CO, USA little research has examined couple- or family-
based treatment for other anxiety disorders.
Anxiety disorders encompass a diverse set of psy-

chological disorders. The current edition of the Theoretical Context for Concept
Diagnostic and Statistical Manual of Mental Dis-
orders (DSM-5; American Psychiatric Asso- Anxiety disorders are generally thought to arise
ciation 2013) recognizes seven distinct disorders when the human capacity for learning and avoid-
within the category. These disorders are generally ance goes awry. When appropriately matched to
characterized by the presence of fears (defined as the dangers at hand, these learning and avoidance
perceptions of imminent threat), anxiety (defined processes can have adaptive functional outcomes
as worry regarding future threat), chronic tension, (e.g., learning not to touch a hot stove). However,
cautiousness, avoidance, and related behavioral when fear associations and avoidance behavior
disturbance. In addition to these symptoms, anx- grow out of proportion with the actual danger
iety disorders also share mechanisms underlying posed or generalize inappropriately, the benefits
their etiology and maintenance, although there is can quickly be outweighed by significant negative
considerable heterogeneity in how these disorders life consequences (e.g., becoming fearful of burn-
present. One implication of these shared mecha- ing the house down to the extent of refusing to
nisms is that there is relatively high comorbidity turn on the heat in the winter).
among anxiety disorders. Anxiety disorders are Avoidance in the face of true dangers can be
also particularly common in the general popula- vital for survival. However, this same process can
tion, with lifetime prevalence estimates nearing also drive clinically relevant anxiety by removing
30% in the United States (Kessler et al. 2005). opportunities to challenge beliefs upholding fears.
Due to their high prevalence, many individuals Fears are typically based in catastrophic beliefs
may be relatively familiar with anxiety disorders. about the outcome of specific situations (e.g., that
However, misunderstandings still abound regard- a future panic attack will lead to death, as seen in
ing how best to care for individuals struggling panic disorder; that an individual will be rejected
with these disorders. Without being involved in and embarrassed if evaluated by others as seen in
the treatment process, family members and signif- social anxiety disorder). Therefore, gaining expe-
icant others may attempt to reassure and care for rience with the feared situation or stimulus and
their loved one, which may actually undermine seeing that the fears do not “come true” provide
the effectiveness of certain treatments, such as compelling evidence against the belief and form
exposure therapy. Therefore, it is important for the foundation of effective anxiety disorder treat-
clinicians to consider incorporating a couple- ment. However, individuals with anxiety disor-
and/or family-based perspective to their approach ders avoid the perceived dangers and therefore
when treating anxiety disorders. the opportunity to collect evidence against the
There is evidence to suggest that couple-based beliefs underlying their anxiety. In fact, when
approaches are effective in reducing both anxiety engaging in avoidance, the fact that the fear does
symptoms and relationship discord (Whisman and not “come true” is attributed to success of avoid-
Robustelli 2016). Attending to both anxiety ance as a countermeasure.
Anxiety Disorders in Couple and Family Therapy 121
Although avoidance is typically considered an Epidemiological studies suggest that marital

individual endeavor, it is also important to con- discord is positively associated with symptoms
sider how interpersonal relationships may help of anxiety (Leach et al. 2013) and that lower levels A
promote avoidance and maintain fear beliefs. It of marital adjustment are reported by people with
can be difficult to observe a loved one suffering anxiety disorders, including people with general-
from distressing anxiety symptoms. For example, ized anxiety disorder (GAD), PTSD, and social
a spouse may attempt to relieve anxiety symptoms phobia (Whisman 2007). One longitudinal
of their partner associated with social anxiety population-based study found that lower marital
disorder (social phobia) by accommodating the quality was associated with an increased risk for
partner’s avoidance of social gatherings or other incidence of social phobia at a 2–3 year follow-up
social situations that create discomfort. It is under- (Overbeek et al. 2006). Much of the research on
standable that family members want to relieve couple functioning and anxiety has focused on
their loved ones of their symptoms of anxiety PTSD. PTSD is associated with relationship dis-
and make them feel less distressed. Although cord and perpetration of both psychological and
these behaviors may be intended to be supportive, physical aggression against an intimate partner
they do not actually help to eliminate the fears and (Taft et al. 2011). In addition, lower relationship
can serve as interpersonal safety behaviors. Thus, quality and higher psychological distress are
it is important to consider the role of relationship reported by partners of individuals with PTSD
partners and other family members in understand- (Lambert et al. 2012). With respect to family
ing and treating anxiety disorders. functioning and anxiety in children, there is a
modest association between parenting and child-
hood anxiety, with parental control more strongly
Description associated with childhood anxiety than parental
rejection (McLeod et al. 2007). However, most
There are several reasons why couple- or family- studies on parenting and childhood anxiety are
based treatments may be effective treatments for cross-sectional, so it remains unclear whether
anxiety disorders. On one hand, relationship or fam- negative parenting behaviors precede the devel-
ily discord may increase the likelihood of a person opment of childhood anxiety, are elicited by child-
experiencing anxiety. For example, conflict between hood anxiety, or are the result of some “third
partners may be stressful, thereby increasing the risk variable.” Taken together, research findings sug-
of experiencing symptoms such as worry or anxiety gest that couple and family problems are likely to
about one’s relationship. On the other hand, symp- be common for people with anxiety disorders.
toms of anxiety may increase the likelihood of rela- Several theoretical approaches have been
tionship problems. For example, if a person with developed to involve partners or other family
social anxiety disorder (social phobia) chooses not members in the treatment of anxiety disorders
to attend social gatherings that their partner wishes (Whisman and Robustelli 2016). Whereas some
to attend, that may strain their relationship, thus treatments are indicated for use with specific anx-
increasing the likelihood of poor relationship func- iety disorders, others have broader treatment
tioning. Finally, symptoms of anxiety disorders and applicability. Cognitive-behavioral conjoint ther-
relationship functioning may exert a bidirectional apy (CBCT) has shown to be an effective couple-
influence. Therefore, individuals with an anxiety based intervention for the treatment of PTSD.
disorder may exhibit behaviors that bring about CBCT targets both PTSD symptoms as well as
relationship discord, which in turn perpetuate anxi- relationship functioning by providing
ety about the state of the relationship, which can in psychoeducation regarding PTSD, communica-
turn exacerbate behaviors and symptoms that can tion skill training for improving relationship
strain the relationship. Thus, the interplay of anxiety adjustment, behavioral approach activities to
symptoms with couple and family functioning is counter avoidance, and cognitive interventions
likely to be complex. that aim to address beliefs that reinforce sources
122 Anxiety Disorders in Couple and Family Therapy
of relationship problems and PTSD symptoms. reinforcement learning and avoidance. However,
Including partners or parents in couple- or psychoeducation in couple- and family-based
family-based interventions has also been shown approaches is also likely to include a discussion
to be effective in treating OCD. This treatment of the ways in which a partner or family member
supplements individual cognitive-behavioral ther- may actually be reinforcing an individual’s anxi-
apy with couple- or family-assisted exposure, ety symptoms. Given the bidirectional effect of
response prevention for accommodation, and anxiety and couple and family functioning,
communication training. Emotionally focused psychoeducation also generally includes educa-
couple therapy (EFT) is another couple-based tion regarding the ways that anxiety symptoms
approach with evidence suggesting it may be an can negatively impact and be impacted by couple
effective treatment for couples in which one part- and family functioning.
ner has symptoms of PTSD. In EFCT, couples Other components to couple- and family-based
learn to identify and understand emotions related approaches to anxiety disorders include interven-
to trauma and those that are related to relationship tions to enhance relationship adjustment. Specifi-
discord and work to form a supportive emotional cally, couples typically learn ways to enhance
connection. Another couple-based approach to their relationship functioning, including ways to
PTSD is strategic approach therapy (SAT), improve communication and problem solving and
which targets both avoidance symptoms associ- ways to enhance intimacy and feelings of connect-
ated with PTSD and enhances communication and edness. These skills help couples become more
healthy relationship skills. resistant to relationship distress that may occur
due to anxiety-related stressors or anxious cogni-
tions. At this point, treatments may vary in foci.
Application of Concept in Couple and Treatments such as CBCT and SAT rely on
Family Therapy partner-assisted exposures in which the partner is
taught how to guide exposures and facilitate new
The majority of couple- and family-based learning to extinguish safety behaviors. Other
approaches for anxiety disorders share several treatments like CBCT utilize cognitive interven-
key components. In order to develop a treatment tions to target maladaptive beliefs that may impact
plan, it is first necessary to assess the individual’s both relationship functioning and PTSD symp-
anxiety symptoms and the impact of these symptoms. EFCT focuses on helping couples identify
toms on the individual’s functioning in multiple problematic relationship patterns and understand-
domains, including their intimate and family rela- ing how trauma-related emotions contribute to
tionships. In addition, it is important to identify these patterns. Once those are identified and better
behaviors that both individuals and their partners understood, couples work to enact more positive
or other family members enact to maintain their patterns of interaction.
anxiety. As previously discussed, by attempting to
decrease a person’s distress or to minimize con-
flict related to a person’s symptoms, partners or Clinical Example
family members may inadvertently reinforce anx-
iety, so a thorough accounting of these Caroline presented for therapy for PTSD follow-
maintaining factors is an important component ing a sexual assault she experienced the previous
of the assessment phase of treatment. year. Although she originally presented for indi-
Another common component to couple- and vidual therapy, she and Joshua, her husband of
family-based approaches is psychoeducation. 7 years, were receptive to the therapist’s sugges-
Just like individual treatments, couple- and tion to pursue couple therapy (i.e., CBCT for
family-based treatments involve general PTSD; Monson and Fredman 2012). The first
psychoeducation about the nature of anxiety, as phase of therapy focused on providing
well as specific topics of interest such as psychoeducation about PTSD and how it was
Anxiety Disorders in Couple and Family Therapy 123
impacting the couple’s relationship. In the second Cross-References

phase of therapy, the couple learned and practiced
communication skills to identify and share their ▶ Cognitive Behavioral Couple Therapy A
thoughts and feelings with one another and used ▶ Communication Training in Couple and Family
these skills to increase emotional intimacy and Therapy
reduce PTSD-related emotional numbing and ▶ Emotionally Focused Couple Therapy
avoidance. They also used these communication ▶ Exposure in Couple and Family Therapy
skills to identify people, places, situations, and ▶ Obsessive Compulsive Disorder (OCD) in
feelings they were avoiding as a couple as a result Couple and Family Therapy
of Caroline’s PTSD. Both partners reported ▶ Posttraumatic Stress Disorder (PTSD) in Cou-
“walking on eggshells” when they were around ple and Family Therapy
one another, and they identified a variety of things
they were avoiding (e.g., going out in public,
physical affection, sexual behavior, talking about References
the assault). This “avoidance” list became their
“approach” list, as each session they identified American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arling-
things they could do during the coming week
ton: American Psychiatric Publishing.
that would not only reduce behavioral and expe- Kessler, R. C., Berglund, P., Demler, O., Jin, R.,
riential avoidance but also serve as rewarding Merikangas, K. R., & Walters, E. E. (2005). Lifetime
activities. They started with the approach activi- prevalence and age-of-onset distributions of DSM-IV
disorders in the National Comorbidity Survey Replica-
ties they thought would be easiest and included
tion. Archives of General Psychiatry, 62, 593–602.
other activities over the course of therapy. In the Lambert, J. E., Engh, R., Hasbun, A., & Holzer, J. (2012).
final phase of therapy, in addition to increasing Impact of posttraumatic stress disorder on the relation-
the frequency of approach behaviors, therapy ship quality and psychological distress of intimate part-
ners: A meta-analytic review. Journal of Family
focused on identifying and modifying trauma-
related cognitions. In CBCT, cognitions that Leach, L. S., Butterworth, P., Olesen, S. C., & Mackinnon,
either partner holds that maintain PTSD or rela- A. (2013). Relationship quality and levels of depression
tionship distress are challenged together as a and anxiety in a large population-based survey. Social
Psychiatry and Psychiatric Epidemiology, 48, 417–425.
couple. The initial focus of the cognitive work
McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining
for Caroline and Joshua was on cognitions the association between parenting and childhood anxiety:
related to the traumatic event (e.g., Caroline’s Ameta-analysis.ClinicalPsychology Review,27,155–172.
recurring thoughts about how she should have Monson, C. M., & Fredman, S. J. (2012). Cognitive-
behavioral conjoint therapy for PTSD: Harnessing
been able to “see the assault coming” and how
the healing power of relationships. New York: Guilford
she could have prevented the assault). The ther- Press.
apist helped Caroline and Joshua work together Overbeek, G., Vollebergh, W., de Graaf, R., Scholte, R., de
to generate alternative ways of thinking about the Kemp, R., & Engels, R. (2006). Longitudinal associa-
tions of marital quality and marital dissolution with the
assault (e.g., by reviewing how the assault
incidence of DSM-III-R disorders. Journal of Family
occurred, Caroline came to see that she couldn’t Psychology, 20, 284–291.
have predicted it in advance or prevented it). Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., &
Over the course of several sessions, the focus of Monson, C. M. (2011). Posttraumatic stress disorder and
intimate relationship problems: A meta-analysis. Journal
the cognitive work was expanded to include
of Consulting and Clinical Psychology, 79, 22–33.
interpersonal beliefs that were a result of the Whisman, M. A. (2007). Marital distress and DSM-IV psy-
trauma (e.g., Caroline would never be able to chiatric disorders in a population-based national survey.
trust Joshua, the couple would never be comfort- Journal of Abnormal Psychology, 116, 638–643.
Whisman, M. A., & Robustelli, B. L. (2016). Intimate
able having sex again). At the end of therapy,
relationship functioning and psychopathology. In
Caroline reported a substantial decline in her K. T. Sullivan & E. Lawrence (Eds.), The Oxford hand-
PTSD symptoms, and both partners reported an book of relationship science and couple interventions
increase in their relationship satisfaction. (pp. 69–82). Oxford: Oxford University Press.
124 Aponte, Harry J.
Minuchin’s Families of the Slums and in return

Aponte, Harry J. sent Minuchin a manuscript of his own for feed-
back (Minuchin et al. 1967).
Martha LaRiviere and Janet Robertson In 1968, Aponte responded to an invitation from
Antioch University New England, Keene, Minuchin to work with him at the Philadelphia
NH, USA Child Guidance Clinic where he settled into the
position of coordinator of clinical services. Aponte
served with Minuchin for 11 years, ultimately as the
Name clinic director from 1975 to 1979. In 1980, Aponte
became a clinical associate professor at Drexel
Harry J. Aponte University’s Couple and Family Therapy Depart-
ment where he remains today. He also maintains a
private practice in Philadelphia, Pennsylvania. He
Introduction
has received two honorary degrees including Doctor
of Humane Letters from Drexel University and the
Harry J. Aponte is a licensed clinical social worker
degree of Doctor of Public Service from the Univer-
and a marriage and family therapist who is widely
sity of Maryland. Some of Aponte’s awards include
respected for his development of the person-of-the-
Distinguished Contribution to Family Therapy and
therapist training model (POTT). With POTT, ther-
Practice from the American Family Therapy Acad-
apists explore their inner selves allowing them to be
emy (1992) and the Outstanding Contribution to the
deliberate as they interact with their clients psycho-
Field of Marriage and Family Therapy from the
logically, culturally, and spiritually. Aponte used the
American Association for Marriage and Family
phrase “wounded healer” to signify the power of the
Therapy (2001). Currently Aponte is a Fellow of
therapist’s experiences (Aponte and Kissil 2014).
the American Association of Marriage and Family
His career began in the early years of systemic
Therapy and a Board-Certified Diplomate in Clini-
marriage and family therapy, and his current contri-
cal Social Work.
butions affect training in the field internationally.
Many of Aponte’s interests are derived from
his life in the impoverished Harlem and South
Bronx sections of New York City. His childhood
in his Catholic Puerto Rican family influenced the
Aponte’s best-known contribution to the field of
development of the concept he termed ecostruc-
couple and family therapy is the person-of-the-
turalism, which refers to seeing clients in relation to
therapist training model, which begins with iden-
their own family and social environment (Aponte
tifying the therapists’ central psychological issue
1976). As he worked with many poor and minority
upon which their emotional functioning is based.
families, he integrated the family system into the
This foundational issue is called the signature
larger communities of school, culture, and faith.
theme. Therapists are then trained with POTT to
incorporate their insight and emotional awareness
Career into therapy. According to Aponte, we are a part
of a vulnerable humanity and cannot succeed in
After graduating from Maryknoll College in Glen completely resolving our own personal issues in
Ellyn, Illinois, Aponte earned his Master of Social this life (Aponte and Kissil 2014).
Work at Fordham School of Social Science in As Aponte worked with Minuchin at the Phila-
New York City. Following graduation, he joined delphia Child Guidance Clinic, he incorporated the
the Menninger Clinic as a postgraduate student topics of poverty, race, and spirituality into structural
where he studied psychodynamic psychotherapy therapy. Aponte used the term ecostructure as he
and attended presentations of visiting therapists worked on structural family therapy to embody the
including Salvador Minuchin. Aponte read socioeconomic context of the family. He worked
Applied Behavior Analysis in Family Therapy 125
with underorganized families, a term Aponte origi- Synonyms

nated to describe families that were inadequately
positioned to cope with their environment. His ABA A
book, Bread & Spirit: Therapy with the New Poor:
Diversity of Race, Culture, and Values, explored the
multidimensional context of these families (Aponte Introduction
1994). The hardships that underorganized families
meet can best be understood by empathic connec- Founded upon the major principles of behaviorists
tions to therapists’ responses to their own ordeals. such as Watson and Skinner, applied behavior
analysis (ABA) is a therapeutic approach that spe-
cifically focuses on increasing quality of life through
Cross-References meaningful and socially relevant behavioral modi-
fication. Proponents of ABA posit that problematic
▶ Person of the Therapist Training Model, The behaviors can be changed via a mixture of reinforce-
▶ Spirituality in Couple and Family Therapy ment and repetition. ABA is used to treat multiple
▶ Structural Family Therapy age groups within a variety of contexts such as
education, healthcare, and business management.
Due to a considerable body of literature demonstrat-
References ing its efficacy, ABA is most commonly known as
the gold standard approach to working with children
Aponte, H. (1976). The family-school interview: An eco- with autism (Baer et al. 1968).
structural approach. Family Process, 15(3), 303–311. ABA has been researched extensively since its
Aponte, H. J. (1994). Bread and spirit. Therapy with the inception in the 1960s, with the majority of studies
new poor. New York: W. W. Norton.
Aponte, H. J. (2017). The philosophy of the person-of-the- being published in the Journal of Applied Behavior
therapist training model: The underlying premises. Analysis. The journal currently presents the most
Seminare. Learned Investigations, 38(4). (in press). recent research on ABA techniques and showcases
Aponte, H. J., & Kissil, K. (2014). “If I can grapple with how behavior analysis applies to socially relevant
this I can truly be of use in the therapy room”: Using the
therapist’s own emotional struggles to facilitate effec- behavioral change and learning. Among the exten-
tive therapy. Journal of Marital and Family Therapy, sive literature in ABA are the findings that it
40(2), 152–164. https://doi.org/10.1111/jmft.12011. improves cognitive functioning, reduces problem-
Aponte, H. J., & Kissil, K. (Eds.). (2016). The person of the atic behavior, and improves academic performance
therapist training model: Mastering the use of self.
New York: Routledge, Taylor & Francis Group. in autistic children. Further studies show that
Minuchin, M. B., Guerney, B., Jr., Rosman, B., & Florence, S. learned behaviors from ABA interventions are
(1967). Families of the slums. New York: Basic Books. maintained over time (Baer et al. 1968; Lovaas
et al. 1973; McEachin et al. 1993).
Applied Behavior Analysis in Theoretical Framework

Family Therapy
“Applied”
Anna Santowski and Ryan M. Earl ABA stems from a group of faculty members
The Family Institute at Northwestern University, and researchers from the University of
Evanston, IL, USA Washington and the University of Kansas in
the 1960s. Members of the group include
Donald Baer, Sidney Bijou, Jim Hopkins, Jay
Name of the Strategy or Intervention Birnbrauer, Todd Risley, Montrose Wolf, and,
later, James Sherman. ABA formed as the result
Applied Behavior Analysis in Family Therapy of efforts to link interventions to observable
126 Applied Behavior Analysis in Family Therapy
changes in behavior and to apply behavior anal- effective treatment for children in classrooms.
ysis techniques to actual social situations (Baer Ultimately, his research popularized the use of
et al. 1968). ABA in classrooms and spread international
awareness of ABA as a treatment for kids with
“Behavior” autism. While the intensive Lovaas method is
ABA’s roots lie in behavior analysis, which is a still used, it is one of several ABA interventions
field of study concerned with studying the factors that have been researched and found effective as
that change or modify human behavior. an autism treatment.
According to the beliefs of behaviorists, observ- ABA is now considered the gold standard for
able behaviors can be learned or modified through treating children with autism since it has the most
techniques involving rewards and punishments. research behind it showing its efficacy. ABA
Although ABA initially used punishments in its works well with children because they respond
techniques, it now encourages the use of rewards well to behavioral interventions with interesting
over punishment as it seeks to drive motivation external stimuli as opposed to solely verbal inter-
rather than fear. Reward systems such as token ventions. ABA methods teach simple skills such
economies paired alongside reinforcement tech- as looking and imitating as well as more complex
niques make up the bulk of many of the ABA skills such as reading, conversing, and under-
techniques seen today. standing others’ perspectives. Its safe, effective,
and research-backed interventions make ABA the
“Analysis” most widely used method for teaching these skills
ABA therapists study the feedback and outcomes to children with autism.
of a behavior change attempt and adjust the ABA can be used within family therapy ses-
approach to the behavior change if needed. sions for children diagnosed with autism. In fam-
Emphasis is placed on the role of the instructor ily therapy sessions, ABA-certified therapists
as they work to control environmental factors to teach parents techniques for changing problematic
produce the target behavior. behaviors or learning new behaviors. Parents are
encouraged to use ABA in the home and in other
naturalistic settings throughout the day to teach
Rationale for the Strategy or social and academic skills across contexts.
Intervention
Prior to ABA, treatments for autism included Description of the Strategy or

separating children with autism from their par- Intervention: What Happens during
ents and later, giving them LSD and removing ABA?
gluten and casein from their diets. Early studies
of ABA applied it to children with autism in Ole In ABA, interventions are intended to reinforce
Ivar Lovaas’s 1987 “Behavioral Treatment and positive social behaviors such as identifying
Normal Educational and Intellectual Function- colors, asking for a toy, maintaining eye contact,
ing in Young Autistic Children” (Lovaas 1987). etc. Interventions can be done in a variety of
In this integral study that came to be known as settings, including in the therapy room, at
“The Lovaas Method,” 47% of children who school, or in the home. Exact techniques used
were exposed to 40 intensive hours of 1:1 dis- vary on a case-by-case basis only after a period
crete trial training (DTT) no longer qualified for of observation in which behavioral triggers are
an autism diagnosis by the end of treatment and assessed by a trained behavior analyst. Typi-
were considered to have normal intellectual and cally, an analyst works alongside teachers and
educational functioning. Over the course of his parents to equip them with specific techniques
life, Lovaas would go on to study ABA and that target the behaviors intended to be learned
publish several studies that found it to be an or modified.
Applied Behavior Analysis in Family Therapy 127
ABA breaks down behaviors into the “Three improve other aspects of children’s lives across
ABC’s of ABA”: the antecedent, the behavior, social, behavioral, and academic contexts and set-
and the consequence. These principles are rooted tings. Important to PRT is the idea that children A
in behaviorism and are applied in various forms must become inherently motivated to engage
across the numerous techniques stemming from within these pivotal areas in order to successfully
ABA. Studying the ABC’s of a behavior of inter- use them in real-life scenarios. Emphasis is placed
est in ABA is often one of the first steps in plan- on children being self-motivated as this drives
ning its development or change. The antecedent them to use learned skills in other contexts.
(A) focuses on what happens before the behavior Because of this, PRT interventions are shaped by
occurs; in other words, what cues and instructions the interests of the participant and ideally take
appear to be triggering the behavior? The behav- place in naturalistic settings such as parks or reg-
ior, (B), is observation of the behavior of interest. ular education classrooms. For example, a thera-
Finally, the consequence (C) looks at the events pist can ask a child to pick from a variety of toys to
happening immediately after the behavior. Within play with in a normal education classroom, and
ABA, consequences typically result in rewards the therapist can teach social engagement skills by
such as food or verbal praise for a correct behavior requesting the child to ask for the toy before
and a correction if the target behavior is not done. playing with it. If the child is able to do so, he or
After the behavior is observed through the ABC’s, she is rewarded with the toy, and in turn, the
ABA therapists, teachers, and parents can choose requesting behavior is reinforced.
from several techniques to teach the participant
the target behavior.
Over the years, numerous behavioral tech- Case Example
niques have been developed for use in ABA.
Two of the more popular evidence-based inter- Franky is a 5-year-old boy who is diagnosed with
ventions include discrete trial training (DTT) and severe autism. He is currently in family therapy
pivotal response treatment (PRT). In DTT, whole with his mother Helen and his father Tom. Franky
skills are broken down into smaller sub-steps of also attends an alternative school with ABA-
(1) antecedent, (2) prompt, (3) response, (4) con- certified teachers who use ABA techniques in
sequence for response, and (5) interval between classroom settings with Franky throughout the
trials (Smith 2001). If the client successfully com- school day. The family therapist is trained in
pletes the task, they are positively reinforced with ABA and is using DTT to teach Franky social
a reward. If the task is done incorrectly, the skills. The target behavior for today is for Franky
instructor will show the correct way to do the to maintain eye contact with someone for 3 s when
task, and the task will be repeated again in a new they say his name. In order to reach the target
trial with the goal of reaching the target behavior. behavior, Franky’s trials are broken down into
DDT has been found to be most effective with successively approximate steps toward the target
teaching new behaviors to children with autism behavior in a method known as “shaping.”
such as new speech sounds or motor movements. In a family session, the therapist demonstrates
It is also used to teach discriminatory skills such and explains DTT to the parents. The therapist
as responding accurately to different requests first gives Franky a piece of popcorn. This estab-
(Smith 2001). lishes the popcorn as the reward that Franky will
Pivotal response treatment (PRT) focuses on be working toward during his trials. Then, the
building upon “pivotal” skill areas such as lan- therapist shows Franky another piece of popcorn
guage acquisition, behavior regulation, and social and says Franky’s name while putting the popcorn
engagement. Created by Koegel et al. (1987), the behind his own head. Franky looks in the direc-
approach was initially designed to teach language tion of the therapist’s head and is rewarded with
acquisition to nonverbal children with autism. the popcorn and verbal praise for doing so as this
PRT posits that development of these areas will is a step toward the target behavior. If Franky does
128 Areas of Change Questionnaire
not look in the direction of the therapist, the pop- Applied Behavior Analysis, 6(1), 131–165. https://doi.
corn reinforcement will be withheld and he will be org/10.1901/jaba.1973.6-131.
McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Long-
guided toward the correct behavior until he is able term outcome for children with autism who received
to look again in the direction of the therapist’s early intensive behavioral treatment. American Journal
head or display a behavior further along in the on Mental Retardation, 97(4), 359–372.
behavior sequence such as making eye contact. Smith, T. (2001). Discrete trial training in the treatment of
autism. Focus on Autism and Other Developmental
After a few more trials, Franky briefly makes eye Disabilities, 16(2), 86–92. https://doi.org/10.1177/
contact with the therapist when his name is said. 108835760101600204.
Again, he is rewarded with both popcorn and
verbal praise for doing so. Now that Franky is
making eye contact, the therapist works to main-
tain the contact for a longer amount of time. The Areas of Change
popcorn and verbal reinforcement is now with- Questionnaire
held until he is able to make eye contact for more
than 1 s and then 2 and 3 s. Cody G. Dodd
The therapist encourages Helen and Tom to Department of Psychology, Central Michigan
work with their son at home every day to extend University, Mount Pleasant, MI, USA
Franky’s eye contact to up to 5 s and then gradu-
ally phase out the popcorn reinforcement. The
therapist explains how the DTT format can be Name and Type of Measure
used to teach other social skills as well such as
saying “thank you” or “excuse me” and that fam- The Areas of Change Questionnaire (ACQ) is a
ily participation in this process helps to create two-part measure of: (a) desired change in partner
lasting change over time. behaviors and (b) changes in one’s own behaviors
that are perceived to be pleasing to the partner.
Cross-References
Synonyms
▶ Behavioral Couple Therapy
▶ Behavioral Parent Training in Couple and Fam- In the research literature, the ACQ has also been
ily Therapy abbreviated A-C, AC, and AOC.
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some The Areas of Change Questionnaire (ACQ;
current dimensions of applied behavior analysis. Jour- Margolin et al. 1983) is a 68-item measure of inti-
nal of Applied Behavior Analysis, 1(1), 91–97. https:// mate relationship functioning, originally designed to
doi.org/10.1901/jaba.1968.1-91.
Koegel, R. L., O’ Deil, M. C., & Koegel, L. K. (1987). facilitate effectiveness research on behavioral cou-
A natural language teaching paradigm for nonverbal ple therapy (Weiss et al. 1973; as cited in Margolin
autistic children. Journal of Autism and Developmental et al. 1983). The ACQ has two parts: first, the
Disorders, 17, 187–200. respondent rates the degree of change desired on
Lovaas, O. I. (1987). Behavioral treatment and normal
educational and intellectual functioning in young autis- 34 common partner behaviors; second, the respon-
tic children. Journal of Consulting and Clinical Psy- dent indicates the degree to which his or her own
chology, 55(1), 3–9. https://doi.org/10.1037//0022- changes on those 34 behaviors is likely to be pleas-
006x.55.1.3. ing to his or her partner. Items are rated on a 7-point
Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S.
(1973). Some generalization and follow-up measures scale from “much less” change ( 3) to “no change”
on autistic children in behavior therapy. Journal of (0) to “much more” change (+3). A common
Areas of Change Questionnaire 129
scoring system for the ACQ produces summative Several studies using the ACQ have shown that
scores for Desired Change (DC) and Perceived women often have slightly higher Desired Change
Change (PC). A Total Change (TC) score is derived scores compared to their husbands (e.g., Heyman A
from the number of cross-partner item agreements et al. 2009; Margolin et al. 1983). Women also tend
and disagreements (Margolin et al. 1983). to over predict their husbands’ Desired Change
(Margolin et al. 1983). These results have primarily
come from studies with heterosexual married cou-
Developers ples in multi-year relationships. Further research is
needed to examine the cultural invariance of the
The ACQ was developed by Robert L. Weiss, instrument and to validate it with same-sex couples
Hyman Hops, and Gerald R. Patterson (Weiss and partners early in relationships.
et al. 1973). Research validating the ACQ as a predictor of
useful clinical outcomes or other phenomena is
limited. Many studies have reported high conver-
Description of Measure gence among the ACQ and similar measures, with
some studies reporting correlations with self-report
The ACQ has been used primarily in behavior indices of relationship problems and marital satis-
couple therapy research; however, it has also faction from 0.59 to 0.72 (Heyman et al. 1994).
been used as a prompt in observations of couple Taken together with other research failing to show
interactions (e.g., Halford et al. 1993). Increased consistent prediction of behavioral observation and
scores on the instrument are associated with mar- daily-assessed pleasing and displeasing behavior
ital dissatisfaction, and several studies have (e.g., Margolin et al. 1983), these results suggest
shown the ACQ to be sensitive to changes in that the ACQ may be best characterized as an indi-
relationship adjustment resulting from treatment. cator of relationship satisfaction.
The ACQ has been shown to differentiate dis-
tressed and nondistressed heterosexual married
couples (e.g., Birchler and Webb 1977; Margolin Example of Application in Couple and
et al. 1983), and some evidence supports its use to Family Therapy
examine parent-child relationships and intimate
relationships among adolescents. After being married 6 years, Zack and Stefani
sought couple therapy to address longstanding
conflict important family decisions. The two
Psychometrics had considered having children, but had delayed
it due to their frequent arguments about finances
The ACQ has not been standardized with a large and Zack’s extended work schedule. Their ther-
normative sample, and the data available on its apist provided them with feedback informed by
psychometric properties is limited. In several more their ACQ results, which indicated that they were
recent studies, the internal consistency coefficients both in agreement on many areas of concern.
for ACQ scores have ranged from 0.76 to 0.85 Their item-level responses demonstrated that, in
(Cordova et al. 2005; Heyman et al. 2009). How- addition to their concerns about finances and
ever, most studies with the measure have not career, they both shared a strong desire for each
reported on the internal consistency of all three of other to show greater appreciation and interest in
its scores. In addition, no information is available on one another. They were surprised and encour-
the ACQ’s test-retest reliability, although studies aged to see that they both had higher Perceived
using it as a marital therapy outcome measure have Change scores than the other’s Desired Change
shown it to be sensitive to changes in treatment (e.g., score. Based on these results, their course of
Baucom 1982; Halford et al. 1993; Margolin and treatment focused on increasing quality time
Weiss 1978). spent together, increasing acceptance and
130 Asen, Eia
affirmation of one another, and improving

problem solving and communication around Asen, Eia
money management. After 8 sessions, the
readministration of the ACQ showed a reduction Rebecca Branda
in both their Total Change scores and signaled The Family Institute at Northwestern University,
the therapist to initiate the treatment termination Chicago, IL, USA
process.
Name
References
Asen, Eia (1946 to present)
Baucom, D. H. (1982). A comparison of behavioral
contracting and problem-solving/communications
training in behavioral marital therapy. Behavior Ther-
apy, 13(2), 162–174. https://doi.org/10.1016/s0005-
Introduction
7894(82)80060-9.
Birchler, G. R., & Webb, L. J. (1977). Discriminating Eia Asen is a pioneer of multi-family group ther-
interaction behaviors in happy and unhappy marriages. apy. He has been influential in the dissemination
Journal of Consulting and Clinical Psychology, 45(3),
494–495. https://doi.org/10.1037/0022-006x.45.3.494.
of the Marlborough model and the integration of
Cordova, J. V., Scott, R. L., Dorian, M., Mirgain, S., mentalization into multi-family group therapy. He
Yaeger, D., & Groot, A. (2005). The marriage checkup: is a world-renowned child and adolescent psychi-
An indicated preventive intervention for treatment- atrist, consultant, editor, author, and speaker who
avoidant couples at risk for marital deterioration.
Behavior Therapy, 36(4), 301–309. https://doi.org/
continues to influence the field of family therapy.
10.1016/s0005-7894(05)80112-1.
Halford, W. K., Sanders, M. R., & Behrens, B. C. (1993).
A comparison of the generalization of behavioral mar- Career
ital therapy and enhanced behavioral marital therapy.
Journal of Consulting and Clinical Psychology, 61(1),
51–60. https://doi.org/10.1037/0022-006x.61.1.51. Asen received his doctorate in medicine in 1972
Heyman, R. E., Sayers, S. L., & Bellack, A. S. (1994). from the Free University of Berlin. He completed
Global marital satisfaction versus marital adjustment: his foundation program in general medicine
An empirical comparison of three measures. Journal of
Family Psychology, 8(4), 432–446. https://doi.org/
followed by a specialization in psychiatry at the
10.1037/0893-3200.8.4.432. Maudsley Hospital in London. During his work
Heyman, R. E., Hunt-Martorano, A. N., Malik, J., & Slep, at the Maudsley Hospital, Asen received an addi-
A. M. S. (2009). Desired change in couples: Gender tional 5 years of training in psychoanalysis and
differences and effects on communication. Journal of
Family Psychology, 23(4), 474–484. https://doi.org/
psychotherapy (1974–1979) as well as family
10.1037/a0015980. therapy (1976–1981) with Salvador Minuchin.
Margolin, G., & Weiss, R. L. (1978). Comparative evalu- These formative training experiences profoundly
ation of therapeutic components associated with behav- impacted his contributions to multi-family group
ioral marital treatments. Journal of Consulting and
Clinical Psychology, 46(6), 1476–1486. https://doi.
therapy. Following the completion of his training,
org/10.1037/0022-006x.46.6.1476. Asen became a member of the Royal College
Margolin, G., Talovic, S., & Weinstein, C. D. (1983). Areas of Psychiatrists. In 2001, Asen was honored with
of change questionnaire: A practical approach to mar- election to the fellowship of the Royal College of
ital assessment. Journal of Consulting and Clinical
Psychology, 51(6), 920–931. https://doi.org/10.1037/
Psychiatrists (FrcPsych).
0022-006x.51.6.920. In 1979, Asen began his career as a child
Weiss, R. L., Hops, H., & Patterson, G. R. (1973). and adolescent psychiatrist in London at the
A framework for conceptualizing marital conflict: Marlborough Family Service (previously the
A technology for altering it, some data for evaluating
it. In L. D. Handy & E. L. Mash (Eds.), Behavior
Marlborough Day Hospital). Asen was an inte-
change: Methodology concepts and practice gral team member and leader over his 34-year
(pp. 309–342). Champaign: Research Press. tenure at the Marlborough Family Service. Over
Asen, Eia 131
the course of his career, Asen was heavily Marlborough Family Service was the first pub-
involved in building the Marlborough model licly funded hospital in South London to create
and applying the model for use in the legal sys- an intensive day unit program treating families A
tem. He assessed over 1000 abused children and 5 days a week for 8 hours a day in a structured
families using the Marlborough model to predict multi-family group therapy program (Cooklin
whether families could be rehabilitated. In 1989, et al. 1983). At the Marlborough Family Ser-
Asen began consulting for the Maudsley Hospi- vice, the team based their model on the family
tal, and he entered academia that same year as a systems approach, emphasizing the paramount
senior lecturer at the Institute of Psychiatry at importance of context and integrating tech-
King’s College. Asen also became the head of niques from structural family therapy. The
parenting assessment and services on the mother structured therapeutic day program setting cre-
and baby unit at Bethlem Royal Hospital from ated a multifamily milieu and helped families
1997 to 2002. In the early 2000s, Asen began that were previously deemed untreatable.
integrating mentalization into multi-family Asen’s notable contributions to the
group therapy and mentalization-based therapy Marlborough model stems from his work with
for families (MBT-F). Asen became a visiting Salvador Minuchin. In 1981, Minuchin came to
professor at University College London and a London for his sabbatical and supervised Asen.
consultant psychiatrist for children, adolescents, Minuchin recommended the use of structural
and adults at the Anna Freud Centre in 2009 and interventions including setting boundaries, chal-
2013. Today, Asen is an internationally lenging hierarchies, and provoking enactments
renowned psychiatrist and lecturer, with several (Cooklin et al. 1983). Asen operationalized the
grants from the European Union to disseminate key elements from Minuchin’s supervision and
his research. built a formal-structured multi-family program.
Asen has numerous book and article publica- Asen also had a considerable contribution to the
tions in English, German, and Italian. He has Marlborough model by decreasing the length of
written seven books in English which include treatment from 18 months to 3 months based on
the following: Psychiatry for Beginners (1986); influences from Gianfranco Cecchin and Luigi
Family Solutions in Family Practice (1992); Fam- Boscolo. Cecchin and Boscolo helped Asen real-
ily Therapy for Everyone (1995); Systemic Couple ize that altering the model to reflect real-world
Therapy and Depression (with E. Jones, 2000); linear relationships benefited the families and
Multiple Family Therapy: The Marlborough decreased their sense of dependence on the cli-
Model and its Wider Applications (with nicians. Additionally, Asen integrated circular
N. Dawson & B. McHugh, 2001); 10 Minutes questioning and the use of a reflection team into
for the Family: Systemic Practice in Primary the Marlborough model.
Care (with D. Tomson, V. Young & P. Tomson, The mainstream applicability of the
2004); and Multi-Family Therapy: Concepts and Marlborough model became evident in the 1990s
Techniques (with M. Scholz, 2010). when Asen and his colleagues began working
with the legal system to predict a family’s ability
to rehabilitate after incidents of abuse. The suc-
Contributions to Profession cess of the Marlborough model inspired other
programs across the world. For example, clini-
Asen and his colleagues pioneered the cians in Germany and the United Kingdom have
Marlborough model, which is a unique model applied the Marlborough model to help families
of multi-family group therapy. The with adolescents suffering from eating disorder.
Marlborough model was named after the Asen continues to pioneer multi-family group
Marlborough Family Service, the hospital therapy. Currently, Asen is focusing on integrat-
where the model was originally formulated and ing mentalization into multi-family group therapy
refined over the course of 25 years. The (Asen and Fonagy 2012).
132 Asian Academy of Family Therapy
▶ Cecchin, Gianfranco The Asian Academy of Family Therapy

▶ Circular Questioning in Couple and Family (AAFT) is a charitable and nonprofit organization
Therapy with a vision to promote family therapy research,
▶ Mentalization in Couple and Family Therapy training, and practice in Asia.
▶ Minuchin, Salvador Originally named as Academy of Family Ther-
▶ Multifamily Group Therapy apy, the same group of visionaries who had
▶ Structural Family Therapy established the HKU Family Institute (HKUFI)
almost a decade ago started the Asian Academy
of Family Therapy in 2012. Through the training
References effort of the Director of HKUFI, Wai Yung Lee, a
collaboration with other Asian regions was
Asen, E. (2002). Multiple family therapy: An overview. formed. As a result, a cross-regional study to
Journal of Family Therapy, 24, 3–16.
compare how couples negotiated their differences
Asen, E., Dawson, N., & McHugh, B. (2001). Multiple
family therapy: The marlborough model and its wider among five regions was made possible. This joint
applications. London: Karnac. venture created a bond among the involving
Asen, E., & Fonagy, P. (2012). Mentalization-based thera- regions. Prominent figures from each region
peutic interventions for families. Journal of Family
started to meet annually, and in 2015, the Acad-
Therapy, 34, 347–370.
Cooklin, A., Miller, A., & McHugh, B. (1983). An institu- emy officially changed its name to Asian Acad-
tion for change: Developing a family day unit. Family emy of Family Therapy to reflect the interests
Process, 22, 453–456. and activities of other family therapists in the
Cooklin, A., Asen, E., Mannings, C., & Costa-Cabellero, M.
Asian region. Currently, AAFT is membership-
(2012). Talking heads: Alan Cooklin and Eia Asen
reflect on the history of the multi- family model at the based. Its membership categories include Fellow,
Marlborough Family Service in London. Context, 3–7. which consist of qualified family therapy practi-
tioners from multidisciplinary backgrounds, as
well as members who support the vision of AAFT.
Asian Academy of Family
Therapy Location
Takeshi Tamura1, Wai Yung Lee2,3 and AAFT is based in Hong Kong, with core members
Viviana Cheng2 from the Asian region, including Hong Kong,
1
International Committee, Tokyo, Japan Japan, Korea, Taiwan, Mainland China, Singa-
2
Asian Academy of Family Therapy, Hong Kong, pore, and Malaysia.
China
3
Aitia Family Institute, Shanghai, China
Prominent Associated Figures
Wai Yung Lee, Ph.D., Ng Man Lun, M.D., Wil-

Name of Organization
liam Fan, M.D., Joyce Ma, Ph.D., Takeshi
Tamura, M.D., Shin-Ichi Nakamura, M.D., Zhao
Asian Academy of Family Therapy
Xudong, M.D., Du Yasong, M.D., Meng Fu,
M.D., Chen Xiang-Yi, M.D., Hao Wei Wang,
Synonyms M.D., Chao Wen-Tao, M.D., Lin Lee-Chun,
M.A., Young-Ju Chun, Ph.D., and Sunin Shin,
AAFT Ph.D.
Asian Academy of Family Therapy 133
Contributions very well received and participants also include

professionals from the United States of America
Asia covers a vast geographic area with diverse and Europe. A
cultures. Each region has very different family AAFT is aiming to provide accreditation for
norms and language expressions. However, Asian therapists. Criteria that pertains to the
while there are different social and family struc- Asian culture is currently being established.
tures, we do share aspects that are uniquely Each participating region is also working toward
Asian, such as an emphasis on collectivism developing their own practice and training model
rather than individualism, religious and ethical that is relevant to their region. For instance,
influences of Buddhism and Confucianism, South Korea has a long history in developing
extended kinship system, and lifelong parent/ family therapy, with very well-systematized
child relationship of filial piety. AAFT is organizations and professional standards within
established to create a strong collaboration and the region. In Taiwan, different therapists have
professional exchange among our counterparts in also been developing their therapeutic
Asia. It should be noted that although there are approaches. Mainland China, in particular, has
many family therapy associations in other parts shown a strong interest in the development of
of the world, AAFT is the first family therapy systemic approach. Not only are family therapy
organization in this region that represents dis- programs provided by universities and mental
tinctive effort in developing family therapy. As health organizations, private institutes, such as
the service system in Asia tends to be more the newly established Aitia Family Institute in
individual-based, we also have a strong mission Shanghai, is one example of how training, prac-
to draw together systemic thinkers and practi- tice, and research can be combined to bridge the
tioners in different parts of Asia to reflect the work between the East and the West. Different
family-oriented culture of this part of the world. regional training efforts are also taking
Our important research includes: place, such as Takeshi Tamura and his peer
supervision group with members who represent
1. A comparison of how couples negotiate their different regions meeting regularly at different
differences among five regions including Japan, parts of Asia to exchange ideas and clinical
Korea, Taiwan, Shanghai, and Hong Kong. Con- contributions.
trary to popular belief that Asians are all the Although a strong bond with some Asian
same, it was found that couples in these five regions have been established, AAFT hopes to
regions have very different styles in negotiating continue to expand its geographical coverage, to
their differences (Lee et al. 2013). elicit more regional and cultural participation
2. Children’s response to parental conflict (Lee from all over Asia in the near future.
et al. 2010). Wai Yung Lee has set up an innova-
tive tool to measure how children respond to
their parents’ impasse. This tool shows to be References
very powerful in activating the parents to change
when used for clinical purpose. Clinicians from Asian Academy of Family Therapy. http://www.
both within the Asian region and abroad are acafamilytherapy.org
Lee, W. Y., Ng, M. L., Cheung, B. K. L., & Yung, J. W.
showing interest for possible cross regional (2010). Capturing children’s response to parental conflict
collaborations. and making use of it. Family Process, 49(1), 43–58.
Lee, W. Y., Nakamura, S. I., Chung, M. J., Chun, Y. J.,
Some of AAFT’s activities include profes- Liang, S. C., Meng, F., & Liu, C. L. (2013). Asian
couples in negotiation: A mixed method analysis of
sional conferences, which are held in a different cultural variations among couples from five Asian
region each year. These conferences have been regions. Family Process, 52(3), 499–518.
134 Asian Americans in Couple and Family Therapy
San Francisco, Los Angeles, and New York with

Asian Americans in Couple their restaurants and quaint shops, are “deplorable
and Family Therapy social conditions” (Sue and Sue 2013). There is
much poverty, drug abuse, criminal gang activity,
Terry Soo-Hoo and physical and mental health problems in many
California State University East Bay, Hayward, Asian American communities. There is also great
CA, USA family distress in these communities. Often, both
parents work long hours in low-wage jobs such as
waiters, seamstress, or laborers. As a result, chil-
Introduction dren are either left alone until late into the night or
older children take care of younger children. It is
The topic of working with Asian American fam- important to understand the socioeconomic com-
ilies and couples in psychotherapy is quite communities in which Asian American clients reside.
plex, and it is difficult to summarize in a very brief An Asian American optometrist living in an upper
article. However, it is possible to discuss a few middle class suburb might present quite differ-
principles that might serve as a guide to such ently in therapy than a seamstress working long,
work. First, it is important to keep in mind that hard hours in a sewing factory in Chinatown.
the term “Asian American” is very broad and can Economic issues are also related to racism and
include many different people from many differ- discrimination. Asian Americans have experi-
ent countries, such as China, Japan, Korea, Viet- enced a long history of racism and discrimination,
nam, India, etc. The rationale for such a term rests from the early Chinese immigrants to the present
on the assumption that many of these nationalities day. In addition, racism and discrimination have a
share similar cultural patterns. This is true despite strong impact on mental health. Brenner and Kim
the diversity in language and other major differ- (2009) found that many Chinese American ado-
ences, such as having different histories in the lescents reported facing discrimination in early
USA and living in different communities, for adolescence. These experiences were associated
example. The general recommendation when with depression, alienation, and lower academic
working with any ethnic or cultural group is to performance in middle adolescence. Many South-
“never assume” the client fits perfectly within east Asian refugees reported experiencing racial
expected norms or common cultural patterns or discrimination, and this was associated with high
set of beliefs. The therapist should always care- rates of depression (Noh et al. 1999).
fully explore the unique characteristics of each
client. Views of Mental Health and Reluctance
to Seek Treatment
Another important issue facing many mental
Description health professionals is the reluctance of Asian
Americans to come to therapy. It is clear that
Myth of the Successful Minority Asian Americans underutilize counseling and
The general population might view Asian Amer- other mental health services (Sue and Sue 2013).
icans as having achieved great success in Amer- Many Asian Americans view psychotherapy or
ica. However, this is not the total story. What counseling as only for “crazy people.” The more
might be visible are the successful Asians who traditional Asian American might prefer to seek
have completed their professional college degrees help from traditional healers such as herbalists,
and are doctors, dentists, optometrists, pharma- acupuncturists, shamans, religious leaders such as
cists, engineers, or accountants. They drive priests or ministers, or important community
around in their Mercedes and BMWs. However, leaders. Often Asian Americans are referred to
what is less visible, behind the glitzy façade of the therapy when there is a crisis in which the tradi-
Chinatowns, Japantowns, and Manilatowns in tion healers or helpers are ill equipped to handle
Asian Americans in Couple and Family Therapy 135
the problem situation. The challenge for therapists those on the other extreme might be highly accul-
is to engage these clients in ways that both turated to the American culture. In fact, there
acknowledge their cultural beliefs on one hand might be significant differences in the level of A
and also express to them that there are ways of acculturation among members within a family. It
helping that may be different than what they might is clear that Asians in America are evolving their
be used to. It is important to listen to what the own culture that may be different in many aspects
client is requesting. Is the client requesting prac- from the traditional Asian cultures found in their
tical, pragmatic, problem-solving type of help or country of origin, be it China, Japan, Korea, Viet-
is the client requesting deeper exploration of inter- nam, India, or another country. There is a blending
nal intrapsychic processing? In general, Asian of traditional Asian culture and American culture.
Americans tend to prefer time-limited, problem- However, this blending can be complex and var-
solving-oriented therapy approaches. Chen and iable, making it difficult to predict how any one
Davenport (2005) suggest using cognitive behav- Asian American might integrate the two cultures
ioral and other solution-focused strategies when together. For instance, an Asian American male
working with Asian Americans. However, they might be rather Americanized and very modern in
also caution that it is important to modify any regards to working in a highly technological field
therapy approach to incorporate a collectivistic and have liberal political views, yet he can still
rather than an individualistic perspective. For hold very traditional views of gender roles. He
instance, a therapist might encourage the Asian may still expect to marry a traditional wife, who
American client to practice assertiveness training. will follow in her traditional role as an Asian wife.
Such training must take into consideration the Furthermore, this blending of cultures is dynamic
social cultural context of the client and relation- and not static, so it is ever evolving and changing.
ships in which the assertive behavior is to be The challenge for family therapists is to assess
practiced. A son needs to approach the father carefully not only the level of acculturation but
with the proper respect and appreciation or the also how a particular client has blended the two
father will be very upset and will not be open to cultures.
hearing what he has to say! A modified strategic
therapy approach might also work effectively with
Asian American clients (Soo-Hoo 1999). This Relevant Research About Family Life
approach emphasizes working within a client’s
unique world or cultural context. Collectivist Culture
Asian cultures are very much “collectivistic.”
Complexity of Asian American Culture Western cultures in general tend to value indepen-
While an individual might operate within the con- dence and individuality, while Asian cultures
text of a particular cultural group, each individual value interdependence and being part of a collec-
will interpret and act out the culture in a different tive, whether it is a family, school, or other types
way. Therefore, counselors should recognize that of organizations. Being part of a group is very
each individual shares the context of the group in important. In fact, each person is defined and
a unique way and that this is never identical. judged by the family and other groups to which
Furthermore, many people of color are socialized he/she belongs. Children are expected to strive for
to live not only in their own culture but also in the family goals. There is strong emphasis on correct
White culture. Chinese Americans have evolved values and behaviors, family harmony, and
an interesting mix of traditional Chinese and adapting to the needs of the family, especially
Western European cultures (Soo-Hoo 1999, elders (Chen 2009). In a traditional Asian family,
2005a). This is also true for many other Asian the father is the head of the household. The mother
American groups. The range of this mix can be is responsible for raising the children. The family
quite wide. At one end of the spectrum are Asian is a central part of life. Often, extended family
Americans who are extremely traditional, while members, such as grandparents or uncles, live in
the same household or close by. There is a strong American students (Sue and Kirk 1975). Sue and
emphasis on diligence, harmony, taking responsi- Sue (2013) recommend that the therapist under-
bility, and self-reflection. Individual accomplish- stand the hierarchical and patriarchal orientation
ment is celebrated by the entire family, and of Asian American families. What is often helpful
failures reflect negatively on the family. Thus, is to find common ground for a collaborative
failure or misdeeds bring “shame” not only to conversation that focuses on a common goal.
oneself but also to the whole family. Each member The common goal for both parents and children
of the family has a responsibility and a duty to the is assisting everyone to be successful in life.
family, while one’s individual rights are not
emphasized. Culture Conflict
In family therapy, this collectivist view will Intergenerational and cultural differences can be a
influence how each family member behaves. Chil- source of difficulty. Young people who have
dren are dependent upon their parents for caretak- grown up with Western norms often find them-
ing, and these same parents will eventually selves at odds with parents who have very differ-
become dependent upon their adult children in ent values and expectations of them. One such
old age. In general, family members have very issue revolves around strong parental pressures
structured roles that benefit the family. Often, a on the young person to excel. This can become
family member, such as the eldest daughter, plays especially problematic when the parents of their
the role of caretaker of the younger siblings and is non-Asian peers are saying to their children, “just
also mother’s assistant. There is conflict when the relax. Do what you want.” In traditional Chinese
daughter feels overwhelmed or is resentful of such homes, discipline is strongly emphasized, as is the
a role. She comes to therapy complaining that she demand to be successful academically and other-
wants to get relief. A therapist might interpret this wise. One symptom that may emerge is depres-
request as wanting to separate and individuate sion, resulting from feelings of failure and
from her family. The more accurate interpretation inadequacy, engendered by internalized, unrealis-
of this type of presentation is that the daughter tic family expectations. Also common is a conflict
wants a way to modify her role so that she can between independence needs and loyalty to fam-
both support and help her family but also manage ily. Guilt can also result from not completely
to have some time and space for her own needs. conforming to family demands. Confucian values
She most likely does not want to separate or emphasize obedience to parents and loyalty.
abandon her family. It is common for Asian American immigrant
It is common for Asian American parents to parents to come to therapy complaining that their
not only emphasize educational achievement but adolescent children are “too Americanized.” They
to also emphasize certain professions, such as have been influenced too much by American cul-
becoming a doctor or some other highly presti- ture and by their American friends. They want too
gious or high-paid profession. Often an Asian much freedom and independence. They do not
American child will feel pressure to take on follow the old traditions and show enough respect
these goals without truly agreeing with them. to their parents. This is particularly the case with
The child feels like he or she cannot argue with Asian American females who feel like their par-
the parents over choice of careers. Over time, this ents are too restrictive and who do not have the
can result in the child becoming emotionally disability to date and go out with their friends just
tressed. The consequences can be the develop- like their white friends are able to do. It is impor-
ment of somatic complaints or symptoms such as tant to assist both parents and adolescent to view
headaches, stomach or digestive disorders, poor the positive intentions of each other. The parents
concentration, anxiety, back problems, sleep dis- want the best for their children, and they are acting
orders, and many other complaints. In fact, these out of love and concern. The adolescent wants to
are quite common presentations in university explore and learn about life in ways that will
counseling centers where there are many Asian enhance his/her future success, but the adolescent
also wants to honor the family and make them and their cultural values. It is important to form a
proud. The goal is to bring both sides together social and cultural connection with the family
cooperatively to work out how both issues can be during the initial stage. In addition, it is also help- A
address effectively. ful to establish expertise and credibility, build alli-
Another possible problem is related to identity ance with members who have power, and mobilize
confusion from minority status and the impact of the family’s cultural strengths. The therapist must
discrimination on personality development. Cul- explore potential internal and external resources. In
ture conflict can impact Asian American youth addition, the therapist needs to activate individual
and their personality development (Kitano and strengths within each family member. The therapist
Maki 1996). Many Asian youths are reluctant to needs to validate how much parents care about
identify with their Asian heritage due to negative their children and how they want the best for
stereotypes fostered by the dominant culture. In them, including the important goal of facilitating
fact, even fourth and fifth generation Asian Amer- their children’s success in life (Soo-Hoo 2005).
icans have been identified as “foreign” (Sue Only after forming this alliance can the therapist
et al. 2009). Often there is a strong pressure to explore different ways to open up new perspectives
assimilate to Western ways. Yet there also is still a to the problem situation (Soo-Hoo 1998). This is
strong pull from the family to conform to the often called reframing, or changing the narrative
traditional Asian culture of their parents. about the problem situation.
Working with Couples

Special Considerations for Couple When working with couples, it is important to
and Family Therapy explore cultural and societal conflicts. Often one
partner is more acculturated and present with dif-
The concept of multicultural competence is very ferent expectations and views of what is desirable
important in working with Asian Americans. in the relationship (Soo-Hoo 2005). An effective
Meyer et al. (2011) found that agreement on the strategy is reframing the problem. Reframing a
cause and treatment of the presenting problem is problem situation requires sensitivity to the cli-
more important than racial match in promoting ent’s cultural context (Soo-Hoo 1999). For
counselor credibility and the therapeutic alliance. instance, a traditional Korean husband balked at
The ability to demonstrate multicultural compe- a therapist’s suggestion that in order to resolve his
tence by addressing the cultural beliefs of clients relationship problem with his wife, he needed to
was also viewed as more competent by Asian be less aloof and become more emotionally
Americans (Wang and Kim 2010). Another key expressive. He must show her greater tenderness.
element is helping Asian American clients to The therapist further suggested that the husband
develop culturally appropriate strategies to cope must show his venerable side to her, as well as
with their problems. In this process the client sweep her off her feet with expressions of love and
improves their problem-solving abilities and affection. He responded by saying that in Korean
develops skills for successful interactions within culture, the traditional husband is supposed to be
the larger society, including balancing conflicting very strong and quiet and does not express intense
values. It is important to work within the client’s emotions directly, especially gentle, tender feel-
unique world rather than to force the client to ings. He felt that his wife was putting unreason-
work within the therapist’s world (Soo-Hoo able demands on him, and that his wife has been
1999). Any new solutions will be effective only influenced too much by American culture. This
if they fit within the client’s cultural context. was his frame of reference which was shaped by
As is true for most therapies, it is very impor- his culture. He quickly became dissatisfied with
tant to develop a therapeutic alliance with Asian this therapist and decided to go to a different
American families. It is critical to enter their world therapist who was more culturally sensitive. This
and to acknowledge and validate their experiences second therapist validated the husband’s love for
his wife (which he had difficulty expressing because she did not have any psychological
directly) and how he wanted the best for her. problems. In her culture only “crazy people”
The new therapist suggested that the wife needed needed counseling or therapy. She only had
the husband’s help in specific ways. As a strong, physical problems and what she needed was
competent, and intelligent man, could he some type of medicine. The Chinese American
“model” for his wife how to be reasonable and psychologist understood that her complaints
teach her by example how to handle difficult were symptomatic of psychological distress. In
situations in the relationship? This framing of this case, Jennifer was experiencing her psycho-
the problem and suggestions for new behaviors logical distress through somatic symptoms,
allowed him to maintain his culturally defined which is quite common for Asian Americans
role in the relationship. This also permitted him (Sue and Kirk 1975).
to collaborate with the therapist to generate new, The therapist began with a thorough discus-
more effective behaviors that resolved the rela- sion about her physical symptoms. It was impor-
tionship problems. In fact, with this new framing tant that Jennifer felt heard about her concerns
of the problem, he was able to show more gentle, related to her physical complains. She also
caring feelings for his wife, but he also under- stated that she had tried many over-the-counter
stood these behaviors as being a more “effective medicines such as aspirin and antacids, but
teacher.” Thus, shifting perceptions helped him nothing helped. The therapist explored with
attribute different meaning to a problem situa- Jennifer that these physical symptoms are
tion. Helping the wife see the problem situation often associated with stress, especially anxiety
in a new way was also helpful. However, and nervousness. She was then able to express
reframing can be effective only when it is done that her mother was pressuring her to return
within a client’s cultural context (Soo-Hoo 1998, home to take care of her three younger brothers
1999). and sisters. She was caught between her desire
to pursue her educational and career goals and
Case Example the needs of her family. Her father was support-
Jennifer is a 19-year-old Chinese American col- ive of her going to college because he believed
lege freshman. She was born in Hong Kong and that she could make good money to support the
immigrated to the USA with her parents when she family when she graduated. However, her
was 6 years old. She was studying accounting and mother was reluctant to let Jennifer travel over
wanted to be a CPA. On the one hand, she con- 130 miles from home to college. Her mother felt
sidered herself acculturated to American culture overwhelmed with having to work long hours
in terms of her preferences for the latest American and still find time to take care of the three youn-
music, food, clothing, movies, and many other ger siblings. Her father was working even lon-
facets of American culture. On the other hand, ger hours and had almost no time for the family.
she had many traditional Chinese cultural values. The mother advised Jennifer that since she was
She was very close to her family and felt a great such an attractive and capable woman, she
sense of responsibility for them. Her primary pre- should come home and prepare herself to
senting problems were anxiety, insomnia, head- marry a “wealthy husband.” That would solve
aches, and stomach problems. Now in her second everything.
semester, she also had difficulty concentrating and Jennifer also felt very lonely and isolated at
focusing on her studies. A physician at the uni- school because she could not relax and make
versity medical center examined her and found no friends. All her time was devoted to studying
physical or medical issues. Subsequently she was and working at the library. Her father told her
referred to the counseling center. repeatedly that the family was paying her way
A Chinese American psychologist saw her for through school to study, “not” to have “fun.”
counseling. Initially, Jennifer complained that “Do not waste our money!” On weekends she
she was not sure why she was seeing a counselor would go to the library to work or to study. She
had no one to talk to. Whenever she did talk to helpful. Reconnecting with the family once a
someone, she felt guilty that she was diverting her month was also reassuring for Jennifer and allo-
attention away from her studies. wed her to make the transition to college a bit A
The therapist validated her for being a caring smoother and less abrupt.
and devoted daughter. Her concern for her mother Jennifer also was able to earn a scholarship that
and rest of the family was clearly part of her paid for all of her college fees as well as her
culture, which she valued highly. She replied housing expenses. The scholarship, along with
that this was the reason she was so conflicted working in the library at the university part-time,
and felt so trapped. Her closest high school friend reduced significantly the financial burden on her
left home right after graduation and got a job in family. These financial improvements reduced the
another city. She told Jennifer on the phone that financial pressures on her family sufficiently so
she should think of herself and not think of her that her mother was able to reduce her hours at her
family. “They will be fine without you!” Jennifer work. Thus, her mother could spend more time
told the therapist that her friend did not understand with the three younger children.
that as the eldest daughter in her family, her role Within a few months Jennifer reported that her
was to take care of her family. She did not want to physical symptoms had subsided significantly and
be selfish and abandon them. she no longer felt as anxious. She had much more
The therapist explored with Jennifer the dif- energy to pursue her studies and was doing very
ference between long-term goals and short-term well in her classes. Whenever some of the old
goals. From ancient times it has been common worries about not being home to take care of her
for a Chinese family member to travel long dis- family appeared, she would say to herself that she
tances to work and earn money or for a family was on a “mission.” This mission was to become a
member to go to school far away. When the successful CPA so that she would earn enough
family member completed the task, she or he money to significantly help out her family! In
returned home and was able to contribute to the the meantime, it was also important that she
family substantially more. The reason for her finds time to get rest and recuperate. In order for
going to college was not only to pursue her own her to excel in her studies, she needed to recharge
career but also to be able to make good money to her batteries periodically. Finding time for rest,
help out her family. This discussion helped her to relaxation, and socializing were important ele-
remember that her original goal was to help the ments of maintaining optimum academic
family financially in the future. She also stated performance!
that she wanted to support her three younger A few months later, she reported that she was
siblings to go to college. finally feeling “more balanced.” Once she
To add to her stress, Jennifer’s mother was became more relaxed and open to
experiencing some separation anxiety and was connecting with people, she was able to form
feeling like she was losing her daughter. Jennifer connections with a group of friends in her dor-
showed the therapist letters from her mother that mitory. They studied together but also had fun
clearly stated this. Jennifer was encouraged to together. The social activities actually helped
reassure her mother that she was still thinking of her to reduce some of the stress due to the
her. She was to call her mother and talk to her academic pressures of her classes. In her social
briefly once a day for the next few weeks. Also group, she discovered that two of the
she agreed to come home for a weekend once a Chinese American students experienced similar
month since she was able to get a ride with a pressures from their parents and families.
female student going to her hometown once a The ability to share common experiences and
month. These arrangements helped to reassure feeling like she was not alone really helped her
her mother that her daughter was still attached to feel more “normal” and subsequently able to
her. Going home once a month also helped cope more effectively with the different
Jennifer take a break from school, which was pressures.
140 Assertiveness Training in Couple and Family Therapy
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Assertiveness training has a long history. and Mavrodiev 2013). Although literature has
The concept of assertiveness originated from an supported the clinical efficacy of AT as a “stand-
American psychologist and psychotherapist, alone” intervention in treating diverse clinical
Andrew Salter, in 1949 (Lazarus 1968). When problems, AT is typically embedded within large
Salter was working with clients with depression, treatment programs currently (Speed et al. 2017).
his efforts to find the cause of uncertainty/non- Peneva and Mavrodiev (2013) provided a history
assertiveness and to treat its neurotic influence of how AT, a behavioral model, gradually integrated
were shown in his theoretical explanation, “Condi- the cognitive and affective models. From the behav-
tioned Reflex Therapy” (Peneva and Mavrodiev ioral point, Salter and Wolpe addressed that people
2013). Salter indicated that inhibitory individuals need to acquire habits to be able to openly express
are not able to openly express their feelings, desires, their feelings. Wolpe identified social fear as the
and needs and consequently experience difficulties source and the cause of nonassertiveness. Wolpe’s
in their interpersonal relationships (Peneva and examples of social fear were fear of criticism, rejec-
Mavrodiev 2013). Salter contrasted inhibition with tion, bosses, new situations, and fear to ask for help
excitation. Salter described excitation as the outward or to provide help. Wolpe stated that the effects of
expression of feelings and emotions that leads to a social fear become associated with a certain social
healthy intra- and interpersonal functioning situation and become enhanced and self-produced
(Lazarus 1968). Later in 1958, Joseph Wolpe, a that it eventually becomes an automatic response
psychiatrist, used the term assertiveness and utilized that is spread out in other daily life situations
assertiveness training (a) to decrease social fears, (Peneva and Mavrodiev 2013). Peneva and
which Wolpe identified as the reason people are Mavrodiev indicated that in 1971, Lazarus com-
unassertive, and (b) to maintain a high level of bined behavioral therapy with cognitive therapy.
self-esteem (Wolpe 1958). Lazarus defined assertive behavior as a social
People are either assertive or nonassertive, and competence and addressed that people need to
those who are nonassertive range from being be able to differentiate assertive and socially
excessively passive/submissive to being exces- acceptable behaviors from aggressive behaviors,
sively hostile/aggressive (Speed et al. 2017). which requires people to use cognition to assess
Caballo (1993) described people who are asser- their own personal life philosophy. Lastly,
tive as those who are satisfied, confident, and able Peneva and Mavrodiev explained that the Ger-
to cope well in their daily social life. Caballo man psychologists Rita and Rüdiger Ullrich
explained that those who are unassertive avoid identified the feelings of guilt and shame as sig-
conflicts, are ignored by others, and lack self- nificant agents of nonassertiveness and therefore
respect and confidence by not being able to affirmed that assertiveness, in addition to behav-
express their thoughts and feelings to others. ioral and cognitive components, consists of an
Lastly, Caballo explained that those who are emotional component. According to Rita and
aggressive break the ethical norms and do not Rüdiger Ullrich, as a person assesses one’s own
care about others’ rights. personal life philosophy and tries to become
assertive, emotions are evoked, which leads to a
process of cognitive interpretations and emotions
Theoretical Framework that can in turn be an overwhelming emotional
condition that affects one’s self-assessment, self-
Assertive training has its roots in behavior therapy esteem, and personal significance (Peneva and
(Speed et al. 2017). However, AT progressed Mavrodiev 2013).
142 Assertiveness Training in Couple and Family Therapy
Rationale for the Strategy or values, expectations, and definitions on assertive-

Intervention ness compared to the dominant culture (Wood and
Mallinckrodt 1990). This means that a behavior can
Most of the assertive trainings utilize various cog- be viewed as appropriate and assertive in one cul-
nitive behavioral interventions in order to assist ture and as inappropriate and aggressive or passive
people in eliminating maladaptive behaviors (e.g., in another culture.
decreasing anxiety) and gaining new responses Wood and Mallinckrodt (1990) addressed that
(e.g., building social skills and being assertive; people from the ethnic minority groups may need
Speed et al. 2017). Behavioral skills aim to build to learn to be assertive in the dominant culture in
social skills, to verbally and nonverbally express order to effectively interact with the dominant cul-
oneself, to decrease the level of social fear, and to ture and may also need to learn how to respond in
increase the level of self-esteem (Speed et al. 2017). an assertively appropriate way in their own cultures
Consequently, AT utilizes behavioral interventions in order to cope in their daily lives. Hence, Wood
such as relaxation, role plays, modeling, reinforce- and Mallinckrodt recommended that therapist to be
ment, homework, coaching, guided imagery, culturally sensitive by exploring and discussing
desensitization, videotape feedback, exposure, and cultural differences in regard to the appropriateness
behavioral rehearsals for communication skills of assertiveness depending on the clients’ sociocul-
such as making requests, using “I” statements, tural contexts and by helping clients to make their
and practicing to maintain an appropriate eye con- own choices instead of therapist implying or per-
tact, affect, volume, and posture (Lee et al. 2013; suading clients to change or reject their own values.
Peneva and Mavrodiev 2013; Speed et al. 2017). Wood and Mallinckrodt noted the importance of
On the other hand, cognitive skills aim to restruc- considering the possible consequences of being
ture negative thoughts about the self and anxious assertive for the minority groups such as experienc-
thoughts that lead to unassertiveness and to gain ing discrimination, shame, and ostracism from their
control over the misconceptions about oneself and families and friends. Wood and Mallinckrodt also
the world in order to improve self-confidence advised considering acculturation levels of the
(Peneva and Mavrodiev 2013; Speed et al. 2017). immigrant families.
Consequently, AT utilizes interventions that help In addition to the ethnic minority groups, Speed
objectify misperceptions, identify maladaptive pat- et al. (2017) suggested that women’s assertive
terns of thoughts (e.g., selective attention, illogical behavior in their workplace may lead to negative
conclusions, overgeneralizations, exaggerations, consequences. Lease (2018) addressed the influence
and underestimation), and evaluate thoughts and of the microsystem that consists of supervisors,
behaviors (Peneva and Mavrodiev 2013). colleagues, and supervisees with whom women
directly interact on a daily basis and the influence
of the macrosystem that consists of the cultural
Description of the Strategy or values, expectations, and norms that the society
Intervention (Critics and Application) defines as appropriate. Consequently, Lease warned
that if women are assertive, women can become
Researchers have criticized AT for defining appro- norm violators and therefore be negatively affected.
priateness based on the values of a White majority Therefore, it is imperative to broaden perspectives
culture and consequently addressed the importance and to consider the clients’ socioecological system
of assessing whether assertive skills are contextu- when utilizing assertiveness training.
ally and culturally appropriate for diverse groups or
need modification (Lease 2018; Speed et al. 2017;
Wood and Mallinckrodt 1990). Culture plays a role Case Example
in defining what is appropriate and inappropriate.
Ethnic minority groups such as Asian-American, Kate, a 58-year-old Chinese-American, is seeking
Black, Latino, and Native American have different individual therapy. Kate stated that she had a
Assertiveness Training in Couple and Family Therapy 143
divorce 12 years ago and is now living with her Assertiveness was introduced, explained, and
30-year-old daughter, Annie. Kate stated that she discussed with Kate. Cultural differences in defin-
was happy and content at home and at her previ- ing appropriateness were explored and discussed, A
ous work until she started working at her current and Kate indicated her willingness to become more
job 8 months ago. Kate stated that she has been assertive at work. Kate’s cultural and the societal
feeling “down” for the last 4 months and has been expectations were further considered and explored.
“dragging” herself to go to work every day. Kate Therapist and Kate adjusted the assertive skills
reported that she is a “horrible employee” and accordingly. Kate’s worries/concerns that she will
added that has recently started to think that she is “backstab” her coworker and that she will be dis-
a horrible mother as well. Kate concluded, “I am respectful to her boss were further explored,
not good at anything.” Kate reported that her boss discussed, and differentiated based on the differ-
does not like her and “picks on” her. Kate stated ences in the culture and the context. Kate learned
that her boss always criticizes her for not doing relaxation techniques in order to cope with her
her job on time. Kate reported that she is worried feeling of anxiety whenever she tried to be asser-
that she may get fired any time soon for being “an tive. Therapist and Kate explored, discussed, and
incompetent employee.” Kate stated that she can- modified the appropriateness of being assertive
not afford to lose her job. based on Kate’s own beliefs and values. The ther-
During the assessment, Kate stated that she apist modeled for Kate on how to be assertive by
would like to talk to her boss and explain her using “I” statements based on Kate’s level of com-
situation, but Kate reported that she cannot do fortableness. Appropriate eye contact, voice vol-
so. Kate’s cultural values and expectations for ume, and physical posture were also discussed,
working with coworkers and communicating modified, and rehearsed based on Kate’s culture.
with superiors were further explored. While Kate engaged in role plays with the therapist
exploring the reason that Kate cannot talk to wherein the therapist played the role of Kate and
her boss, Kate reported that she does not want Kate played the role of being the boss and vice
to “backstab” or “shame” her coworker/partner versa to practice being assertive. Kate did her
in the group project. Kate explained that she homework by practicing the use of “I” statements
does not want her partner to get into trouble and being assertive with her daughter Annie at
because of her. Kate also reported that she home. Therapist performed guided imagery with
does not want to give excuses or “talk back” Kate on Kate explaining to her boss about the
to her boss when her boss criticizes her for not work situation. In addition, Kate’s maladaptive
doing her work on time. Kate explained that she thoughts of “I am a horrible employee,” “I am not
cannot disrespect her boss. When detailed ques- good at anything,” “I am not good enough and fast
tions were asked in regard to Kate’s group pro- enough,” and “I am an incompetent employee”
ject, Kate revealed that her partner has not been were identified, evaluated, and challenged. Eventu-
doing her part of the work and she has been ally, Kate became successful in being assertive by
doing her best to cover her partner’s role. Kate expressing the situation to her boss, and appropriate
reported that she is not good enough and fast changes were made in the office. Kate also reported
enough to complete and turn in the weekly that she was able to be assertive with her coworker/
reports on time to her boss. Kate reported that partner in the group project as well. Kate reported
her boss questions and accuses her of not doing that she is feeling high levels of self-confidence and
her work in a timely manner. When specific satisfaction at work, at home, and in her daily life.
questions were asked in regard to Kate’s work
context, Kate reported that her boss is a White
man who is older than her. Kate also explained Cross-References
that her partner is one of the people who has the
longest seniority while Kate she is the newest ▶ Communication Training in Couple and Family
employee in her department. Therapy
144 Assessment in Couple and Family Therapy
References Synonyms
Alberti, R., & Emmons, M. L. (1974). Your perfect right: Clinical interviews; Questionnaires; Semi-
A guide to assertive behavior. San Luis Obispo: Impact
structured interviews
Press.
Caballo, V. (1993). Manual de evaluación y entrenamiento
de las habilidades socials [Handbook of social skills
assessment and training]. Madrid: Siglo XXl. Introduction
Lazarus, A. A. (1968). Behavior therapy in groups.
In G. M. Gazda (Ed.), Basic approaches to group
psychotherapy and group counseling (pp. 149–175). Assessment in couple and family therapy refers to
Springfield: Charles C. Thomas. the process by which a therapist evaluates the
Lease, S. H. (2018). Assertive behavior: A double-edged clients’ individual and dyadic characteristics,
sword for women at work? Clinical Psychology:
and environmental circumstances. Clinical assess-
Science and Practice, 25(1), 1–4. https://doi.org/
10.1111/cpsp.12226. ment is aimed at evaluating the nature, scope, and
Lee, T.-Y., Chang, S.-H., Chu, H., Yang, C.-Y., Ou, K.-L., severity of the presenting concerns. It also
Chung, M.-H., & Chou, K. R. (2013). The effects of includes collecting relevant information that may
assertiveness training in patients with schizophrenia:
assist in selecting an appropriate course of treat-
A randomized, single-blind, controlled study. Journal
of Advanced Nursing, 69(1), 2549–2559. https://doi. ment and establishing methods for evaluating pro-
org/10.1111/jan.12142. gress throughout treatment. Often, assessment is
Peneva, I., & Mavrodiev, S. (2013). A historical approach thought of as a first step in treatment, aimed at
to assertiveness. Psychological Thought, 6(1), 3–26.
identifying targets of intervention and guiding
https://doi.org/10.5964/psyct.v6i1.14.
Speed, B. C., Goldstein, B. L., & Goldfried, M. R. treatment planning. However, assessment can be
(2017). Assertiveness training: A forgotten used throughout treatment in order to monitor
evidence-based treatment. Clinical Psychology: Sci- progress and make decisions about termination;
ence and Practice, 25(1), 1–20. https://doi.org/
furthermore, assessment itself can be used as a
10.1111/cpsp.12216.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. therapeutic intervention.
Stanford: Stanford University Press.
Wolpe, J., & Lazarus, A. A. (1966). Behavior therapy
techniques: A guide to the treatment of neuroses.
New York: Pergamon Press.
Wood, P., & Mallinckrodt, B. (1990). Culturally sensi-
tive assertiveness training for ethnic minority clients. All models of couple and family therapy include
Professional Psychology: Research and Practice, some form of assessment, though they vary
21(1), 5–11.
widely in the role that assessment plays.
Approaches to assessment also vary, with some
models including only a brief initial assessment
and others incorporating ongoing assessment into
Assessment in Couple and the treatment throughout.
Family Therapy The clinical interview* is certainly the most
common form of assessment and is used more or
Lane L. Ritchie, Kayla Knopp and Galena K. less universally in couple and family therapy. Ther-
Rhoades apists typically talk with all involved parties
University of Denver, Denver, CO, USA together and/or individually about the primary
issues currently impacting the couple or family
dynamics and what changes or improvements they
Name of the Strategy or Intervention would like to experience during the course of ther-
apy. Some therapeutic approaches emphasize a
Assessment in Couple and Family Therapy semi-structured interview*, such as is used during
Assessment in Couple and Family Therapy 145
the assessment phase of Integrative Behavioral Cou- create and test hypotheses about the causes and
ple Therapy (IBCT; Christensen and Jacobson maintenance of couple or family dysfunction. The
1996), whereas others gather information in an process of IPCM therapy is explicitly empirical, A
unstructured, conversational manner. Some models as therapists use the data collected throughout
of couple and family therapy also incorporate some treatment to adjust treatment approaches and tar-
form of a screening assessment, often in a ques- gets as new information is learned. Importantly,
tionnaire* format, in order to ensure that couple or assessment in IPCM is done collaboratively with
family therapy is an appropriate intervention. For clients: data from assessments are incorporated
example, the presence of severe partner or family into therapy in a way that allows clients and ther-
violence may be an exclusionary criterion for some apists to increase their understanding together
couple or family interventions, and clients who about the particular couple or family dynamics at
endorse this particular problem will usually be play. IPCM has provided the theoretical frame-
referred for anger management or other violence work for the development of the Systemic Ther-
prevention-focused services prior to beginning apy Inventory of Change (STIC), an assessment
couple or family therapy. Substance abuse, individ- tool optimized for both measurement and feed-
ual mental health disorders, and ongoing infidelity back in a therapeutic context (Pinsof et al. 2015).
are other common targets of screening assess- Other forms of couple and family therapy may
ments, as they will frequently influence treatment incorporate assessment initially and throughout
targets and approaches or, in some cases, may treatment in a way that helps to focus treatment
preclude couple or family therapy. on the most pressing issues and monitors progress
As mentioned previously, IBCT is perhaps the toward goals. The focus of assessment typically
model of couple therapy with the most formalized mirrors the focus of a particular mode of therapy;
initial assessment process (Christensen et al. 2015). for example, in Cognitive-Behavioral Couple
The first four sessions of therapy are explicitly ded- Therapy (CBCT; Baucom et al. 2015), assessment
icated to an assessment and feedback phase of treat- often probes for specific behaviors and partners’
ment, with one conjoint assessment session, two evaluations of those behaviors that contribute to
individual assessment sessions (one with each part- relationship dissatisfaction, whereas in Emotion-
ner), and a conjoint feedback session. During the ally Focused Therapy (EFT; Johnson 2015),
assessment phase, a semi-structured interview* is assessment frequently aims to elicit the present-
used to discover the relationship, individual, and moment emotions that are associated with rela-
contextual factors that comprise a DEEP tionship distress. Information gathered during
(Differences, Emotional sensitivities, Environmen- assessments may be presented to clients in order
tal stressors, and Patterns of interaction) formula- to increase insight about relational issues and
tion. The DEEP formulation is presented to the highlight the potential for change to occur.
couple during a feedback session and is used to Finally, some models of couple or family therapy
focus and anchor the targets of treatment throughout focus on the treatment of specific psychological
therapy. IBCTemphasizes the functional assessment disorders, in addition to alleviating relational dis-
of behaviors in order to discover how the meaning tress. For example, Cognitive-Behavioral Conjoint
of problematic behaviors is related to larger themes Therapy for PTSD and Behavioral Family Therapy
of dissatisfaction that cause relationship distress. for Bipolar Disorder both utilize the couple or fam-
The Integrative Problem-Centered Meta- ily context to support treatment of individual mental
frameworks approach (IPCM; Breunlin et al. health concerns. In these cases, assessment specific
2011) is perhaps the best example of an interven- to the relevant disorder is typically included. Assess-
tion model that uses assessment therapeutically ment at the beginning of therapy may be used to
throughout treatment. IPCM treatment involves confirm a particular mental health diagnosis and to
an ongoing, systemic assessment that is used to quantify the severity of impairment or distress, and
146 Assessment in Couple and Family Therapy
assessment may continue to be incorporated assessment are similar. Most approaches include
throughout treatment to monitor improvement in some assessment of individual, dyadic, and envi-
symptoms. Importantly, these models of therapy ronmental factors. This information is most often
also focus on improving the couple or family rela- collected through a combination of question-
tionship, and therefore may include relevant assess- naires*, clinical interviews*, and observations.
ment of the couple or family functioning similar to Although couple and family therapists are pri-
other models of couple or family therapy. marily focused on addressing challenges at the level
Assessment can be and often is used in preven- of the dyad or larger family group, it is important to
tive or psychoeducational programs for couples. assess several characteristics of each individual
When teaching the Prevention and Relationship involved. For example, information about individ-
Education Program (PREP; Markman et al. 2001), ual psychopathology, trauma history, and previous
for example, many facilitators may use initial relationship history may be relevant, depending on
assessments to learn about the couples they are the current presenting concerns. In many cases,
serving. PREP also offers several self- individuals hold attitudes and beliefs that contribute
assessments as part of the curriculum so that part- to the dyadic- or family-level concerns. These char-
ners can learn about themselves and each other. acteristics, which often interact with cultural back-
Some other preventive approaches use assessment ground and previous relationship experiences, are
and feedback as the basis of the program. Exam- important for a clinician to understand.
ples of these kinds of programs are PREPARE/ Another important component of assessment
ENRICH (Olson and Olson 1999) and the Mar- across models is collecting information about the
riage Checkup (Cordova 2009). couple or family’s level of distress. In couple and
family therapy, assessment includes developmen-
tal relationship history (e.g., in couple therapy,
Rationale for Strategy or Intervention how the couple met, how intimacy and commit-
ment changed over the course of the relationship,
Assessment in couple and family therapy can significant events in the relationship including
serve several purposes. First, it can be used to transitions such as engagement, marriage, or par-
guide treatment planning by identifying specific enthood). Particularly in couple therapy, an
targets of intervention, and identifying which assessment of current commitment to the relation-
approach will be best suited to a couple or family’s ship can also inform treatment planning. When
circumstances. With a rich understanding of a assessing current presenting problems, clinicians
family’s strengths, challenges, and resources, cli- generally benefit from asking each family member
nicians are better-prepared to select a course of about their own perceptions of the problems,
treatment that is most appropriate. However, including attributions about why the problems
assessment can do more than guide treatment. are occurring. Further, clinicians may ask each
Some approaches include ongoing assessment as family member’s opinion about what it would
a core component of the intervention. For exam- take for the problem to be adequately addressed.
ple, many couple and family therapists administer Assessment may also include investigating
assessment measures at several time points during prior efforts that the couple or family has made
treatment in order to track progress and remaining in order to address relationship problems or
areas of challenge (e.g., Christensen et al. 2015). enhance relationship strengths. Some common
efforts include individual, couple, or family ther-
apy; enrichment programs such as retreats; self-
Description of Strategy or Intervention help resources including books or blogs; and sup-
port from others such as religious leaders.
Although models of couple and family therapy Most approaches also encourage clinicians to
vary in the role and method of assessment ask about strengths of the couple or family rela-
recommended, many of the general purposes of tionships. An overly strong emphasis on negative
Assessment in Couple and Family Therapy 147
qualities can leave a couple or family feeling (PCIT) may particularly benefit from observation
discouraged about the status of their relationship. of communication or interaction patterns during
Asking couples and family members to generate session. A
information about the positive aspects of their Upon conclusion of the initial assessment period,
relationships can serve at least two purposes: many clinicians compile the information and share it
identifying areas of strength to build on during with the couple or family in some way. Some
treatment and reminding family members that approaches to therapy encourage smaller, less for-
there are positive characteristics of the relation- mal presentations of the information. For example, a
ships even though negative aspects may be more clinician may briefly summarize a couple’s history
readily accessible during periods of distress. and review mutually agreed-upon goals, ensuring
Another important component of assessment is that both partners are in agreement about targets of
related to the environmental context of each cou- treatment. Other approaches call for a more formal
ple or family. Contextual factors include financial presentation of the assessment. For example, IBCT
resources, social resources, family support, and consists of a highly-structured assessment phase,
health-related concerns. Assessing these factors with the first four sessions devoted specifically to
external to the dyad or family allows clinicians assessment. There is a feedback session, during
to identify areas of strength and challenge that which the therapist shares a detailed summary of
each couple or family faces. assessment data and collaboratively reviews the
The individual, dyadic, and environmental fac- case conceptualization with the couple. Many ther-
tors reviewed here can be assessed using question- apists use this opportunity to orient couples and
naires*, clinical interviews*, and observation of families to the model of treatment to be used. This
interactions. Clinicians are encouraged to make may include discussing the role of the therapist and
thoughtful decisions about which type of format is the clients. Importantly, clinicians may address who
likely to yield the most useful information in each the client is (e.g., the couple’s relationship? One of
domain. the individuals involved?).
Some approaches emphasize the importance of Assessment can be used throughout treatment in
collecting some information by individual clinical order to assess progress toward therapeutic goals.
interview*, even when a dyad or family presents for Interventions can be altered accordingly. For exam-
treatment. For example, the IBCT protocol includes ple, interventions can shift toward other areas of
a conjoint assessment session, followed by individ- focus once a particular goal has been attained.
ual assessment sessions with each partner. Among
other purposes, the individual interviews are meant
to provide an opportunity for each partner to speak Case Example
openly about information that they may be unable or
unwilling to discuss fully in the presence of the José and Ally began couple therapy after two years
partner. For example, the individual interviews proof marriage due to growing dissatisfaction in their
vide an opportunity for those who do not feel safe in relationship. The partners reported that they gener-
their relationship to express that information without ally get along but would like to improve communi-
concern for additional danger. cation, specifically around sensitive topics about
Observing family members’ current interaction which arguments escalate quickly. The couple had
patterns can be a useful tool. Although each family no children, though they had been trying to conceive
member can report their perception of how conflict for the duration of their marriage. Conflict often
occurs at home, clinicians often find that observing arose when communicating about their difficulty
small segments of conflict provides additional infor- becoming pregnant. Both partners worked and
mation that was not easily gathered from interview. Ally managed the couple’s business. José occasion-
Models emphasizing behavioral change strategies, ally helped out with the business, though this fre-
such as Cognitive Behavioral Couple Therapy quently became an area of contention due to
(CBCT) and Parent-Child Interaction Therapy discrepant expectations about roles and who should
148 Assimilation in Integrative Couple and Family Therapy
be in charge of different components of their family References

and business. Ally considered the two of them to be
generally equal partners across contexts, while José Baucom, D. H., Epstein, N. B., Kirby, J. S., &
LaTailade, J. L. (2015). In A. S. Gurman, J. L. Lebow,
drew a distinction between their home life, where
& D. K. Snyder (Eds.), Clinical handbook of couple
they would interact as equals, and their life outside therapy (5th ed., pp. 23–59). New York: Guilford Press.
of the home, where Jose was in charge. Breunlin, D. C., Pinsof, W., & Russell, W. P. (2011).
A packet of questionnaire* measures was admin- Integrative problem-centered metaframeworks therapy
I: Core concepts and hypothesizing. Family Process,
istered to each partner at the first session to collect
50(3), 293–313. https://doi.org/10.1111/j.1545-
demographic information and some individual char- 5300.2011.01362.x.
acteristics such as psychopathology. Standardized Christensen, A., & Jacobson, N. (1996). Acceptance and
scales measuring relationship quality were also change in couple therapy: A therapist’s guide to trans-
forming relationships. New York: WW Norton.
included in this packet. The use of standardized
Christensen, A., Dimidjian, S., & Martel, C. R. (2015).
measures allowed for the couple’s scores to be com- Integrative behavioral couple therapy. In A. S. Gurman,
pared to established norms. Further information J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook
about relationship history, current presenting con- of couple therapy (5th ed., pp. 61–94). New York:
Guilford Press.
cerns, and relationship strengths was collected dur-
Cordova, J. V. (2009). The marriage checkup: A scientific
ing a conjoint interview session. Specific individual program for sustaining and strengthening marital
information (e.g., relevant previous relationship his- health. New York: Jason Aronson.
tory) and some key pieces of safety-related informa- Johnson, S. (2015). Emotionally focused couple therapy. In
A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.),
tion (e.g., aggression in their relationship) were
Clinical handbook of couple therapy (5th ed.,
collected during individual interview sessions with pp. 97–128). New York: Guilford Press.
each partner. Although no specific interaction task Markman, H. J., Stanley, S. M., & Blumberg, S. L. (2001).
was administered, the clinician used several oppor- Fighting for your marriage. San Francisco: Jossey-Bass,
Inc.
tunities during the conjoint session to observe inter-
Olson, D. H., & Olson, A. K. (1999). PREPARE/ENRICH
action patterns that emerged naturally without program: Version 2000. In R. Berger & M. T. Hannah
therapist interjection. (Eds.), Preventive approaches in couples therapy
A thorough assessment of this couple yielded a (pp. 196–216). Philadelphia: Brunner/Mazel.
Pinsof, W. M., Zinbarg, R. E., Shimokawa, K., Latta, T. A.,
great deal of information that was useful in guiding
Goldsmith, J. Z., Knobloch-Fedders, L. M.,
treatment planning. Specifically, after learning that Chambers, A. L., & Lebow, J. L. (2015). Confirming,
physical safety was not consistently maintained, the validating, and norming the factor structure of systemic
clinician was able to prioritize some brief therapy inventory of change initial and intersession.
Family Process, 54(3), 464–484.
cognitive-behavioral interventions aimed at
establishing physical safety within the home.
Throughout treatment, a standardized measure
was administered regularly in order to monitor
ongoing relationship satisfaction. The clinician Assimilation in Integrative
also conducted regular informal assessments during Couple and Family Therapy
sessions regarding progress toward goals and work-
ing alliance. George Stricker
Argosy University, Arlington, VA, USA
Cross-References
Introduction
▶ Cognitive Behavioral Couple Therapy
▶ Emotionally Focused Couple Therapy Psychotherapy integration has been defined as
▶ Integrative Behavioral Couple Therapy including various attempts to look beyond the
▶ PREP Enrichment Program confines of single-school approaches in order to
▶ Prepare/Enrich Enrichment Program see what can be learned from other perspectives. It
Assimilation in Integrative Couple and Family Therapy 149
is characterized by openness to various ways of Application of Concept in Couple

integrating diverse theories and techniques and Family Therapy
(Stricker 2010). A
The couple or family is viewed through the
preferred lens of the therapist. In the assimila-
Theoretical Context for Concept tive psychodynamic integrative approach, in
order to understand each of the patients as indi-
There are four generally accepted approaches to viduals, the lens is psychodynamic, and this is
psychotherapy integration. These include the supplemented by a systems lens in order to view
following: the meaning of the interaction between them.
Interventions then may be generated from a
1. A common factors approach to understanding variety of different approaches to psychother-
psychotherapy, which identifies those aspects apy other than the basic psychodynamic
of psychotherapy that are present in most, if approach of the therapist, including cognitive-
not all, therapeutic system behavioral, humanistic, and systems. It is
2. Technical integration, in which a combination important to recognize that theory and tech-
of techniques is drawn from different therapeu- nique are separable, so that one theory can be
tic systems without regard for any specific used with multiple techniques, as long as the
theoretical approach integration is conducted seamlessly.
3. Theoretical integration or an attempt to under-
stand the patient by developing a superordinate
theoretical framework that draws from a vari- Clinical Example
ety of different frameworks
4. Assimilative integration, which combines treat- Mrs. A. was a 40-year-old woman, married for
ments drawn from different approaches but 10 years, with two children, aged 4 and 2. She
remains guided by a unitary theoretical came to therapy because of a growing dissatis-
understanding faction with her husband, based on a very dif-
ferent set of values and lifestyle. She felt he had
not risen to the occasion of their children’s birth
Description and had become increasingly uncommunica-
tive, and they had become more distant from
Assimilative integration may begin with any of each other physically and emotionally. She
several theoretical approaches. A psychodynamic didn’t seem to feel that she was getting much
approach is used by Stricker and Gold (2005) and from the relationship now and had little roman-
a cognitive-behavioral approach by Castonguay tic interest in him (or anyone else) but acknowl-
et al. (2005). When doing couple and family ther- edged that he was a good father. He offered to
apy, it is difficult to imagine treatment being carried live in the basement and allow her to have a
out without the incorporation of a systems perspec- boyfriend, which was not what she wanted,
tive, whether it is the primary orientation or is and this also suggested something about his
assimilated into an alternative approach. In assimi- personality to the therapist, who had a psycho-
lative psychodynamic psychotherapy integration, dynamic orientation. They came together to the
one of several assimilative approaches, the therapist next session, and it was obvious that communi-
begins with a psychodynamic approach to concep- cation was almost absent between them, leaving
tualizing the clinical situation, uses many psycho- Mrs. A. frustrated and unhappy and Mr. A. not
dynamic techniques, but also integrates cognitive- being bothered very much. This formulation had
behavioral, humanistic, and systems techniques. In both psychodynamic and systems components,
addition, of necessity, some systems thinking is used and the therapist encouraged them to speak to
in couple and family therapy. each other without much direction. By the end
150 Assimilative Family Therapy
of the session, she became more expressive of References

her feelings, and he was surprised that she was
actively considering separation. At the next ses- Castonguay, L. G., Newman, M. G., Borkovec, T. D.,
Grosse Holtforth, M., & Maramba, G. G. (2005).
sion they reported a much better week, a con-
Cognitive-behavioral assimilative integration. In
frontation of sorts in the car, with Mr. A. upset J. C. Norcross & M. R. Goldfried (Eds.), Handbook
about the mention of divorce and Mrs. A. about of psychotherapy integration (2nd ed., pp. 241–260).
his not realizing her concerns. However, the talk New York: Oxford University Press.
Duncan, B. L., Sparks, J. A., & Miller, S. D. (2006). Client,
went well, and they did a little better after that.
not theory, directed: Integrating approaches one client
The importance of communicating was at a time. In G. Stricker & J. Gold (Eds.), A casebook of
highlighted by the therapist, as was the need to psychotherapy integration (pp. 225–240). Washington,
make time for each other if it was to happen. DC: American Psychological Association.
Lambert, M. (2007). Presidential address: What we have
This more directive approach to a psychody-
learned from a decade of research aimed at improving
namic orientation was an early example of psychotherapy outcome in routine care. Psychotherapy
assimilation. It also meant that Mr. A., who Research, 17, 1–14.
was laid back, would have to be more assertive Stricker, G. (2010). Psychotherapy integration. Washing-
ton, DC: American Psychological Association.
and Mrs. A., who was reluctant to make waves,
Stricker, G., & Gold, J. (2005). Assimilative psychody-
also would have to be more expressive. Because namic psychotherapy. In J. C. Norcross &
of the value of outcome assessment (Lambert M. R. Goldfried (Eds.), Handbook of psychotherapy
2007), at the beginning of each session, they integration (2nd ed., pp. 221–240). New York: Oxford
University Press.
were given an outcome form to fill out and, at
the end, a scale to assess the session (Duncan
et al. 2006). This too was an assimilation of a
non-psychodynamic intervention. Interestingly,
Mrs. A. rated the sessions very highly, as most Assimilative Family Therapy
patients do, but Mr. A. was much more reserved
in his rating. The therapist asked him about this Patricia Pitta
and he said that he never rated anyone highly, as Department of Psychology, St. John’s University,
he did not think it was possible to be perfect. Jamaica, NY, USA
The therapist then remarked that his approach
must make it very difficult for his wife. Her face
lit up, as though she finally felt heard, and he Name of the Strategy or Intervention
recognized what was being said.
Assimilative Family Therapy Model
▶ Common Factors in Couple and Family Pitta integrated Bowen Family Systems Therapy
Therapy with cognitive behavioral, psychodynamic, com-
▶ Eclecticism in Couple and Family Therapy munications, and other systems therapies into
▶ Integration in Couple and Family Therapy Integrative Healing Family Therapy (Pitta 2005).
▶ Integrative Couple Therapy: The Functional As her thinking evolved, she began to consider
Analytic Approach context (Brabender and Fallon 2009) and com-
▶ Integrative Problem-Centered Metaframeworks mon factors (Davis et al. 2012). She then labeled
▶ Stages of Change in Couple and Family this therapy for individuals, couples, and families
Therapy the Assimilative Family Therapy (AFT) model
▶ Therapeutic Alliance in Couple and Family (Pitta 2014). The home theory of AFT is a sys-
Therapy temic theory or family therapy model, and the
Assimilative Family Therapy 151
concepts and interventions from other therapies dysfunction, this framework also looks for health
can be from individually oriented treatment ther- in the system to promote changes. The major
apies and other family therapy models. goals of Bowen Family Systems work are to A
lower anxiety and emotional reactivity and
increase differentiation (Bowen 1976).
Theoretical Framework for the AFT Pitta added concepts and interventions from
Model Cognitive Behavioral Therapy, including cogni-
tive relabeling, assertiveness training, relaxation
Four major models have been identified within therapy, role-play and modeling, behavioral par-
the field of integration: technical, theoretical, ent training, contingency contracts, reinforce-
common factors, and assimilative integration ment, punishment, and mindfulness to integrate
(Norcross and Goldfried 2005). Technical integra- with the home theory. Additionally, AFT exam-
tion uses a systemic reasoning process and inte- ines psychodynamic defenses such as repetition
grates techniques from different approaches to compulsion, denial, doing and undoing, repres-
meet the needs of the client to attain growth sion, distortion, splitting, and projection and
and change. Theoretical integration looks at projective identification are also integrated.
how different models can be integrated to form a Gottman’s Sound House Theory is utilized within
model of treatment that is more powerful than this model (Gottman 1999). Lastly, other systemic
either model separately. Common factors look at theories, concepts, and interventions such as
how effective treatments result in positive change re-parenting parents, drawing boundaries, and
processes that are not specific to any theory or exposing family secrets are also integrated with
model, while also measuring the alliance between the home theory.
client(s) and therapist. These factors include: the Included in the AFT model (Pitta 2014) is a
client viewing the therapist as someone who can deep respect for context (age, ethnicity, culture
help; the client(s) being committed and motivated and racial backgrounds, sexual identity and
to do the work of therapy; having hope that their relationship status, socioeconomic status, life
realistic expectations can be reached (Davis et al. stage, life cycle, resilience, attachment, emo-
2012). Finally, Assimilative Integration names tional regulation, optimism, chronic illness,
a home theory as the main theory and then inte- religion, spiritual affiliation, and spiritual
grates concepts and interventions from other the- beliefs). Levels of resistance are determined
ories to support the goals of the home theory through the use of a resistance questionnaire
and the goals set out by therapist and clients (Pitta 2014, p. 293).
for the course of their treatment (Messer 2015). Building on a genogram (McGoldrick et al.
Bowen Family Systems Therapy is a theoreti- 2008) assembled in the initial sessions, the thera-
cal framework that looks at generational patterns, pist is able to formulate a case conceptualization
including transmission processes, that addresses that holds an important key to help clients and
why a client may be acting in a certain way. Often, therapist to form their goals of treatment. In
they are repeating the patterns of previous gener- Solving Modern Family Dilemmas: An Assimila-
ations. It also looks at triangulation within a sys- tive Family Therapy Model (Pitta 2014), a case
tem and addresses how a person can get stuck conceptualization questionnaire (p. 295) is pre-
within the family processes and not be able to sented that enables therapists to create their own
further differentiate. This therapy also defines conceptualizations about the cases they are
concepts such as cutoffs, intergenerational trans- treating. Assimilative models, and the AFT
mission processes, triangulation, fusion, differen- model in particular, are generic models; therapists
tiation, pursuit-distance patterns, coaching, and can create their own AFT model by identifying
how these concepts defines and help change their systemic model as a home theory and then
thoughts, behaviors, and feelings of individuals integrating concepts and interventions from other
and family functioning. In addition to identifying theories.
152 Assimilative Family Therapy
Populations in Focus learn further about the patterns of functioning

within and between the generations that might
The AFT model can be applied to couples, fami- be contributing the presenting dilemmas. As the
lies, and individuals, because it uses Bowen Fam- therapist conducts the first few sessions, she is
ily Systems Therapy, a systemic theory, as the getting the necessary information to create a case
home theory. This theory has been applied to all conceptualization with the help of the family,
populations throughout the life cycle. Its main where goals are identified and therapist presents
goals of lowering anxiety, regulating emotions, ways to solve presenting dilemmas. This gives
and helping individuals differentiate can apply to the family members a sense of control and under-
all systems. standing about the process of treatment and
offers them an active role in creating their ther-
apy to help them resolve issues. The major goals
Strategies Used in the Model of the home theory are always kept in mind when
setting goals and creating a treatment plan. Treat-
The process for the model is as follows: Before ment plans can change as clients make changes in
beginning treatment, each family member fills contexts, goals, and extra-therapeutic influences.
out a contextual questionnaire to offer the Important to note is that therapist takes tempera-
treating therapist essential information about ture checks (Pitta 2014) during sessions asking
their specific contexts. From this, the therapist clients such questions as: Do they feel comfort-
draws a contextual diagram that indicates the able with therapist; do they feel their goals for the
contexts that this family lives within. This offers session are being addressed; Is there anything
the therapist a photo of who the family members else that needs to be addressed before the session
are in relation to their ages, culture, ethnicity, and ends that helps with ensuring the development
racial backgrounds, sexual identity, marital sta- and maintenance of the alliance between clients
tus, life stage and life cycle, socioeconomic sta- and therapist.
tus, levels of resilience, attachment and
emotional regulation, optimism, chronic ill-
nesses, religion, spiritual affiliation, and spiritual Research About the Model
beliefs. Second, the therapist has the clients fill
out a resistance questionnaire that the author Integrative approaches have found to be effective
created (Pitta 2014) based on the work of Beutler when looking at them through a common factor
and Harwood (2002). Through the resistance lens, which consider therapy to be most effective
questionnaire, the therapist can determine if cli- when clients feel comfortable and allied with the
ents are demonstrating low or high levels of therapist, and thus also hopeful that positive
resistance. Those with low levels can be change can take place (Davis et al. 2012). Further,
approached by the therapist in a more research shows that any one method of treatment
direct manner while those who presented as is far surpassed by using the lens of common
more resistant, the therapist will need to factors with an integrative perspective (Wampold
approach in a less directive manner and using and Imel 2015). AFT integrates cognitive behav-
questions rather than statements as a means to ioral, psychodynamic concepts, and interventions
ascertain information. Third, the therapist meets and communications interventions derived from
with the individual, couple, and/or family and their respective theories. These approaches have
ascertains why they are seeking treatment. been shown to be effective treatments through a
Fourth, the therapist builds an alliance while number of primary and meta-analytic studies
meeting with members of family to build a strong (Babcock et al. 2013; Butler et al. 2006; Shedler
bond and provide a safe environment to promote 2010). AFT is a model that clearly delineates steps
growth and change. Fifth, as the therapist meets that the therapist adheres to, promoting more
with the family, she is constructing a genogram to effective treatments (Datchi and Sexton 2016).
Assimilative Family Therapy 153
Case Application communication so they could learn to demon-

strate how they appreciated each other and
A mother, father, and their teenage daughter pre- express their own feelings, (3) differentiate them- A
sented in therapy because the daughter was being selves from the patterns of their families of origin
very oppositional at home, despite being an to become a true self by identifying their “I”
A-student with a flourishing social life. She was positions on matters within themselves and
particularly disrespectful towards her mother and between themselves, (4) remove their daughter
very demanding of her father for attention and from the triangle that was created to keep their
material things. After noticing how both the father marriage together and to allow her to differentiate
and daughter expressed resistance towards ther- her position as a daughter to both parents and as an
apy, the therapist began focusing not only on the individual, and (5) lower their mutual and indi-
issues with the daughter but in what might be vidual levels of anxiety and mutual reactivity so
causing those issues from a larger systemic per- the couple could learn how to interact in a more
spective. The therapist discovered the parents’ effective, gentler manner. The couple met with the
marriage was fraught with tension because they therapist for a total of 18 sessions.
were repeating the patterns they had witnessed in During the third session, the therapist offered
their own parents’ relationships. The couple’s the family her conceptualization of how she
issues stemmed from around the time they had envisioned the dilemmas they presented and
begun having children. When the wife began then thanked the daughter for acting out suffi-
dividing her attention among the children and ciently to get the parents to look at their rela-
her husband, the husband began to grow angry tionship. The teen did not want to be in therapy
and distant. To further complicate matters, the as she clearly stated in the sessions. She said, “I
wife had become obese as a result of using food don’t want you to change the way my family
as an outlet for her marital anxiety, while her functions. I like it just the way it is”. In the
husband smoked cigarettes and pot as a means middle of the third session, the therapist joined
of coping. the teen and said that the therapist would work
The therapist created a case conceptualization with the parents and she was free for the time
to aid in formulating her treatment plan for this being to not be part of the sessions and asked the
case (Pitta 2014). It appeared that disappointment, teen to please wait in the waiting room. The teen
rage, and anger described the relationship that was stunned and left the room. This was the first
the husband and wife had created with each attempt on the part of the treatment to create a
other. Family patterns that were learned in their boundary that focused on the couple’s function-
families of origin were repeated in their relation- ing and to put power back to parents. The ther-
ship as a couple and in their nuclear family. Their apist identified for the parents that they allowed
daughter had learned their patterns and introjected the teen to run the family since their behaviors
aspects of their personalities and patterns and were so conflictual and non-connected and they
acted it out within her personal life and within did not take charge of the family functioning We
the nuclear family. If the couple would agree to explored how on some unconscious level the
work on changing their thoughts, feelings and teen was trying to make order in her life, but
behaviors towards each other, it was possible her adjustments in the home were not func-
that their daughter would see the change and tional, but due to her inner strengths, she
more than likely, also change. They needed to excelled in school and with friends.
work on understanding their mutual responsibility The therapist worked with the couple on their
for the dysfunction as well as to appreciate what anger revolving around their sense of mutual
was functional in themselves and their relation- abandonment of each other upon the birth of
ship. They needed to: (1) build new behaviors and their child. They worked on learning to express
interactions that could overcome the negative their feelings that they fought about and distanced
interactions of the past, (2) work on their from. We worked on each taking responsibility for
154 Athenian Institute of Anthropos, The
their behaviors and feelings. They also were Datchi, C., & Sexton, T. L. (2016). Integrating research and
encouraged to identify the dream behind their practice through intervention science: New develop-
ments in family therapy research. In T. L. Sexton &
selfish and childlike behaviors. They then were J. Lebow (Eds.), Handbook of family therapy
enabled to mourn and grieve the loss of their (pp. 434–453). New York: Routledge/Taylor & Francis
childlike fantasies. Group.
We also explored how their behaviors were a Davis, S. D., Lebow, J. L., & Sprenkle, D. H. (2012).
Common factors of change in couple therapy. Behavior
repetition of their same sex parent in their family Therapy, 43(1), 36–48.
of origin and how each needed to differentiate to Gottman, J. (1999). The marriage clinic. New York: W. W.
become their own person. The therapist utilized Norton.
mindfulness techniques to enable them to relax McGoldrick, M., Gerson, R., & Petry, S. (2008).
Genograms: Assessment and intervention (3rd ed.).
and become more cognizant of their behaviors. New York: W. W. Norton.
With learning how to communicate more appro- Messer, S. B. (2015). In E. Neukrug (Ed.), The Sage
priately and developing a more unified stance, the encyclopedia of theory in counseling and psychother-
couple experienced a reduction in their anxiety apy (Vol. 1, pp. 63–66). Thousand Oaks: Sage.
Norcross, J. C., & Goldfried, M. (2005). Handbook of
and became more emotionally regulated and dif- psychotherapy integration (2nd ed.). New York: Basic
ferentiated offering each other connection and Books.
their daughter a different form of interaction Pitta, P. (2005). Integrative healing couple’s therapy:
with boundaries, limits and love. These interac- A search for the self and each other. In Haraway (Ed.),
Handbook of couples therapy (pp. 211–227).
tions created the family unit with the parents in New York: Wiley.
charge of the family and the daughter allowed to Pitta, P. (2014). Solving modern family dilemmas:
be a teenage who did not have to try and control An assimilative therapy model. New York: Routledge.
the family unit. Shedler, J. (2010). The efficacy of psychodynamic psycho-
therapy. American Psychologist, 65(2), 98–109.
Wampold, B. E., & Imel, Z. E. (2015). The great psycho-
Cross-References therapy debate: The evidence for what makes psycho-
therapy work. New York: Routledge.
▶ Assimilation in Integrative Couple and Family

Therapy
▶ Coaching in Bowen Family Therapy
▶ Family Therapy
Athenian Institute of
▶ Triangles in Bowen Family Therapy
Anthropos, The
Mina Polemi-Todoulou
Scientific Council Member, The Athenian
References
Institute of Anthropos, Athens, Greece
Babcock, J., Gottman, J., Ryan, K., & Gottman, J. (2013).
A component analysis of a brief psychoeducational
couple’s workshop: One year follow-up results. Νame
Beutler, L. E., & Harwood, T. M. (2002). What is and can be
attributed to the therapeutic relationship? Journal The Athenian Institute of Anthropos (AIA).
of Contemporary Psychotherapy, 32(1), 25–33.
Bowen, M. (1976). Theory in the practice of psychother-
apy. In P. J. Guerin (Ed.), Family therapy: Theory and
Introduction
practice (pp. 42–90). New York: Gardner Press.
Brabender, V., & Fallon, A. (2009). Contextual variables
requiring further examination. Washington, DC: The Athenian Institute of Anthropos (AIA) –
American Psychological Association. the first center for family therapy, group therapy,
Butler, A., Chapman, J., Forman, E., & Beck, A. (2006).
community interventions, and systemic practice
The empirical status of cognitive behavioral therapy:
A review of meta-analyses. Clinical Psychology in Europe – was founded in 1963 in Greece, by
Review, 26, 17–31. George and Vasso Vassiliou, as a center for
Athenian Institute of Anthropos, The 155
training, therapy, prevention, consultation, (b) acknowledging the coevolution among the
research, and development of systemic appli- interrelated systems as a primary factor in
cations to the systems of Anthropos (meaning therapy and learning, (c) fostering the devel- A
the whole human being, in Greek). opment of dialogue within and among mem-
The AIA logo, with the image of a lantern, bers holding different roles or points of view
accompanied by the ancient Greek philosopher within or around each system, and
Diogenes’ quote “For Anthropos I search,” (d) appreciatively reflecting the unique contri-
symbolizes the vision of its founders for a bution of each different viewpoint.
world where cooperation and humanness The development of this approach and
would prevail over antagonism and intervention model constitutes a primary con-
exploitation. tribution of the AIA to the therapeutic commu-
The ΑΙΑ has been functioning for over nity. Along with this are two related techniques
50 years as a collective professional coevolving introduced by the Vassilious in the late 1950s and
process, as an international interdisciplinary extensively applied for five decades by the AIA
meeting point and incubator of theory devel- network of professionals in a wide range of con-
opment, and as a base for launching collabora- texts, populations, and enriched variations: the
tive community-oriented projects. Synallactic (meaning changing together in
Greek) Collective Image Technique (SCIT)
that utilizes the group or family members’ inter-
The Scope and Character action on a common stimulus and the Sequence
Analysis (SA) of their contributions that provides
Developing an Approach the group or family theme as the frame for therapy
Since the beginning, the ongoing contact with (Vassiliou 1968).
innovative movements across the world kept the
AIA community constantly fertilized with new Developing the Activities: Rationale and
ideas. Associates getting their academic training Target Groups
abroad brought back influences and acquaintances The AIA therapeutic and health promoting inter-
from different schools of thought. A strong feeling ventions and training programs have been devel-
was generated throughout that of being part of an oping around the following axes:
open process contributing to the creation of a new
field. 1. Activities encompass the whole family life
The basic theoretical frame for AIA’s work is cycle: children, adolescents, young adults,
the “systemic-dialectic multilevel-multifocal couples, parents, and families from pregnancy
approach”: Anthropos is conceptualized as a to the “empty nest.” Activities address the
bio-psycho-social-economic-cultural, open sys- needs of the particular developmental
tem, spiraling toward more organized com- phase (e.g., for teens and young adults, pro-
plexity through its interaction with other grams aim at autopoiesis (i.e., self-forming)
systems in the wider context. and creating viable relationships while for
The model addresses the self-leading aspects older adults at the road to maturity).They are
of the whole system, as it emerges through the carried out separately or in combination (e.g.,
interconnectedness, transaction, and coevolu- parallel as well as mixed parent-children
tion of processes at different levels of groups or daughters-mothers-grandmothers).
complexity – the individual, the family, the 2. A primary goal has been the sensitization of
group, the community, and the culture. These a wide spectrum of professionals – related
levels are utilized, in varied ways, in all interven- directly or indirectly with family functioning –
tions, training, and family or group therapy. in the systemic approach and applications
Priority is given to (a) forming and keeping for the promotion of functioning of the
throughout a secure relational context, Anthropos systems. Included are all mental
health practitioners, child carers and educators, Training Program on Developing Human
as well as family physicians, human resource Relations in the School Community,
managers, organizational consultants, cultural addressed to about 16,000 school teachers
mediators or animators, etc. in various parts of Greece (Polemi-
3. The AIA activities are largely carried out- Todoulou 2010).
side its murals, within the community, in 5. Interprofessional consultation programs are
collaboration with a wide range of institu- regularly offered for the interdisciplinary
tions relevant to family, welfare, mental health, teams of institutions, such as the drug preven-
and the challenges arising from crisis: public tion community centers in various parts of
and private schools, childcare centers, welfare Greece, family therapy or child-guidance
agencies, universities, hospital clinics, mental clinics, rural community psychiatry programs,
health and child psychiatry institutions, com- substance addiction institutions, mental health
munity centers, drug addiction institutions, res- centers for immigrants and refugees, welfare
cue teams, institutions for children from programs, and schools, in response to their
broken homes, professional associations, own requests for help with bullying, substance
municipal agencies, and Ministries abuse, or relationship difficulties, often leading
(Education, Health, Culture, or Work) – the to whole school community interventions uti-
list includes almost every section of the socie- lizing the systemic-dialectic multilevel-
tal structure. The collaboration encompasses multifocal methodology.
staff training, consultation, supervision, and 6. Interventions are tailor-made and interac-
relevant research. tional: Rather than following a predetermined
4. Large-scale projects have frequently been plan, an attempt is made to acknowledge the
the product of these collaborations. For needs of the system as they emerge from the
example: interactions unfolding during the course of
(a) In the early days, in collaboration with the intervention and to redesign step by step
University of Illinois, a large-scale research accordingly. Therefore, the outline of the inter-
was carried out comparing subjective cul- vention course, rather than existing before-
ture data from different countries hand, usually emerges as the process develops.
(Vassiliou and Vassiliou 1973). 7. Therapy utilizes a combination of different
(b) In the mid-1990s, responding to an invita- contexts: In order to effect a more holistic
tion by the Organization Against Drugs approach to a particular family case, for example,
(OKANA), the AIA designed and materi- the therapists may flexibly combine sessions
alized a large-scale community program with the family, group therapy for one member
Preparing Anthropos for the 2000 in six over a period of time, couples group, children’s
municipalities (population ranging from group, genogram exploration, and family recon-
28,000 to 85,000). The main goal was to struction, even experiential training addressing
introduce systemic training for parents, role or developmental phase challenges. Like-
teachers, adolescents, young couples, and wise, professionals are encouraged to under-
professionals working in the community, stand in depth more than one system – not
sensitizing them to the changing social only the family but the therapeutic process in a
realities and the new required skills, thus group, the individual’s inner dialogue, the large
creating the ground work to be further group process dynamics, and at least one broader
developed by the newly created public Pre- system, e.g., a school community or a large
vention Centers (Gournas et al. 1995). organization, in order to better understand com-
(c) In 2011, in the context of the Major Foun- plex systems.
dation Program for Educators of the Min- 8. As a living system, the AIA is actively
istry of Education, AIA Associates responding to the changes happening in the
designed and implemented an Experiential wider context, and the prioritization of its
Athenian Institute of Anthropos, The 157
activities reflects this. For example, in recent B. Intermediate cycle: Systemic-dialectic epis-
years, the activities addressed to adolescents temology and personal professional
need to take into account the reduced opportu- development A
nities for autonomous face-to-face peer- C. Advanced in-depth training cycle: Family
grouping socialization (Polychronis 2018). therapy, group therapy, multilevel group pro-
The challenges arising from the widespread cess interventions in broader systems
socioeconomic, political, and cultural crisis D. Supervised practice: On family and group
have urged the AIA associates to initiate or therapy and systemic interventions in and out-
participate in programs addressing refugees, side the institute
immigrants, or families with reduced financial
viability, as well as school – mental health – or Examples of other seminars offered: Systemic
social welfare institutions that need to accom- diagnostic methodology, children’s animation
modate members from these populations. New programs, sequence analysis, systemic applica-
elaboration of the approach and the techniques tions in education, professional role
is necessitated to handle new emerging roles as dynamics, etc.
the cultural mediators or the much needed All training is experiential, actualizing the per-
cooperation among the many institutions sonal experiences of the participants in the context
(governmental/nongovernmental/private, of a developing group process (Polychroni
local/international) that address refugees with et al. 2008).
different approaches and methods. The course of training for each participant is
9. The AIA has developed its own guiding value personalized in collaboration with the Scientific
system as any organization in the course of its Consultative Committee, and his/her unique pro-
history: commitment to teamwork, meeting the fessional profile is encouraged, along with coop-
challenges of cooperative over antagonistic ori- erative peer relations, leading to lifelong
entation, utilizing differences within or among collaborations.
groups through open dialogue, acknowledging Apart from the formal training, the trainee
what is valuable in every member’s contribution, commits to a personal therapeutic process, includ-
seeking meaning in life though responsible and ing didactic group therapy and family of origin
creative community membership, responding to exploration and reconstruction. Therapy for the
changes affecting society, and taking leadership therapist, including family members, is
for community welfare. The G. Vassiliou’s motto encouraged.
“Autonomy through and for With all the above, skills in both autonomy
Interdependence” and the AIA’s logo “For and interdependence and awareness of both self
Anthropos I search” reflect these values. and context are targeted.
Yearly, on the average, about 150 professionals
participate in the AIA seminars.
Training Program
The AIA basic training in family and group ther- Impact

apy and systemic thinking and applications
involves four cycles. The first two are offered to The AIA since its inception has had a leading
a wider body of professionals; for therapists and presence in the systemic field of family and
system process specialists, the completion of all group therapy and community interventions
four is required: for the promotion of mental health in Greece and
abroad.
A. Introductory cycle: Sensitization to the It has extensively contributed to the develop-
systemic-dialectic multilevel-multifocal ment of systemic theory and applications in
approach therapy, prevention, and training. Over
300 texts by AIA Associates are presented at the Family and Systemic Therapy), and
AIA Communication Series: chapters in books, HELASYTH (Hellenic Association for Sys-
articles in journals, technical reports and pre- temic Therapy).
sented papers, books, and research monographs. They have been actively involved in various
It has provided the context for pioneer dis- policy-making committees on social welfare,
cussions on family therapy and systemic ideas mental health, educational issues, and profes-
through the Delphic Symposia it organized, sional certification, or in task forces preparing
along with a wide range of international meetings reforms relevant to family functioning (e.g.,
and a rich schedule of visiting and hosting preschool childcare reform or the process of dein-
leaders in the field up to current times: Virginia stitutionalization in the 1990s), leaving an impact
Satir, Paul Watzlawick, Salvador Minuchin, on important institutions.
Yvonne Agazarian, Mony Elkaim, Karl Tomm, Locally and internationally, through an exten-
Kenneth Gergen, Carlos Sluzki, Luigi Boscolo, sive involvement in collaborative projects and
Maurizio Andolfi, Luigi Onnis, Peter Lang, scientific meetings, the AIA has contributed to
Elspeth McAdam, and Sue Johnson. an ever-growing network of systemic profes-
The AIA Newsletter was sent quarterly till the sionals working and cooperating in a wide spec-
mid-1980s to an international network of about trum of different fields and sectors of the society,
600 professionals in 55 countries (The AIA News- private and public, addressing different
letters: 1963–1988). populations and challenges in a turbulent society
AIA Associates have been serving in the edi- that requires more than ever a holistic, coopera-
torial board of many journals and book series. tive, process-oriented, dynamic approach. The
Since 2008, the AIA is a joint publisher of Human large community of systemic therapists that prac-
Systems, the journal of systemic consultation and tice today in various parts of Greece to a large
management, in collaboration with Leeds Family extent see their roots in the pioneering work of the
Therapy and Research Centre of the UK AIA and its founders.
(K. Polychroni and P. Stratton (Eds)). The AIA has been awarded by the World Asso-
Over its 55-year course, more than 500 mental ciation of Social Psychiatry (WASP) in 1974, in
health professionals have completed the Insti- Athens, for Organizing a Congress Pioneering
tute’s training cycle, who in turn have expanded Structure Content and Spiritwise and by the Med-
the field, founding new systemic therapy and iterranean Sociopsychiatric Association
training institutions, disseminating systemic (MESPA) in 1980 in Dubrovnic for its Outstand-
ideas, and widening the spectrum of applications. ing Contributions to the Prevention of
Many leaders of the systemic and family therapy Malfunctioning and Promotion of Functioning of
institutions in Greece and elsewhere, as well as the Anthropos Systems in the Mediterranean
university professors, have been trained or asso- Region and the World Over.
ciated with the AIA and continue their
collaboration.
The AIA Associates have played a leading Operation
role in the formation of the professional scene
of family therapy and systemic practice by The AIA functions in the frame of the profes-
participating as founders, chairs, and board sional, nonprofit, self-financed Society for the
members of many Greek, European, and Inter- Advancement of Human Relations Research
national associations, e.g., EFTA (European (SAHRR), with the goal of catalyzing coopera-
Family Therapy Association), WASP (World tion in the sciences of Anthropos, both nation-
Association of Social Psychiatry), MESPA ally and transnationally. The interdisciplinary
(Mediterranean Sociopsychiatric Association), body of SAHRR includes prominent figures in
NORG (National Organization for Psychother- the society, who support the shared AIA vision.
apy in Greece), ETHOS (Hellenic Federation of For many years it has been chaired by Dr
Atkinson, Brent 159
C. Spinellis, Professor Emeritus of Sociology at Polychronis, P. (2018). Depriving adolescence from its
Athens University. growing processes. Metalogos, 33, Thessaloniki.
(In process).
The AIA has been directed for 38 years by the The Athenian Institute of Anthropos. (1963). The AIA A
Vassilious couple; since 2001 it is being operated by Newsletters: 1963–1988. Athens: AIA.
a team of long-standing Associates, consisting of Vassiliou, G. (1968). A transactional approach to mental
Petros Polychronis, Child Psychiatrist, AIA Direc- health: An experiment in greece. In B. Riess (Ed.), New
directions in mental health. New York: Grune & Stratton.
tor, and the AIA Scientific Consultative Commit- Vassiliou, G., & Vassiliou, V. (1973). Subjective culture
tee Members: Giorgos Gournas, Ph.D., and psychotherapy. American Journal of Psychother-
Psychiatrist; Mina Polemi-Todoulou, Ph.D., Psy- apy, 27(1), 42–51.
chologist; Kyriaki Protopsalti-Polychroni, M.A.,
Psychologist; and Dionyssis Sakkas, Ph.D., Psychi-
atrist, all psychotherapists, members of the
European Family Therapy Association, certified by Atkinson, Brent
the European Association of Psychotherapy and
The American Group Psychotherapy Association. Jason Nicol
Currently, about 20 professionals are regularly The Couples Research Institute, Geneva, IL, USA
involved as AIA trainers, therapists, and supervi-
sors, while the wider AIA project-supporting net-
work includes more than 80 AIA-trained associates. Name
The AIA is an accredited member of the
European Family Therapy Association-Training Brent J. Atkinson, Ph.D. (1956–).
Institutes’ Chamber (EFTA-TIC) of the
European Association for Psychotherapy (EAP)
and of the National Organization for Psychother- Introduction
apy of Greece (NOPG).
Brent Atkinson is the principle architect of the
Pragmatic/Experiential Method for Improving
Cross-References Relationships (also called the PEX Method), an
approach that translates findings from neurobiol-
▶ European Family Therapy Association
ogy and the science of intimate relationships into
▶ Human Systems (Journal)
practical methods for improving relationships.
▶ Systemic-Dialectic Multilevel-Multifocal
His pioneering work is detailed in the books Emo-
Approach
tional Intelligence in Couples Therapy and Devel-
▶ Vassiliou, George and Vasso
oping Habits for Relationship Success, has
appeared in leading professional journals, and
has been featured in outlets such as the Oprah
References Magazine, the Washington Post, and the Psycho-
Gournas, G., Polemi-Todoulou, M., Polychronis, P., &
therapy Networker. He is known for his ability to
Vassiliou, V. (1995). Educating the anthropos of present complex scientific ideas in compelling
2000: A systemic-dialectic multilevel-multifocal com- and easy-to-understand ways.
munity intervention. . A five-year program subsidized
by the organization against drugs (OKANA). Athens:
The Athenian Institute of Anthropos.
Polemi-Todoulou, M. (2010). Systemic thinking as a key to Career
redesigning training, Metalogos, 18, Thessaloniki.
Polychroni, K., Gournas, G., & Sakkas, D. (2008). Actu- After completing a Ph.D. in Marriage and Family
alizing inner voices and the group process: Experiential
Therapy from Texas Tech University in 1985,
systemic training in personal development. Human
Systems: The Journal of Therapy Consultation and Atkinson accepted a faculty position in Marriage
Training, 19(1-3), 26–43. and Family Therapy at Northern Illinois
160 Atkinson, Brent
University (NIU) where he spent the next deliberately restimulating and interrupting old
27 years. He served as Director of the Marriage emotional reactions through visualization,
and Family Therapy Program, guiding it through relaxation, and mental rehearsal. Like athletes
successful AAMFT accreditation renewals in and musicians who learn new movements
1995 and 2002. He also served as Chair of the and skills so thoroughly that they become
State of Illinois Marriage and Family Therapy instinctive, Atkinson asks partners to practice
Licensing and Disciplinary Board, and President new mental and physical reactions frequent-
of the Illinois Association for Marriage and Fam- ly enough so that they became part of their
ily Therapy. In 1999, he cofounded the Couples mental muscle memory and begin happening
Clinic and Research Institute where, drawing on with little or no conscious effort.
research methods detailed earlier in his career 2. Practices that increase naturally-occurring
(Atkinson et al. 1991), he began assembling the feelings of love and connection. Atkinson
components of the PEX Method. Atkinson is cur- has been particularly interested in studies
rently Professor Emeritus at NIU and Director of suggesting that the brain can be primed so that
Post-Graduate Training at the Couples Research it naturally generates more of the feelings
Institute. needed for relationships to thrive. He identified
the active ingredient across studies of successful
priming as sustained inviting – a process
Contributions to Profession in which subjects invite specific feelings while
remembering times when the feelings were pre-
Atkinson’s methods for rewiring automatic emo- sent or imagining situations where they would
tional processes in the brain are widely recognized. likely have the feelings. Studies suggest that the
Early in his career, Atkinson noted that the skills process of sustained inviting stimulates and
needed to successfully navigate relationships can be strengthens areas of the brain associated with
difficult to execute because people may experience intimacy-related feelings, increasing the degree
1) automatic emotional tendencies or inclinations to which they emerge spontaneously in the
that take them in the wrong direction, and 2) a course of everyday life. Atkinson developed
paucity of naturally occurring feelings that enable specific practice protocols that are used by part-
attachment and connection. The automatic patterns ners to prime their brains for more empathy,
of emotional activation and suppression that enable attentiveness, warmth, fondness, playfulness,
successful relationships cannot be generated on and desire for connection.
demand, but rather develop naturally over time in
children who have well-attuned and non-anxious
caregivers. But Atkinson saw evidence emerging
Cross-References
from neuroscience suggesting that with the right
kind of practice, even people who don’t have the
▶ Attachment Theory
benefit of well-attuned caregivers can still develop
▶ Gottman, John
automatic internal tendencies and inclinations that
▶ Neurobiology in Couples and Families
facilitate relational competence. He incorporated
several empirically-verified practices into his treat-
ment method for couples and developed further
References
practices of two different varieties:
Atkinson, B. (2005). Emotional intelligence in couples
1. Practices that strengthen mood-regulation therapy: Advances from neurobiology and the science
and response-flexibility. Atkinson developed of intimate relationships. New York: W.W. Norton.
Atkinson, B. (2013). Mindfulness training and the cultiva-
exercises that rewire the way people automat-
tion of secure, satisfying couple relationships. Couple
ically react in emotionally charged situa- and Family Psychology: Research and Practice, 2(2),
tions. These exercises include methods for 73–94.
Attachment Disorders in Couple and Family Therapy 161
Atkinson, B. (2016). Developing habits for relationship from severe and persistent neglect, and caregivers
success (version 4.6). Geneva, IL: The Couples often experience intense challenges with raising
Research Institute.
Atkinson, B., Heath, A., & Chenail, R. (1991). Qualitative these children. A
research and the legitimization of knowledge. Journal
of Marital and Family Therapy, 17(2), 161–166.
Atkinson, B., Atkinson, L., Kutz, P., Lata, J., Szekely, J., Theoretical Context for Concept
Weiss, P., & Wittmann Lata, K. (2005). Rewiring
neural states in couples therapy: Advances from affec-
tive neuroscience. Journal of Systemic Therapies, Attachment theory posits that children are biolog-
24(3), 3–13. ically wired to form close, long-term, and depen-
dent relationship with their caregivers from
infancy. Four infant styles of attachment (secure,
avoidant, resistant-ambivalent, and disorganized-
Attachment Disorders in disoriented) has been identified. Infants that have
Couple and Family Therapy a secure bond with their caregiver experience
distress when the caregiver leaves and seek
Quintin Hunt, Maliha Ibrahim and reunion upon the caregivers return. Infants with
Guy S. Diamond an insecure bond either do not attempt reunion
Center for Family Intervention, Drexel with caregiver upon return or do so ineffectively.
University, Philadelphia, PA, USA While insecure attachment styles are related to
Reactive Attachment Disorder (RAD) and
Disinhibited Social Engagement Disorder
Name of Concept (DSED), the relationship is not causal and the
appropriateness of classifying these disorders as
Attachment Disorders in Couple and Family attachment disorders is increasingly questioned.
Therapy. There are several major questions that should
be considered with the RAD or DSED diagnoses.
First, given that RAD and DSED are almost
Introduction entirely seen with institutionalized children, we
must question if the disorders can be generalized
Attachment disorders have several meanings in to other developmental experiences. The lack of
the field of couple and family therapy. The first information about their prevalence also severely
refers to the relatively rare, diagnosable disorders limits the generalizability of what we do know
of Reactive Attachment Disorder (RAD) and about the disorders. Second, although RAD and
Disinhibited Social Engagement Disorder DSED are considered relational disorders, they
(DSED) which are seen exclusively in maltreated are primarily defined by the individual symptoms
children. The second refers to commonly endur- of a child (attachment) rather than the relational
ing attachment styles of parent-child interactions dynamics at play. Namely, the role of caregivers
that were first identified by John Bowlby (1969) failing to bond with RAD/DSED children is
and Ainsworth et al. (1978) for children and later essential to the development of the disorders and
expanded to adults (Hazan and Shaver 1987). The is absent from literature on the disorders. This
third meaning of “attachment disorder” is a leaves the main conceptualization of the disorders
pseudo-diagnostic term with criteria ambiguous as the child’s problematic behaviors as the prob-
enough to include most developmentally appro- lem rather than the systemic pattern of neglect in
priate child behavior such as lying, persistent which the child was raised. Although there is
questions, or triangulation of caregivers. This question about the caregivers’ role in the devel-
entry focuses on RAD and DSED. Both RAD opment of the disorder that may never be
and DSED have particular relevance to field of answered due to ethical limitations, some care-
Couple and Family Therapy as the disorders result givers may be less likely to bond with children
162 Attachment Disorders in Couple and Family Therapy
that are less likely to seek comfort. Third, attach- partings with attachment figures. Essentially, this
ment styles and several of integral aspects of manifests through children rarely turning to an
attachment theory, like internal working models, attachment figure for comfort. These children
are missing from the discussion of RAD and may approach others without making eye contact
DSED. In fact, many have suggested that an or stare into the distance while being held or
attachment framework may not be appropriate embraced. RAD children respond to social and
for these disorders (Allen 2016; Lyons-Ruth parenting cues inconsistently – sometimes
2015). Perhaps most importantly, the disconnect appearing welcoming or accepting and other
between attachment theory and RAD/DSED is times showing avoidance or resistance. When
confusing the public and may encourage care- experiencing their own distress or in proximity
givers that are have exhausted all other options of others in distress, RAD children are typically
to consider “attachment therapies” that include unresponsive, withdraw entirely, or sometimes
dangerous and controversial tactics that have no become physically aggressive. They are noted
established evidence of efficacy. These “attach- for displaying hypervigilance and fearfulness.
ment therapies” are typically marketed as treat- For complete diagnostic criteria and further dis-
ments designed for attachment disorders. cussion of differential diagnoses (autism spectrum
disorder, intellectual disability, and depressive
disorders), we recommend consulting the DSM-5;
Description the diagnosis cannot be made before the age of
9 months and should be made with caution after
Reactive Attachment Disorder (RAD) and the age of five.
Disinhibited Social Engagement Disorder The DSED diagnosis was originally a subtype
(DSED) manifest through disturbed and develop- of RAD but is now considered distinct disorder.
mentally inappropriate social behaviors. Children Given that there are differences in how DSED and
that have been severely neglected, maltreated, or RAD symptoms respond to in-home placement
abused are more likely to be diagnosed with RAD after institutionalization, this separation appears
or DSED, but no epidemiological studies have to be appropriate. Children with DSED are seen to
examined their prevalence. Children at risk for have inappropriate or overly familiar relationships
RAD and DSED are those who have been placed with people unknown to the child. This manifests
in foster care or raised in institutions such as through comfortable and intimacy with strangers.
orphanages, hospitals, or long-term care facilities. These children are often overly clingy as infants
The development of these attachment disorders is but become indiscriminately friendly as older
rooted in both biological factors (e.g., tempera- children. Children with DSED are comfortable
ment) and contextual factors (e.g., parent ability to sitting on the laps of strangers and leaving the
bond). A stress-diathesis model may be useful to presence of caregivers with a stranger. They also
understand the development of these disorders. have extreme difficulty in creating close relation-
This model assumes that most people have some ships with peers and commonly have emotional
level of diathesis (predisposition) for any disorder and behavioral disturbances. Many DSED chil-
that is then activated by stress. People with high dren also suffer from cognitive delays and devel-
levels of diathesis require lower levels of stress opmental delays.
but no amount of stress can activate the disorder in Although the prevalence of RAD in the general
people with no amount of diathesis. Given that population is unknown, some literature suggests
even within extremely maltreated populations few that approximately 1 out of every 100 children in
children develop these disorders, it appears be that foster care or other placement outside of a home
some biological factor underlies the disorder. will be diagnosed with RAD (Gleason et al.
Children with RAD demonstrate contradictory 2011); the DSM-5 reports the prevalence of
or ambivalent social responses at reunions or RAD to be about 10% and of DSED to be about
Attachment Disorders in Couple and Family Therapy 163
20% in extremely neglected populations. Though Application of Concept in Couple and

RAD is more likely to develop in cases of mal- Family Therapy
treatment, many children are able to subsequently A
form a stable attachment relationship and only The primary interventions RAD and DSED
40% of children diagnosed with RAD spent time focus on enhancing caregiver sensitivity or find-
in foster homes or orphanages. There is no stan- ing new caregivers when current caregivers are
dard diagnostic protocol for either attachment dis- unable or unwilling to meet the heightened and
orders, though the Disturbances of Attachment intense needs of the child (Bakermans-
Interview has effectively been able to identify Kranenburg et al. 2003). Enhancing caregiver
both RAD and DSED (Smyke and Zeanah sensitivity requires observation of a caregiver
1999). Children typically do not develop attach- providing care for their child to accurately
ment disorders from a mild history of maltreat- assess caregiver sensitivity patterns. The thera-
ment or disrupted attachment although there is peutic target is how the parent and child interact
some connection between mild maltreatment and and specifically, how the caregiver responds to
the RAD/DSED disorders (Lionetti et al. 2015). the child. Much of this work involves
Most of the foundational research on RAD psychoeducation about the development of
and DSED has come from or has been inspired attachment disorders and the child’s inability
by two longitudinal projects which tracked a to just get over it. This involves building a belief
group of institutionalized children in the United within the caregivers that it is their responsibil-
Kingdom and children from Romanian Orphan- ity to help the child learn to be a more functional
ages. Barbara Tizard et al. (1972) followed a and normative adult. This belief fits very well
group of children from the UK who were placed with most family-based interventions that
outside of a home or in an institution. Tizard and believe that the parent/caregiver plays an
colleagues first identified the emotionally with- integral role in the child’s development. The
drawn and socially disinhibited categories that child’s behaviors are not the focus; rather, treat-
have been utilized as bases for RAD and DSED, ment focuses on teaching the parent to better
respectively. The other project involved the understand and be able to respond to the child’s
study of Romanian orphans in the 1990s needs.
(O’Connor et al. 2000). O’Connor and col- Interventions also aim to help parents and care-
leagues found that some DSED behaviors are givers develop greater empathy for their child
likely to persist in-home placement. Fortu- through helping caregivers better understand
nately, there has been a sizable increase in their own attachment history. When parents are
research to attachment disorders in the last able to increase their understanding and empathy
decade (cf. Zeanah and Gleason 2015). Perhaps of their child, they are then able to comfort and
the most hopeful and striking finding from provide care more effectively. Because of the
recent research is that children placed into severity and persistence of attachment disorders,
homes, and receive care adequate to their when efforts to increase the caregiver’s capacity to
needs show significant (or complete) remission be sensitive to the child’s needs and behaviors is
of their RAD/DSED symptoms in most cases. not possible – due to unwillingness or inability of
However, it appears that DSED symptoms are the caregiver – it may be appropriate to work on
more persistent post in-home-placement than finding a new caregiver that is capable of the
RAD symptoms; the most important factor pre- increased level of sensitivity needed. Though
dicting reduction of symptoms appears to be the there is no model that specifically addresses
amount of time the child has spent in an institu- RAD and DSED attachment disorders, both
tion (Guyon-Harris et al. 2018). Specifically, the RAD and DSED appear to be responsive to
less time in an institution, the greater the reduc- enhanced and stable caregiving (cf. Zeanah and
tion in symptoms has been found. Gleason 2015).
164 Attachment Disorders in Couple and Family Therapy
Clinical Example loving a child that may, at times, be challenging.

Perhaps most important is that Maria has a stable
Maria was 5 years old when her foster parents and consistent home to live in – good enough but
sought additional help to understand some of the consistent caregivers are key.
challenges they were facing with Maria. Maria An integral aspect of both these goals
had been severely neglected by her biological involves psychoeducation with the caregivers
parents. She was found alone when she was regarding the DSED diagnosis and some of the
12 months old by her parents’ landlord after a history that Maria, and her sister, has experi-
neighbor reported a noise disturbance and the enced. When the caregivers better understand
parents were not home. This started a process the context in which Maria has lived, they are
several years long of bouncing between systems- more able to forgive the difficulties they are
of-care and short-term placements before she was dealing with currently. Given that many DSED
placed in a more stable foster home with her older children also are developmentally or cogni-
sister. tively delayed, it may be useful help the care-
Maria’s foster parents reported erratic and givers learn how to listen and speak with
unpredictable moods with behaviors that toddlers and young children. This may occur
would escalate quickly from hugging to biting through play-therapy or sandbox treatments
and yelling. According to the foster parents, due to Maria’s age.
Maria had no friends at school. They also Given the increased effort that parenting a
reported frequent physical altercations, lying, DSED child takes, it is likely the caregivers expe-
and a lack of remorse after acting aggressively. rience frustration and may even wonder if they
Most recently, the foster parents reported an should continue to try as foster parents. Empathiz-
incident in which Maria followed an unknown ing with the caregivers about their frustrations will
adult male and tried to get into his car. Many help the caregivers to feel competent and revital-
elements of DSED appear present with Maria, ize their efforts to parent a difficult child. Struc-
particularly the early and sustained neglect, dif- tured sessions in which the therapist helps the
ficulty in mood regulation, and the willingness caregivers to identify and respond to Maria’s
to wander off with an unfamiliar adult. An inte- needs may be useful. Most important is that the
gral aspect that distinguishes DSED from RAD caregivers find the support, the need, and the
is the pattern of overly familiar and inappropri- belief that they themselves are good enough to
ate social behavior with strangers. While provide consistent care.
Maria’s pattern of indiscriminate behavior of Several changes identify when termination of
nonselective attachment behavior is a clear indi- treatment with Maria and family should be con-
cator of DSED, utilizing the Disturbances of sidered: (1) Maria is able to consistently turn to
Attachment Interview (Smyke and Zeanah her caregivers (reunited parents or foster parents)
1999) may be useful during assessment. when she has questions or difficulties, (2) when
Perhaps most important in Maria’s treatment is Maria’s parents (foster or reunited) are able to
the inclusion of the caregiving system (and par- consistently be emotionally available and respond
ents should reunification ever take place). The to Maria’s concerns rather than their own reac-
development of secure attachment can occur in tions to her, and (3) Maria’s caregivers feel revi-
the foster-care family environment but only if the talized and confident in parenting on their own
foster parents also demonstrate more secure and seeking additional help when they need
attachment patterns for Maria. The mains goals it. Though treatment duration may vary between
for treatment are to help Maria’s foster-parents cases, what little outcome data does exist on chil-
(1) learn how to increase their empathy for dren diagnoses with RAD or DSED suggest that
Maria, (2) increase their ability to be emotionally almost all youth that are placed in a home show
available and respond sensitively to Maria, and few differences when compared to non-neglected
(3) to help them feel confident and capable of or institutionalized youth.
Attachment Injury Resolution Model in Emotionally Focused Therapy 165
Cross-References Tizard, B., Cooperman, O., Joseph, A., & Tizard, J. (1972).
Environmental effects on language development:
A study of young children in long-stay residential nurs-
▶ Anxiety Disorders in Couple and Family eries. Child Development, 43, 337–358. https://doi.org/ A
Therapy 10.2307/1127540.
▶ Attachment Theory Zeanah, C. H., & Gleason, M. M. (2015). Annual research
review: Attachment disorders in early childhood –
Clinical presentation, causes, correlates, and treatment.
Journal of Child Psychology and Psychiatry,
56, 207–222. https://doi.org/10.1111/jcpp.12347.
References
Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S.

(1978). Patterns of attachment: A psychological study
of the strange situation. Hillsdale, NJ: Erlbaum.
Attachment Injury Resolution
Allen, B. (2016). A RADical idea: A call to eliminate Model in Emotionally Focused
“attachment disorder” and “attachment therapy” from Therapy
the clinical lexicon. Evidence-Based Practice in Child
and Adolescent Mental Health, 1, 60–71. https://doi.
org/10.1080/23794925.2016.1172945.
Lorrie Brubacher
Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., & University of North Carolina, Greensboro,
Juffer, F. (2003). Less is more: Meta-analyses of sensi- NC, USA
tivity and attachment interventions in early childhood.
Psychological Bulletin, 129, 195–215. https://doi.org/
10.1037/0033-2909.129.2.195.
Bowlby, J. (1969). Attachment and loss: Attachment. Synonyms
Guyon-Harris, K. L., Humphreys, K. L., Fox, N. A., EFT AIRM
Nelson, C. A., & Zeanah, C. H. (2018). Course of
disinhibited social engagement disorder from early
childhood to early adolescence. Journal of the Amer-
ican Academy of Child & Adolescent Psychiatry, 57,
329–335. https://doi.org/10.1016/j.
Introduction
jaac.2018.02.009.
Hazan, C., & Shaver, P. (1987). Romantic love conceptu- Emotionally focused couple therapy (EFT) is an
alized as an attachment process. Journal of Personality empirically validated therapy (Wiebe and Johnson
and Social Psychology, 52, 511–524. https://doi.org/
2016) for increasing relationship satisfaction and
10.1037/0022-3514.52.3.511.
Lionetti, F., Pastore, M., & Barone, L. (2015). Attachment creating secure bonds in distressed couple rela-
in institutionalized children: A review and meta- tionships. As an attachment-based, systemic,
analysis. Child Abuse and Neglect, 42, 135–145. humanistic-experiential therapy, it places emotion
https://doi.org/10.1016/j.chiabu.2015.02.013.
in the forefront as the target and agent of change,
Lyons-Ruth, K. (2015). Should we move away from an
attachment framework for understanding disinhibited making it particularly relevant for repairing inter-
social engagement disorder (DSED)? A commentary personal injuries. Johnson et al. (2001) first pre-
on Zeanah and Gleason. Journal of Child Psychology sented the construct of “attachment injury” to
and Psychiatry, 56, 223–227. https://doi.org/10.1111/
describe a particular type of interpersonal injury
jcpp.12373.
O’Connor, T. G., Rutter, M., & English and Romanian and delineated a model for resolving such injuries.
Adoptees Study Team. (2000). Attachment disorder Johnson developed a model of forgiveness and
behavior following early severe deprivation: Extension resolution to address relationship traumas such as
and longitudinal follow-up. Journal of the American Acad-
infidelity and other moments of betrayal or aban-
emy of Child and Adolescent Psychiatry, 39, 703–712.
https://doi.org/10.1097/00004583-200006000-00008. donment, defining an attachment injury (AI) as a
Prior, V., & Glaser, D. (2006). Understanding attachment specific relational incident where one partner vio-
and attachment disorders: Theory, evidence and prac- lates the expectation that she/he will offer comfort
tice. Philadelphia: Jessica Kingsley Publishers.
and caring at a particular moment of urgent need.
Smyke, A., & Zeanah, C. H. (1999). Disturbances of
attachment interview. New Orleans, LA: Tulane Uni- Attachment injuries emerge in therapy “in an alive
versity School of Medicine, Department of Psychiatry. and intensely emotional manner, much like a
166 Attachment Injury Resolution Model in Emotionally Focused Therapy
traumatic flashback, and overwhelm the injured between partners, and sets the stage for attach-
partner” (Johnson et al. 2001, p. 145), redefining ment injury resolution. The second stage of EFT
the safety and trustworthiness of the relationship is one of reprocessing underlying emotions to
and blocking relationship repair. From the reshape the couple’s relationship. When there
moment of injury, the specific event continues to has been an attachment injury a couple will
be the standard by which one partner measures the reach an impasse in therapy and because of the
dependability of the offending partner (Zuccarini disproportionate impact of the injury, will be
et al. 2013). unable to move beyond de-escalation. The
AIRM provides an empirically validated 8-step
model to use in Stage 2 for resolving attachment
Prominent Associated Figures injuries and rebuilding trust. In the third stage of
EFT partners integrate and consolidate their
Susan Johnson newly shaped attachment bond.
Stage 1 – de-escalation of the couple’s negative
interaction pattern – precedes the Stage 2 AIRM
Theoretical Framework forgiveness and resolution process. When the
injured partner is the critical pursuer, the AIRM
The theoretical framework of the EFT AIRM process is followed after withdrawer
includes attachment theory as a theory of romantic re-engagement. Without de-escalation and
love, the empirically validated EFT theory of withdrawer re-engagement, the depth of this pro-
change, the empirical study of hurt and social cess could not be tolerated without triggering
pain, and the reparative responses created through reactivity.
the AIRM. Rationale for a model of forgiveness and
Romantic love as an attachment process. resolution. The attachment meaning of an injuri-
Attachment theory holds that the human need for ous event – that in a moment of urgent need one’s
affectional bonds extends throughout the life expected source of comfort is unavailable or
span. The attachment view of romantic love (see unresponsive – shatters trust, making the relation-
Attachment Theory, Johnson, this volume) – that ship unsafe and catapulting it into ongoing dis-
partners develop emotional bonds of tress. To rebuild trust in a relationship and resolve
interdependence – is a core concept for under- the injury, the hurt surrounding the injurious event
standing the power of a single event to rupture a needs to be explored and reprocessed. The AIRM
relationship and redefine its security. is a blueprint for clinicians (Zuccarini et al. 2013)
According to attachment theory, events in to do this.
which one partner responds or fails to respond in Hurt or social pain is distinguished from other
times of danger and extreme distress are found to emotions as a complex blend of sadness, anger,
influence the quality of an attachment relationship and fear of rejection or abandonment. It is con-
disproportionately (Simpson and Rholes 1994). It ceptualized as an experience that devalues the
is not the content of the event but rather the life- relationship and the injured person (Vangelisti
and-death sense of threat experienced during the 2007). With the AIRM, partners can transform
event – in the absence of the other partner’s the hurtful impact of an AI. Injured partners are
comforting response – that gives it the power to helped to experience the emotional depth of the
rupture an attachment bond. hurt and to disclose it in an increasingly vulnera-
The EFT theory of change: Working with ble manner, and offending partners are supported
emotion to shape security. EFT consists of three to respond with emotionally engaged empathy
stages (see Emotionally Focused Couple Ther- and remorse (Zuccarini et al. 2013). In this vul-
apy, Johnson & Wiebe, this volume). Stage nerable reaching and responding process, the hurt
1 (Steps 1 to 4 of EFT) culminates in is reprocessed, forgiveness occurs, and trust is
de-escalating the negative interaction cycle restored.
Attachment Injury Resolution Model in Emotionally Focused Therapy 167
Populations in Focus couple] deviated significantly from the expected

sequence” (Greenman and Johnson 2013, p. 54).
The AIRM is relevant for couples in distressed The resolver couple also showed “increasing A
relationships for whom the nature of their rela- depth of emotional experience in both partners
tionship is linked to one or more attachment inju- and increasingly more affiliative responses to
ries in which there was a pivotal injurious event each other” (p. 54).
that redefined the relationship and shattered trust. The first outcome study (Makinen and Johnson
2006) validated the effectiveness of the model as a
map for the forgiveness change process. It was
Strategies and Techniques Used in conducted with 24 couples who experienced an
Model attachment injury. Sixty-three percent resolved
the injury, forgave the injuring partner, and
Therapist interventions used in EFT include intra- reshaped the attachment bond. A 3-year follow-
psychic experiential interventions in combination up study (Halchuk et al. 2010) showed that
with interpersonal systemic interventions. Explor- increase in relationship satisfaction and forgive-
ing and deepening attachment related fears and ness in the resolver couples was maintained.
needs and facilitating emotionally engaged disclo- In 2013, Zuccarini et al. examined the process
sures and responses between partners are central of change following the steps outlined in the 2006
to successful outcomes in EFT and particularly to study. They delineated the specific therapist inter-
the resolution of attachment injuries. Zuccarini ventions and client processes that promoted suc-
et al. (2013) identified particular interventions cessful attachment injury resolution and further
associated with the resolution of attachment inju- validated the change process identified in the ear-
ries to include empathic reflection and validation, lier studies.
evocative responding, reflecting and tracking pro-
cess patterns and emotions, heightening softer
primary emotions, and structuring enactments. Case Example of Resolving an
The first four steps of the AIRM de-escalate the Attachment Injury with the AIRM
cycle related to the injury, preparing the terrain for
more explicit processing of the emotional injury. A 5-year-old incident emerges in Stage 2 with
AIRM Steps 5 and 6 are the core of the interper- Dom and Sofia, illustrating that a seemingly
sonal forgiveness and resolution process, wherein small incident can have as devastating an impact
new cycles of emotional engagement related to and be as sharp an attachment threat as a recently
the injury are created. Finally, in AIRM Steps discovered incident of infidelity. Dom and Sofia, a
7 and 8 the newly restored bond is consolidated. couple in their mid-forties, have two adolescent
The case example below illustrates this process children. They entered therapy with a well-
with an injured partner who was a withdrawer in entrenched cycle of Sofia pursuing with escalating
the relationship. criticism and hostility and Dom “going cold” and
disappearing into his work. Silence would hang
heavy between them for days, until Sofia would
Research About the Model explode, insisting they “talk about what’s happen-
ing.” Their talks – which eventually brought them
Naaman et al. (2005) published the first report closer for a while – were filled with accusations
linking the hypothesized model to outcome. In a from Sofia and admissions and apologies from
case study comparing one couple who success- Dom for being such a “poor recreational partner”
fully resolved their attachment injury with a cou- and for disappearing into work. Shortly thereafter
ple who did not, they found that the resolver the pattern would recur.
couple “went through the steps of the AIRM in After several months of therapy they success-
the expected order. . . [whereas the nonresolved fully de-escalate their negative interactive pattern.
168 Attachment Injury Resolution Model in Emotionally Focused Therapy
Dom becomes increasingly engaged and able to felt like blame and guilt levied at her for going to
share his fears of disappointing Sofia. In EFT Step Disney was Dom’s painful sense that she was
5, therapist Casey helps Dom to deepen and dis- rejecting him. When Casey inquires how Sofia
close his core fear of eventually losing her. Sofia is could brush Dom off like she did, she tearfully
touched: “I had no idea you had any fears at all!” discloses, “You were in a precarious medical condi-
she says in amazement. “No idea you still want to tion and I had no idea you’d understand all the
be close to me!” (EFT Step 6). obligations tugging at me. I couldn’t burden you
While Dom is emotionally engaged with his with this. I just froze – terrified you might die – and
attachment fears and longings, Casey inquires carried on as though I’d already lost you.”
what he needs from Sofia to remain open and After hearing Sofia’s description of how this
engaged (inviting EFT Step 7, withdrawer happened, Dom (AIRM Step 5) deepens his emo-
re-engagement). An injurious memory from the tional expressions and tells a clear, coherent state-
past resurfaces and stops Dom in his tracks. His ment of the painful impact of the event. Sofia
face goes blank, he drops his head and stares at his listens wide-eyed – never having seen Dom so
shoes. Haltingly he utters, “She wants a strong, vulnerable and open. Tears brimming in his eyes,
active husband, not me. Ever since Disney – it’s Dom discloses, “I needed you that day and I felt in
been clear – I’m a bother to her.” Sofia is incred- one moment when you brushed past me that
ulous that he is talking about Disney, 5 years after I became useless and insignificant to you.
their trip, and initially becomes defensive about I wouldn’t have tried to stop you from going on
revisiting the event. the trip – but you didn’t even seem to like me
Casey recognizes the AIRM is needed to help anymore or want me in your life!”
the couple move forward. Using EFT interven- Sofia rolls her chair in close to Dom with both
tions described above, Casey processes the injury hands on his knees, tears streaming down her face
and choreographs the forgiveness and resolution (AIRM Step 6), clearly moved by his pain. Her
process. In AIRM Step 1 Dom repaints the scene face mirrors his anguish as she says, “I had no
of the injury. “We booked a family trip to Disney idea – five years ago! My heart aches to see how
just before I was placed on a waiting list for a heart my brushing you off that day hurt you so much!”
procedure and I said, ‘I guess we’ll have to put the She feels how important she is to him, and
trip on hold,’ and she just shrugged and said, expresses deep remorse and regret for turning
‘Well I’d better learn to do things without you!’ away from him in that moment. “I totally need
She was angry. She just pushed me away.” Casey you in my life. I want you to know how much
validates Dom’s pain. I need you and like you. I am so sorry!”
Sofia interrupts (AIRM Step 2), “How could Dom could now receive her empathy and
I have done it differently? The pressure was on remorse (AIRM Step 7). With Casey’s prompting
me! Our kids and nephews were counting on he asks to have his needs, sparked by this attachment
us. And now it’s all about how much I hurt injury, met. “I worry that there are so many ways
you?” Casey supports Sofia in her defensive reac- I’m not quite the partner you want – and now with
tions, validating that she cannot hear Dom’s pain all my medical concerns I need to know you still
at feeling rejected – only his anger at her for going want me – to be a full partner in this relationship.
to Disney without him. That you still need me – as I am.”
Dom experiences and discloses his core pain of Sofia replies (AIRM Step 8): “I want you to
feeling rejected by Sofia (AIRM Step 3). “I just feel safe and loved – to know I need and want you!
keep going back to the moment you brushed me You are everything to me! I want you to feel
away. You literally pushed me away, like you completely safe with me. I want to care for you
didn’t need me in this family anymore and you every way I can!” Casey validates how Dom and
went off without me!” Sofia are beginning to create a new attachment
Sofia begins to grasp the significance of the event bond, redefining their relationship as one of safety
(AIRM Step 4). She begins to understand that what and shared support.
Attachment Theory 169
This AIRM was Dom’s withdrawer

References
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event, Casey processes Sofia’s blamer softening Greenman, P. S., & Johnson, S. M. (2013). Process A
where Sofia is helped to reach from a vulnerable research on emotionally focused therapy (EFT) for
position of attachment fears to ask Dom for what she couples: Linking theory to practice. Family Process,
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Finally, Stage 3 of EFT marks the integration of tionally focused therapy: A three-year follow-up. Jour-
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operationalizes forgiveness and resolution as an Naaman, S., Pappas, J. D., Makinen, J. A., Zuccarini, D.,
& Johnson, S. (2005). Treating attachment injured
interpersonal process, wherein the depth of
couples with emotionally focused therapy: A case
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relationships in adulthood. In K. Bartholomew &
partners beyond forgiveness into rebuilding
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▶ Clarifying the Negative Cycle in Emotionally J. A. (2013). Forgiveness and reconciliation in emo-
Focused Therapy tionally focused therapy for couples: The client change
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Restructuring the Bond in Emotionally
Focused Couple Therapy
▶ Emotion in Couple and Family Therapy
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Physical Health in Couples and Families
▶ Emotionally Focused Couple Therapy and Sue M. Johnson
Trauma The International Centre for Excellence in
▶ Emotionally Focused Family Therapy Emotionally Focused Therapy, The University
▶ Hold Me Tight Enrichment Program of Ottawa, Ottawa, ON, Canada
▶ Hold Me Tight/Let Me Go Enrichment Pro-
gram for Families and Teens
▶ Johnson, Susan Name of Theory
▶ Training Emotionally Focused Couples
Therapists Attachment Theory.
170 Attachment Theory
Introduction Attachment theory has seven basic principles

that are now supported by hundreds of studies on
In the last several decades, attachment theory has child–parent and adult–partner bonding. This the-
provided couple and family therapists and ory has already revolutionized understanding of
researchers with a map for understanding love the task of parenting and the emotional needs
and bonding in couple and family relationships. of children and is now being applied to the field
The science of attachment has grown tremen- of adult romantic bonds. The first central tenet of
dously and now has a large base of research sup- attachment theory is that seeking and maintaining
port from the fields of social psychology, contact with significant others is an innate and
development, and neuroscience. primary motivating force in human beings at all
phases of the lifespan. Dependency is an innate
part of being human, not a sign of enmeshed
Prominent Figures relationships, immaturity, or of lack of differenti-
ation from others. Rejection and emotional isola-
British psychiatrist John Bowlby (1907–1990) tion are inherently traumatizing and coded as
outlined the basic theory of attachment: a devel- danger cues by a nervous system wired for close
opmental understanding of personality with a connection with trusted others. New research in
focus on emotion regulation in his trilogy on neuroscience suggests that this connection is the
Attachment and Loss (1969–1982). baseline condition for coping and survival
Mary Ainsworth helped Bowlby create the assumed by our mammalian brain; human beings
Strange Situation research paradigm where a are indeed bonding animals (Coan 2016). Attach-
mother leaves a baby alone with a stranger for a ment research began with infants and mothers but
few minutes and the babies’ responses are coded adult bonding research has now grown to more
on reunion. This allowed the normative and indi- than 500 studies (Mikulincer and Shaver 2007). In
vidual differences principles of attachment to be adults, the sense of connection with loved ones
outlined. can be maintained more readily on the cognitive,
Since the late 1980s, adult attachment has representational level. For example, one might
been outlined by North American researchers hear a partner’s reassuring voice in one’s head
such as Mary Main, Phil Shaver, and Mario before going into a challenging interview, but
Mikulincer. contact is still a primary need. This need appears
to be universal across cultures, although it may be
expressed somewhat differently in different con-
Description texts. The bonds of love are viewed here as an
ancient wired-in survival code designed to keep
John Bowlby was arguably the first family ther- those we depend on close to us, especially at times
apist, writing his book Forty-Four Juvenile of vulnerability or perceived danger and to pro-
Thieves in 1944. He crafted the main principles vide a felt sense of expansive safety where we can
of attachment theory after studying the effects of grow and thrive.
World War II on orphans and widows, rebelling The second principle is that a felt sense of
against the analytic teachings of his time: secure connection offers a safe haven where one
Bowlby believed his own observations that it can find comfort and reassurance with trusted
was emotional experiences in real relationships – others. This sense of safety and support allows
rather than intrapsychic fantasies and conflicts – humans to find and maintain a sense of emotional
that shape how we deal with emotions, create our balance in the face of challenges and uncer-
models of self and other, and habitually engage tainties. This inner sense of security arises from
with loved ones. He laid out the theory in his repeated interactions with key loved ones who
trilogy on attachment and loss (Bowlby 1969, respond when called. Houston’s research on pre-
1973, 1982). dictors of success in newlyweds finds that
emotional responsiveness is indeed the best pre- finding is invaluable for intervention in that it
dictor of future relationship satisfaction (Houston tells the therapist what has to happen to create
et al. 2001). significant change in family relationships; emo- A
The third principle – based on observations tional disconnection has to be contained and emo-
that children who can turn to and take in comfort tional presence in the form described above
from their mothers are much more likely later in enhanced to shape more secure supportive
life to move away, take risks, and explore their bonding interactions. The attachment perspective
universe – is that secure connection with others focuses therapy on issues of connection and dis-
offers us a secure base from which to take on the connection and allows for the active validation of
world. Constructive dependency makes people needs and fears concerning attachment. It offers
stronger. Feeney (2007) found that young career the therapist a language for the emotional starva-
women who could turn to and confide in their tion that characterizes an insecure relationship. It
partners took more risks, felt more confident, also helps therapists understand how insecure
and reached their career goals faster. The evidence attachment is such a risk factor for problems
that a combination of a safe haven and a secure such as depression and anxiety (Mikulincer and
base fosters resilience in the face of threat and Shaver 2007).
challenge is considerable (summarized in The fifth principle is that a close relationship is
Mikulincer and Shaver 2007). This perspective a powerful circular feedback loop in the sense
suggests that members grow and differentiate outlined in systems theory (Johnson and Best
with each other rather than from each other. 2003) where patterns of interaction shape the cre-
A felt sense of secure connection is seen as the ation of internal working models, sets of if-this-
best route to confident autonomy – a state that is then-that expectations. These models then set up
often a key goal in family therapy, especially with or maintain patterns of interaction. Such models
adolescents. The secure base provided by a loving of self and other may be out of awareness and
attachment figure encourages a cognitive open- mostly define the self as lovable or unworthy and
ness to new information and promotes the confi- others as trustworthy and reliable or not. These are
dence necessary to risk, learn, and continually called “working models” in that they can be
update models of self and others, so that adjust- revised in new relationships by new corrective
ment to new contexts is facilitated. It also emotional experiences of secure connection. Self
strengthens the ability to stand back and reflect and relational systems are intertwined in these
on oneself, including one’s behavior and mental working models. An attachment-oriented clini-
states (Fonagy et al. 2016). cian would see emotional isolation and loss
The fourth principle of attachment defines the entwined with a model of self as failing and
core variables that define a secure or less secure unlovable as a constant trigger for depression.
bond and therefore the quality of couple and fam- The sixth principle of attachment is that when
ily relationships. It is worth noting that this prin- we cannot find emotional connection with an
ciple privileges emotion and recognizes that attachment figure, a process of separation distress
emotional communication – the music of the occurs. The person moves into protest at discon-
dance between intimates – organizes key relation- nection. This often looks like anger, especially in
ship defining interactions. Bowlby always adult couples, but is triggered by a sense of aban-
stressed the importance of emotion and that turn- donment or rejection. If this does not elicit respon-
ing to others is the foundational way in which siveness, a stage of clinging and disorganized
we regulate our own emotions, especially fear. pleading and clinging begins. If this does not
Attachment research suggests that the core ques- result in repair and reconnection then despair fol-
tion in bonding relationships is, “Are you there for lows. This process eventually leads to a general
me when I need you”? This question really con- sense of grieving and detachment. From an attach-
tains three elements: emotional Accessibility (A), ment perspective, much acting out in families or
Responsiveness (R), and Engagement (E). This angry escalation in adult couples is best seen in
terms of separation distress rather than simply in emotional worlds, helping therapists tune into that
terms of disagreement or conflict. Conflict may be world and make sense of their client’s realities and
seen as inflammation, while emotional disconnec- interactions.
tion coded as danger is the virus. More generally, attachment in adolescents
All of the above are normative principles. The implies that they need – not to separate per se
last principle addresses individual differences – from their parents – but to move into a more
what are commonly called attachment styles. reciprocal connection where they can be autono-
Research finds three basic patterns in ways of mous and yet securely attached. In adult relation-
engaging with others and regulating emotions: ships, attachment is seen as shaping other aspects
secure, anxious or preoccupied, and dismissing of the relationship, in particular caregiving (secure
or avoidant patterns. For a video illustration of connection fosters empathy for others and more
these patterns in infants and in adult partners, see attuned responsive caregiving) and sexuality.
http://www.drsuejohnson.com/videos/. Securely attached partners can take risks and
Secure children and adults can generally listen play in erotic contexts and in general have higher
to their emotions, make sense of them, and, when sexual satisfaction.
lonely or uncertain, reach for those they are
bonded to. When this person responds, they can
take in comfort and find emotional balance. They Relevance to Couple and Family Therapy
can also tolerate less than optimal responses at any
one time because of their basic trust in others Attachment theory provides the rich, deep, empir-
responsiveness. Anxiously attached individuals ically validated theory of close relationships that
are very sensitive to rejection or abandonment has been missing from couple and family therapy.
and hyperactivate their emotions and emotional This allows therapists to go to the heart of the
signals to others, often becoming controlling, crit- matter and target the key variables that define
ical, or demanding, to the point of driving others relationship quality rather than being caught in
away. They also have trouble really taking in addressing more tangential symptoms or interven-
comfort and tend to stay vigilant rather than find ing in general ways that have been found not to
a way to emotional equilibrium. As adults, these impact close relationship repair or satisfaction,
partners often end up blaming and demanding, such as teaching communication skills (Rogge
triggering withdrawal in others which then main- et al. 2013). This theory also allows therapists to
tains their alarm and insecurity. Avoidant partners address aspects such as nurturance and love itself
have experienced calling to others as futile and see that have been generally missing in this field. It
closeness as risky at best. They shut down their offers the therapist a guide to the emotional fears
own attachment emotions and needs and with- and unmet needs of partners that trigger anger and
draw at any sign of vulnerability in themselves withdrawal in couple relationships, and a map to
or others. They offer stonewalling responses to the creation of powerful new corrective emotional
others and do not grasp the impact of their lack experiences of bonding that have been shown in
of response. Some individuals who have been research (Greenman and Johnson 2013) to signif-
seriously hurt or abused by those they love – icantly transform a relationship.
who have experienced violations of human As already outlined in the literature, attach-
connection – are overwhelmed and cannot orga- ment theory and science now forms the basis
nize themselves into anxious or avoidant stances for several cutting-edge couple and family inter-
so they flip between the two and this is usually ventions including two that have extensive empir-
termed disorganized in children and fearful- ical validation, emotionally focused couple and
avoidant in adults. Others are, at one and the family therapy, or EFT and EFFT (Johnson
same time, a desperately needed form of comfort 2004) and attachment-based family therapy, or
and a feared source of pain. Attachment science ABFT (Diamond 2005). Another approach, less
offers a map to the structure of individual’s inner validated but increasingly popular, is dyadic
developmental psychotherapy or DDP (Dan in-session moments of increased mutual accessi-

Hughes 2004). There are some differences in bility, responsiveness, and engagement; that is,
how these models use the attachment frame. corrective bonding moments when attachment A
For example, the family interventions offered in fears and needs can be acknowledged and
ABFT are generally more cognitive and less emo- responded to, and new ways of regulating emo-
tionally focused than in the other two, and family tions and making connection shaped. These
DDP is generally used with young children who moments then access working models of self and
have been in foster care, while ABFT and EFFT other so they can be revised. This contrasts to the
are used with adolescents and parents or, in the communication skill building, insight provision,
case of EFT, with adult partners. cognitive reframing, or role reversals to unbalance
The general implications for the repair of negative homeostasis that are typically found in
bonded relationships and associated problems the field of couple and family therapy. At the end
can be outlined as: of therapy, for example, a 13-year-old boy might
First, the therapy session has to be a safe haven be able to say to his stepfather,
and a secure base for partners and family mem-
bers, even when they present as living in opposing When I was little, with my first dad, I decided I was
a bad kid. That was why he was so mad at me. Now
universes. Therapy tends to be collaborative and I assume you think I’m bad, and when you get upset
egalitarian but parents are, naturally, given more with me, I just tell you I don’t care. I’ll never please
responsibility for redefining a troubled relation- you anyway. I just give up. Get depressed. Shut you
ship as a more secure bond than are children or out. But it hurts cause then I don’t have a Dad.
adolescents. Bowlby noted that, if attachment is His stepfather can now lean close and tell him,
understood, all responses – even those that are “I don’t want you to feel like you’re a bad kid.
You are my kid now – my special son. I don’t
apparently very dysfunctional – are in fact “per-
want you to give up with me. I want us to be
fectly reasonable.” Like Carl Rogers, Bowlby close. And I want to learn to be a kinder dad.”
advocated meeting the client in acceptance and
compassion rather than beginning from a pathol- Third, emotional regulation and habitual ways
ogizing stance. An attachment-oriented therapist of expressing emotion are viewed as structuring
acts as a surrogate attachment figure by actively interactions and so being at the heart of the pre-
helping clients regulate emotion, particularly the senting problem, but emotion is also an ally in
attachment-related anxiety or panic (Panksepp creating change rather than a problem to be coped
1998) that triggers negative emotional flooding with or bypassed. Newly accessed and distilled
or requires avoidant emotional suppression and emotional responses translate into new responses
withdrawal in insecure relationships. to loved ones and new interactional cycles.
The attachment-oriented therapist, especially Attachment theory provides a guide for under-
in EFT, EFFT, and DDP, is emotionally present standing and normalizing many of the extreme
and engaged and deliberately regulates the emo- emotions that accompany distressed relationships.
tions of clients with their pacing, voice, repetition, The longing for connection is also a powerful
and reflection of emotions. The therapist creates motivator in therapy and facilitates new levels of
safe emotional engagement with clients and engagement in the therapy process. Separation
models responsivity which then expands the cli- distress, indicated by powerful emotions of
ent’s window of tolerance and encourages explo- anger, panic, and hurt; abandonment; and sadness
ration. The therapist orders a client’s experience results from the perception that an attachment
the way a good parent reflects and orders the figure is inaccessible or does not care. Attachment
emotional experience of a child in challenging relationships are where our strongest emotions
situations. arise. A positive sense of connection with a
Second, the goal of therapy is to reduce loved one is a primary emotion-regulation device
emotional escalation and interactions that main- and family members are “hidden regulators” of
tain distance and disconnection and create each other’s physiological and emotional realities
(Johnson et al. 2013). The exploration and 2007). This also offers the promise of relational
reprocessing of key emotions and how they are therapies to effectively address symptoms in indi-
expressed, and a focus on barriers to constructive viduals such as depression, anxiety, PTSD, and
emotional connection, such as vague or confusing coping with physical illness such as heart attacks,
bids for responsiveness, are part of any attachment as attachment oriented therapies such as EFT
oriented intervention. Therapists who understand have done.
the process of separation distress can look beyond
disruptive responses such as hostility or stone-
walling and place them in the context of legitimate Clinical Example of Application of
attachment needs and fears, translating what Attachment Theory in Couples and
might appear to be characterological deficits or Families
lack of social skills into context-specific responses
to loss of connection – responses that can be Laura and Mick come to couples therapy to deal
restructured. with the escalating fights and days of distance that
Fourth, the attachment-oriented therapist have taken over their relationship since Mick’s
deliberately choreographs and shapes particular serious heart attack. Laura has been diagnosed
kinds of new interactions in a therapy session with clinical depression and Mick is not comply-
that transform distance and disconnection into a ing with his cardiac program, missing appoint-
dance where vulnerabilities and needs can be ments and not taking his meds. The pattern of
shared and heard. The therapist will both offer a Laura pursuing for closeness and then becoming
meta-perspective on the cycles of disconnection angry at Mick’s lack of response has always been
in a relationship, so that partners or family mem- part of their 35-year relationship but has now
bers can see this dance and its emotional conse- completely erased any positive interactions.
quences, and also, later in therapy, deepen Laura is enraged and critical and Mick is zoned
emotions to help clients access and share their out and withdrawn. In session three, the therapist
triggers, sensitivities, and needs in a way that draws out the steps in their dance of disconnection
fosters an empathic response and secure bonding. and paints this dance as the enemy (rather than
The relevance of attachment science for this one of the partners), linking in the attachment
field cannot be exaggerated in that it offers a consequences.
secure base of empirically supported, develop-
Laura – I told him – “Why are you drinking that big
mental relational theory from which to shape
glass of wine. You know you are not supposed to.”
on-target intervention in therapy and in relation- He ignored me of course. (To Mick) You don’t care
ship educational programs. It is clear that the about how much I worry. You just act like you don’t
habitual forms of engagement with one’s own have any health problems at all. As always – if there
is a problem you just put your head in the sand.”
emotions and with key others, as well as mental
models of self, can be modified by new or Mick – All you do is keep telling me how sick
I am. Years ago it was how I was too silent, or
changed relationships (Simpson et al. 2007). The
worked too much. Maybe I just don’t want to hear
latest outcome study on EFT found that this inter- it. You are always telling me there is something
vention significantly impacted both anxious and wrong with me. Shooting me down.
avoidant attachment, moving partners into more Laura – You just don’t want to hear me is all. You
secure attachment and this result was stable at never listen. I don’t know why I bother. (Mike looks
2-year follow-up (Burgess-Moser et al. 2015). out the window with a flat face and set mouth)
Thus, this science not only offers a way to heal Therapist – Can I stop you for a minute. This is what
relationships but to shape relationships that heal happens much of the time isn’t it – this dance you
and grow the sense of self in partners and families. are doing now (they nod). And it just keeps going –
almost runs by itself and pulls you both along with
Attachment security is associated with greater it. Laura, you are speaking very angrily but I see the
self-efficacy and a more coherent, articulated, teariness in your eyes and maybe this is about the
and positive view of self (Mikulincer and Shaver “struggle” you spoke of when you see Mick doing
something that you see as dangerous – that might lonely place. Let’s slow down – scaring each other
have you even lose him to another heart attack (she we are. Want a coffee?”), the therapist moves into
agrees). So you try to reach him – warn him – poke
him to get his attention. But Mick you just hear her shaping positive cycles of connection. Here this A
criticizing – trying to bring you down (he nods). couple can share vulnerabilities and ask for com-
You poke and tell him to be different and you hear fort and support – that is they can move into safe
her trying to hurt you – telling you there is some- accessibility, responsiveness, and engagement.
thing wrong with you, so you shut down.
The therapist stays with Mike and helps him
Mick – I leave is what I do – get away from her and move into his emotions and needs.
then we don’t talk for days. Therapist – So Mike, when Laura gets mad, you act
Therapist – That must be pretty hard. To hold up like you don’t care, but in fact this is very hard
that wall for days (Mick grimaces and agrees). And on you.
the more you prod and warn him Laura, the more Mike – Well yes, especially since the heart attack.
you see her as putting you down and the more you That was a lesson in fragility that was. I do turn
shut down. The more you withdraw, the more frus- away but I get now that she feels like I am gone –
trated you get Laura and the more you poke. Poke, like she doesn’t matter. But it’s just too hard to stay
then shut down and shut her out, so then she slams there. I run (He waves his hand in the air like he is
you to get a response. That is hard and seems like it trying to get away from something).
leaves you both alone and both upset – and then
Mike you forget to take your meds and Laura you Therapist – And she sees “indifference,” like “Mike
give up and get depressed cause you are all alone. is a rock,” but you have to get away – there is
Am I getting it? The dance leaves you both lonely. It something here that is difficult – almost a threat?
would be good if you could help each other step out Mike – Yes. I look calm but inside I am coming
of it so that you could help her with her depression apart. I hear that I have failed again and she is mad
Mike, she could help you stay on you regime – and at me – sees me as a screw up.
you guys could be close again.
Therapist – And that hurts
The therapists tracks and distills the cycle of Mike – Yes (he tears). I get so stirred up inside –
emotional disconnection in a safe way and invites I get so – well – shaky. I just never get it right with
them to stand together and look at their pattern. her – and now I am less of a man ‘cause I had a heart
attack – so –
They decide to call it the Bang-Slam. She bangs
on the door – he sees it as an attack and slams it Therapist – Right – I hear that. You look stoic and
unaffected but you are “coming apart” – feeling like
shut again. The therapist also helps them touch
Laura is disappointed in you and you are failing.
and find words for and share the more vulnerable Helpless and hopeless and less of a man – that is a
feelings that trigger these reactive responses and very dark, lonely place. Kind of overwhelming – so
push the other away. Laura is able to say – “I get you try to shut down and shut it all out. You can’t
just turn to her for comfort, reassurance that you are
scared when you do risky stuff like drink a lot and
still her man.
that fear is familiar. I never know if I can reach
you, say “Mick, where are you – are you with me” Mike – (Very soft) That would be nice. Comfort.
I know my heart attack scared her. It scared me too.
and have you respond. So I ramp up the message. Why would she want a sick guy who doesn’t even
I am all by myself here with the fear of losing know how to tell her. . .. . .. . .. . .. . .. . .. . ..
you.” Mick is able to find his feelings of loss Therapist- That is the fear Mike – you won’t meet
around his heart attack and his fear that his wife her standards now – so she will not want you – be
sees him as a failure and a “sicky” who she there for you?
doesn’t value. He hears her saying he is a “screw Mike – Well I am fine. I can manage alone (He looks
up” and that triggers his “hurt’ so he just tries to at the therapist’s face). You don’t buy that do you?
“get away”. The therapist validates, distills and Right. Neither do I. In the hospital I really knew
how much I needed her. THAT is scary!
helps the couple share these emotions, putting the
music into the dance of disconnection. Therapist – She is your life line (Mike nods) and its
scary when she gets mad or frustrated with you. But
In session 11, after this couple have reported shutting down just leaves you alone (Mike nods
that they can stop this dance at home (Mick says – again) and none of us can handle that. Can you tell
“Heh we are caught in the Bang-Slam again. It’s a her Mike – I do shut down and shut you out ‘cause
I am so afraid to hear that you might not think I am ▶ Emotionally Focused Family Therapy
good enough – strong enough – loving enough. I get ▶ Hold Me Tight Enrichment Program
shaky and overwhelmed – just because I need you
so much. ▶ Hold Me Tight/Let Me Go Enrichment Pro-
gram for Families and Teens
Mike – Yes – all of that (He laughs)
He then turns and tells her his version of this

and with the therapists help he shares how
intimidated he is about talking about emotions, References
how ashamed he is of his vulnerability, and how
Bowlby, J. (1969). Attachment and loss (Vol. I). New York:
scared he gets when he fear he might be rejected. Basic Books.
The therapist helps him say this in a way that Bowlby, J. (1973). Attachment and loss (Vol. 2).
evokes tenderness in Laura and she softly reas- New York: Basic Books.
sures him. In fact is amazed to see her husband Bowlby, J. (1982). Attachment and loss (Vol. 3).
in a new light and to feel so connected to him Burgess-Moser, M., Johnson, S. M., Dalgleish, T.,
after 35 years of conflict. This is a withdrawer Lafontaine, M., Wiebe, S., & Tasca, G. (2015).
re-engagement event in EFT and the therapist Changes in relationship specific romantic attachment
will then go on to shape moments where Laura in emotionally focused couple therapy. Journal of
is able to talk about her “panic” around losing Coan, J. (2016). Towards a neuroscience of attachment.
Mike, and her fear that he does not need her or In J. Cassidy & P. Shaver (Eds.), Handbook of attach-
need her closeness. She is then able to ask ment: Theory, research and clinical applications
directly and clearly for connection in a way (3rd ed., pp. 242–272). New York: Guilford.
Diamond, G. (2005). Attachment based family therapy for
that Mike can hear and respond to. The bonding depressed and anxious adolescents. In J. Lebow (Ed.),
moments that then occur provide a safe haven Handbook of clinical family therapy (pp. 17–41).
bond where this couple can help each other with New York: Wiley.
their fears and form a more satisfying connec- Feeney, B. C. (2007). The dependency paradox in close
relationships: Accepting dependence promotes inde-
tion. They also craft a secure base where Mike pendence. Journal of Personality and Social Psychol-
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fears and thoughts, so her depression remits, Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2016).
and she can help him stay on track with his Reconciling psychoanalytic ideas with attachment
theory. In J. Cassidy & P. Shaver (Eds.), Handbook of
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potent source of resilience, happiness, and Greenman, P., & Johnson, S. M. (2013). Process research
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Houston, T., Caughlin, J., Houts, R., Smith, S., &
George, L. (2001). The connubial crucible: Newlywed
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Johnson, S. M., & Best, M. (2003). A systemic approach to
▶ Bowlby, John restructuring adult attachment: The EFT model of cou-
▶ Circle of Security ples therapy. In P. Erdman & T. Caffery (Eds.), Attach-
▶ Circle of Security Parenting Enrichment Program ment and family systems (pp. 165–192). New York:
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interventions. Journal of Consulting and Clinical critical treatment processes. These tasks serve as a
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Guy Diamond, Ph.D.

Attachment-Based Family Gary Diamond, Ph.D.
Therapy Suzanne Levy, Ph.D.
Guy S. Diamond1, Jody Russon2 and
Suzanne Levy2 Theory
1
University, Philadelphia, PA, USA ABFT is a brief family-based therapy with a solid
2
Center for Family Intervention Science, Drexel grounding in attachment theory (Bowlby 1969).
University, Philadelphia, PA, USA This theory proposes that when children are dis-
tressed, they are “hard-wired” to seek support and
comfort from their parents. When children expe-
Name of Model rience their parents as responsive and available in
the face of distress, they begin to feel that (a) the
Attachment-Based Family Therapy world is a safe place and (b) they are worthy of
being loved protected. Over time, these experi-
ences of protection become internalized as work-
Introduction ing models (or expectations) of relationships. If a
child is treated well, then they seek out similar
Attachment-based family therapy (ABFT; relationships. When a child is treated poorly, they
Diamond et al. 2014) is a trust-based, emotion- internalize expectations that their relationships
focused, empirically supported treatment that will be unresponsive, if not hurtful. In the face of
aims to repair interpersonal ruptures and rebuild these untrustworthy relationships, children
secure, protective caregiver-child relationships. develop attachment (interpersonal) strategies that
ABFT is designed to improve the family’s capac- will protect them from more harm: dismissive,
ity for affect regulation, relational organization, preoccupied, or disorganized.
and problem solving. This strengthens family If internal working models are shaped by real
cohesion, which can buffer against depression, relationships, then these real relationships can
suicidal thinking, and risk behaviors (Restifo and revise internal working models and other behav-
Bogels 2009). This framework is particularly rel- ioral changes. ABFT aims to revive the adoles-
evant to adolescents for whom the family context cent’s hope for attachment security and promote
is inescapable (Maccoby and Martin 1983). responsive parenting. Improving the family’s
ABFT is rooted in structural family therapy, communication, problem-solving, and emotional
178 Attachment-Based Family Therapy
regulation can create the corrective attachment empathy from their caregivers, they become
experiences that help adolescents work through more willing to consider their own contributions
past traumas and relational ruptures. This estab- to family conflicts. As caregivers acknowledge
lishes the groundwork for rebuilding secure rela- adolescents’ experiences, adolescents become
tionships with parents. more emotionally regulated and cooperative.
Although these conversations may not address or
resolve all relational problems, this mutually
Strategies and Techniques Used in ABFT respectful, and often emotionally profound, dia-
logue serves as a “corrective attachment experi-
In ABFT, the “corrective attachment experience,” thus revising the adolescent’s internal
ence,” and subsequent autonomy building, is working model of self and other. In this new
engineered using five distinct treatment tasks. emotional climate, caregivers become a resource
Tasks are not equated with sessions. Instead, a and secure base for their adolescent. Task V then
task is a set of procedures, processes, and goals focuses on using the caregiver to support the
related to resolving or accomplishing specific adolescent’s exploration of competency and
aims in therapy (e.g., building alliance). Task autonomy. Adolescents begin to seek comfort,
I offers a roadmap for establishing an essential advice, support, and encouragement from their
and common process inherent to many family caregivers while exploring new opportunities
therapy models: getting the family members to and managing life stressors. Table 1 summarizes
agree to work on relationship building rather the treatment targets and expected outcomes for
than behavioral management. To achieve this, each of these five treatment tasks.
the therapist focuses on resuscitating the ado-
lescent’s desire for protection and support as
well as the caregivers’ longing for love and Populations in Focus
connection with their child. The therapist pro-
motes the caregivers as “the medicine” to help ABFT is a therapy for adolescent depression and
the adolescent cope with, and recover from, suicide; however, youth with other presenting
depression and suicidal ideation. problems can benefit from the clinical model.
Task II consists of individual sessions with the ABFT has been useful for clients with histories
adolescent. The therapist aims to help adolescents of trauma, eating disorders, substance use, or vic-
identify and articulate their perceived experiences timization due to their sexual identity (see full
of caregivers’ attachment failures and prepare review in Diamond et al. 2016a). ABFT is flexible
them to discuss these felt injustices in Task IV. enough to incorporate comorbid conditions and
Task III consists of individual sessions with the has gained empirical support for young adults
caregivers. The therapist aims to help each care- with unresolved anger toward a caregiver
giver consider how their own life stressors and (Diamond et al. 2016b).
intergenerational legacies of attachment ruptures Low income, minority families have been
affect their parenting style. This insight helps absent from many of the clinical trials testing
caregivers develop greater empathy for their ado- psychotherapies for youth depression and sui-
lescent’s experiences. With this insight, caregivers cide (Bernal et al. 2009). ABFT, however, has
become more motivated to learn new emotion had a history of success working with diverse
coaching and parenting skills. families. In general, ABFT is recommended for
Next, in Task IV, the therapist brings the ado- clients 12 years of age and older and is not
lescent and caregivers back together to discuss limited by treatment context. The model has
and understand how these relational disappoint- been used in outpatient, inpatient, home-based,
ments have damaged trust in the relationship. As hospital settings, and residential care. ABFT is
adolescents share these thoughts, feelings, and not recommended as a treatment approach for
memories and receive acknowledgment and clients with active psychosis, low-functioning
Attachment-Based Family Therapy, Table 1 Targeted risk factors, relevant treatment task, and expected out-
comes. Adapted from Diamond et al. (2003)
Treatment targets Interventions Expected outcomes
A
Caregiver criticism and Relational reframe Caregivers and adolescent become more willing to
blame focus on relationship building instead of behavior
management
Adolescent hopelessness Alliance building with Build treatment bond with adolescent, help them
about, and disengagement adolescent understand their attachment rupture narrative, and
from, caregiver prepare them to discuss these stories with their
caregivers in task IV
Caregiver stress and Alliance building with Build treatment bonds with caregivers, increase
abdication caregivers caregiver awareness of adolescent’s attachment
needs, and teach parenting skills that will promote
attachment-repairing conversations in task IV
Adolescent-caregiver Repairing attachment Increase adolescent’s perceptions of caregivers’
disengagement and conflict availability and protection, increase adolescent’s
confidence in communicating his or her needs, build
caregivers’ view of their adolescent as having
legitimate concerns (who can express themselves in
a direct and emotionally regulated manner), work
through memories of loss and abuse, and improve
interpersonal and conflict resolution skills
Poor adolescent functioning Promote caregiver support for Increase adolescent’s use of the caregivers as a
in extra-familial contexts adolescent competency and secure base for problem solving and identity
autonomy development
autism spectrum disorders, borderline intellec- predictors of poor response in treatment with
tual functioning, or severe externalizing behav- combined medication and cognitive behavioral
iors. However, the guiding principles and tasks therapy (Asarnow et al. 2009; Barbe et al.
of ABFT can be applied when working with any 2004). Also several process studies have
family. explored the proposed mechanisms of change
(see Diamond et al. 2016a for a review).
A new study comparing ABFT to Family-
Empirical Support Enhanced Non-Directive Supportive Therapy
has just been completed. Results are not yet
ABFT research is conducted at the Center for available, but seem very promising.
Family Intervention Science (CFIS) at Drexel Several effectiveness research projects have
University and at partnering sites throughout the been conducted or are currently underway. Israel
world (Diamond et al. 2016a). ABFT research and Diamond (2013) explored the feasibility of
has focused primarily on reducing depression training therapists to conduct ABFT in a hospital
and suicide in adolescents, ages 12 to 18. To setting in Norway. Similar implementation chal-
date, several studies have been conducted dem- lenges are explored in three recent papers on
onstrating the efficacy of ABFT. These studies implementing ABFT in Australia (Diamond
have shown that ABFT is more effective than et al. 2016c), Belgium (Santens et al. 2016), and
waitlist control groups or treatment as usual in Sweden (Ringborg 2016). In the United States, we
reducing depression and suicidal ideation. have recently partnered with an LGBTQI youth
ABFT has also been adapted for use with sui- center to conduct an implementation study of
cidal LGB adolescents (Diamond et al. 2012). ABFT in a community counseling center working
Secondary data analysis indicates that ABFT is with this population. This empirical support
effective for severely depressed adolescents and reviewed above meets the criteria for a promising
those with a history of sexual abuse, both intervention (Chambless and Hollon 1998) and
ABFT is currently listed on the National Registry sessions focused on being bullied, school strug-
of Evidence-based Programs and Practices gles, career goals, identity development (e.g.,
(NREPP). what it means to be a biracial woman), and
sexuality.
Task I: Relational Reframe. Initially the ther-
Case Study apist joined with Sharise around her concerns
about her daughter’s depression, sexual behavior,
Brittney was a 17 year old, African American, and peer relationships. She also joined with
and Caucasian (biracial) adolescent who lived Brittney around her depression which resulted
with her mother, Sharise, and younger brother. from being bullied, feeling rejected by her father,
The father lived in the home until Brittney was and feeling as though she did not “fit in” given her
nine; however, he was not involved in her life at biracial identity. The primary focus of the Rela-
the time of this therapy. The family was referred tional Reframe was captured in the following
from a local inpatient psychiatric hospital after question: “When you feel so bad that you want
treatment for severe suicidal ideation. Brittney to hurt yourself, why don’t you go to your mother
struggled throughout her life socially and aca- for help?” In response, Brittney disclosed that she
demically. Although very creative, athletic, and worries about her mom’s negative opinions of her
intelligent, Brittney reported difficulties “fitting and does not want to stress and burden her mother.
in” and being bullied given her biracial identity. Brittney expressed that, in the past, she had felt
She discussed how she felt “not black enough.” more comfortable talking to her few close friends
These issues with peers impacted her ability to and boyfriend; however, with her recent struggles
attend school. with peers, she felt completely “alone.” At first,
Sharise self-identified as African American Sharise was frustrated with Brittney for not com-
and came to therapy with concerns about her ing to her. The therapist shifted Sharise’s tone by
daughter’s suicidal ideation, depression, anger, acknowledging her love and concern for Brittney
and “out of control” sexual behavior. Specifically, and asking her to share those emotions: “Let your
Sharise had recently “caught” her daughter daughter know how sad you are that she does not
kissing “an older guy” outside of her school. trust you. Let her know how worried you are that
Sharise described her daughter as being highly she is all alone.”
susceptible to peer influence (e.g., cutting class This softened the mood in the room and shifted
to hang out with friends, provoking fistfights in the family from anger to sadness. At this point,
school, and staying out past curfew). Sharise Brittney and Sharise could focus on interpersonal
reported no history of family mental health con- ruptures instead of problem behavior. Both
cerns, but described a history of domestic violence mother and daughter were able to remember the
in several of her past romantic relationships and close relationship they once shared and how dis-
between her own parents in childhood. At the time tant they had become. The therapist helped them
of treatment, Sharise had a steady job and was acknowledge that they felt this loss of closeness.
single. With the relational narrative now at the center of
Brittney and Sharise attended ABFT sessions the conversation, Sharise agreed to the relational
for 4 months. Sessions were focused on repairing treatment contract: to make relationship repair the
ruptures between mother and daughter. The pri- initial goal of the treatment. Brittney was more
mary ruptures involved Brittney’s feelings of hesitant. She, like many adolescents, had lost
“being attacked” by her mom when she tried to hope that family relationships could improve.
share feelings about being bullied at school, feel- Brittney was protecting herself from further hurt
ing rejected by her father, and feeling abandoned by no longer wanting attachment security. The
by her mom during episodes of domestic violence therapist validated this concern but also talked
between Sharise and her previous partners. After about the consequence of being so alone in life:
trust was rebuilt between mother and daughter, depression and suicide. After the therapist
explored her resistance and validated her con- her work responsibilities, social life, supportive
cerns, Brittney agreed to come to the next session relationships, and current stressors. Sharise was
and discuss this further with the therapist alone. burdened with balancing childcare and her job. A
Task II: Adolescent Alliance. The therapist She described feeling “stressed,” “exhausted,”
met with Brittney for her first Task II session to and “guilty” on a daily basis. Sharise acknowl-
continue building an alliance and to better under- edged that these stressors impacted her capacity to
stand her depression and suicidal ideation. After be present with her children. The therapist also
this initial session, Brittney participated in two helped her realize that when she felt worried about
more Task II sessions where she discussed what her daughter (e.g., when Brittney failed to arrive
got in the way of going to her mother for help and home on time), this would trigger her own feel-
support (e.g., relational ruptures). Brittney noted ings of guilt. Sharise actually attributed her
two ruptures that were different from those origi- daughter’s acting out behavior as a result of her
nally identified in Task I. First, rather than being own lack of availability as a mom. When these
worried about her mother’s opinion of her or feelings of guilt were triggered, Sharise tended to
feeling like a burden, Brittney actually felt lash out verbally at her daughter. Despite this
attacked and humiliated by her mother. Specifi- initial work to understand how current stressors
cally, she said that when she shared things with impacted her, Sharise remained highly defensive.
her mother, the mother would then follow her In the next Task III sessions (sessions two
around the house and “yell” at her if she did not and three), the therapist explored Sharise’s
keep talking about these things. If she brought up intergenerational history, specifically helping her
feelings about her father, her mother would “lash- talk about vulnerable moments as a child. At first,
out” and reprimand her for wanting a relationship Sharice resisted exploring her own history of
with such a “horrible man.” attachment ruptures. The therapist worked slowly
Brittney also described feeling abandoned by with Sharise to uncover fears and disappointments
her mother during the scariest moments in her life. resulting from witnessing domestic violence in
Brittney had witnessed episodes of domestic vio- her own family of origin. The therapist used infor-
lence that her mother suffered at the hands of mation gathered in Task II with Brittney to look
multiple romantic partners. This had never been for similar attachment themes in mom’s life.
discussed before. In sessions, Brittney talked Sharise struggled to emotionally connect to her
about the impact that witnessing the violence own childhood experiences of betrayal and
had on her as well as the consequences of not abandonment.
being able to talk with her mother about these In the therapy, Sharise would often distance
events. These conversations helped Brittney herself from the emotional intensity of the con-
understand how these relational ruptures impacted versation by flippantly saying, “Oh I just had to
her sense of safety and security in her relationship get over all this.” Each time Sharise retreated like
with her mother (i.e., her attachment rupture nar- this, the therapist would gently invite her back
rative). The therapist spent the fourth session of into uncovering more vulnerable feelings. To
Task II helping Brittney see the link between her stay in this zone, Sharise’s primary emotions
attachment narrative and her depression and sui- related to abandonment and neglect needed to be
cidal ideation. Understanding this link motivated identified and validated. Only when Sharise could
Brittney to talk to her mom about the ruptures. allow herself access to these more vulnerable feel-
The therapist then spent time preparing Brittney ings could she begin to have more empathy, rather
for these conversations. than indifference, for her own painful experiences
Task III: Caregiver Alliance. In this task, as a child.
Sharise was initially very guarded and worried Once she was able to acknowledge this, the
about being judged or blamed for her daughter’s therapist helped her empathize with her daugh-
problems. In the first session of Task III, the ter’s experience of witnessing domestic violence
therapist got to know Sharise better, including and having no one to turn to for support. Sharise
quickly realized what her daughter needed to providing comfort and protection: a corrective
resolve these frightening experiences. attachment experience. This conversation also
Brittney needed to have someone help her laid the foundation for the more difficult discus-
understand these frightening events and tell her sions about domestic violence.
it was not her fault; just what Sharise wished she In the second Task IV session, they talked
had gotten from her mother. about Brittney’s experience of fear and abandon-
The therapist spent the fourth session of Task ment during the episodes of domestic violence.
III helping Sharise identify how themes of aban- With the support of the therapist, Brittney
donment permeated her own life and her current disclosed feeling abandoned by her mother
approach to parenting. Sharise acknowledged because she had never asked Brittney about
that she was “walking with blinders on.” She these events. After mom validated, rather than
admitted that she wanted to deny that the dismissed, Brittney’s feelings, Brittney began to
witnessing of domestic violence had an effect share her memories of the violence. In this con-
on her daughter. She also acknowledged that she versation, the therapist encouraged Sharice to lis-
attacked her daughter out of guilt. Specifically, ten, be curious, ask questions, and not talk too
when her daughter unknowingly reminded much. The therapist also discouraged her from
Sharise of her own “failings” as a caregiver, apologizing too quickly, as this often brings clo-
she felt accused and blamed. Sharise now rec- sure to a conversation that the therapist wanted to
ognized how her daughter must have felt during sustain. When the time was right and Brittney had
their times of conflict; Sharise said “I didn’t shared her full story, Sharise gave her daughter an
know how to manage my own hurt when honest apology for not being there for her during
Brittney needed me.” In this task, Sharise devel- those difficult times. Sharise also shared a bit
oped a new narrative about herself, her child- about her own life experiences as a child, but not
hood, and her parenting – an approach that had so much that the mom would become the center of
more tolerance for painful feelings. In the fifth attention.
and final Task III session, the therapist offered In Task IV sessions, the conversations between
Sharise the opportunity to change her relation- Brittney and Sharise were different from those in
ship with her daughter. Once Sharise agreed, the the past. Mom was softer and Brittney was more
therapist prepared her for the first Task IV willing to share her experiences and emotions
conversation. openly. At the end of Task IV, the therapist asked
Task IV: Repairing Attachment. Building on the family to reflect a bit on how these conversa-
the preparation in Task II and Task III sessions, tions had gone. Mom and daughter both acknowl-
Brittney and Sharise immediately engaged in an edged how different the other one had been: both
attuned discussion about relational ruptures in more open, more receptive, and more honest.
Task IV. In the first session of Task IV, they They both realized how often they bury their
discussed how Brittney felt alienated and hurt feelings and how much better it was to
attacked by her mother when she tried to talk share them with each other. Mom and daughter
to her about upsetting experiences. After some only needed two Task IV sessions before moving
discussion of this, Brittney shared her feelings on to Task V.
of being rejected by her father and how bad this Task V: Promoting Autonomy. Sharise and
made her feel about herself. With the help of the Brittney had four Task V sessions to discuss
therapist, Sharise listened to her daughter’s feel- issues contributing to Brittney’s depression
ings with empathy, rather than criticism and (e.g., being bullied, struggling to fit in, school
interrogation. In fact, Sharise was so moved by attendance), plans for the future (e.g., work,
Brittney’s sadness that she physically moved college), and personal development (e.g., sexu-
closer and comforted her daughter as she cried. ality, romantic relationships, biracial identity).
In this moment, the therapist had the adolescent All of these conversations allowed Sharise to
sharing vulnerable feelings and the parent practice supporting her daughter on her path
toward womanhood. The therapist encouraged References

Sharise to serve as a support for her daughter
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Spirito, A., Vitiello, B., et al. (2009). Treatment of A
make better decisions). By the end of Task V,
selective serotonin reuptake inhibitor-resistant depres-
the family felt like trust was coming back, sion in adolescents: Predictors and moderators of treat-
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Bernal, G., Jimenez-Chafey, M. I., & Rodriguez,
Brittney began college preparatory courses with
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her mom’s support and actively visited local com- A resource for considering culture in evidence-based
munity colleges to learn more about business pro- practice. Professional Psychology: Research and Prac-
grams. By the end of therapy, Brittney had begun tice, 40(4), 361–368.
Bowlby, J. (1969). Attachment and loss: Attachment (Vol.
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1). New York: Basic Books.
styling and braiding service. Suicide was no longer Chambless, D. L., & Hollon, S. D. (1998). Defining empir-
a needed coping strategy, and the family had a plan ically supported therapies. Journal of Consulting and
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Diamond, G.S., Siqueland, L., & Diamond, G.M.
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(2003). Attachment-based family therapy for
and support. Brittney’s depressive symptoms and depressed adolescents: Programmatic treatment
suicidal ideations had dropped to a nonclinical development. Clinical Child and Faily Psychology
level. Brittney and Sharise found ABFT to be Review, 6(2), 107–127.
Diamond, G. M., Diamond, G. S., Levy, S., Closs, C.,
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Although not all cases go this smoothly, many family therapy for suicidal lesbian, gay, and bisexual
families successfully progress through the five adolescents: A treatment development study and open
tasks in 12 to 16 weeks. ABFT can accomplish trial with preliminary findings. Psychotherapy, 49(1),
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Diamond, G. S., Russon, J., & Levy, S. (2016a).
Attachment- based family therapy: A review of the
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184 Attention Deficit Hyperactivity Disorder (ADHD) in Couple and Family Therapy
Hetherington (Ed.), Mussen manual of child psychol- end their relationships. The ADHD partner often
ogy (pp. 1–102). New York: Wiley. listens poorly, fails to finish tasks or fulfill commit-
Restifo, K., & Bogels, S. (2009). Family processes in the
development of youth depression: Translating the evi- ments, manifests inappropriate emotional outbursts,
dence to treatment. Clinical Psychology Review, 29(4), and generally acts in the relationship more like a
294–316. https://doi.org/10.1016/j.cpr.2009.02.005 child than an adult.
Ringborg, M. (2016). Dissemination of attachment-based Compounding the potential for disruption to
family therapy in Sweden. Journal of Family Therapy,
37(2), 228–239. https://doi.org/10.1002/anzf.1153 the couple and the family unit: Adult ADHD itself
Santens, T., Devacht, I., Dewulk, S., Hermans, G., & is associated with sequelae including higher than
Bosmans, G. (2016). Attachment-based family therapy average rates of undereducation, underemploy-
between Magritte and Poirot: Dissemination dreams, ment, bankruptcy, traffic accidents, and interper-
challenges and solutions in Belgium. Australian and
New Zealand Journal of Family Therapy, 37(2), sonal violence (Barkley 2014). When ADHD
240–250. goes long unrecognized or misunderstood – as it
has for most adults – domestic problems tend to
intensify over time. The partners of these adults
misattribute ADHD-related problem behaviors to
Attention Deficit malicious motives, lack of love, immaturity, or
Hyperactivity Disorder their own deficiencies. The adults with ADHD
(ADHD) in Couple and Family themselves feel misunderstood and frustrated.
Therapy Both partners’ negative reactions to the “invisible
elephant in the room” of ADHD gradually create a
Gina Pera1 and Arthur L. Robin2,3 downward spiral in the relationship and for each
1 individual.
Adult ADHD-Focused Couple Therapy,
San Francisco Bay Area, CA, USA Traditional marital therapy typically proves
2 unsuccessful because it does not address the spe-
Children’s Hospital of Michigan, Detroit,
MI, USA cial challenges that ADHD poses for the couple
3 (Pera 2014). Snyder et al. (2003) succinctly
Dennis, Moye, and Associates, Bloomfield Hills,
MI, USA describe the situation currently facing therapists
seeking to help ADHD-challenged couples:
Therapists trained primarily in couple or family
Synonyms interventions sometimes feel ill prepared to address
significant individual psychopathology contribut-
ing to or interacting with relationship concerns—
ADHD in couples; ADHD marital therapy; Adult in part because traditional systemic formulations
ADHD couple therapy; Counseling couples with have often marginalized or ignored the etiological
ADHD role of individual pathology in family system
functioning.
Adult ADHD-Focused Couple Therapy (Pera

Introduction and Robin 2016) is specifically designed to
address relationship dysfunction and the full
Attention deficit hyperactivity disorder (ADHD) is a
range of issues around domestic cooperation
genetically based, neurobiological disorder that
for couples where one or both partners
begins in childhood but persists into adulthood at a
have ADHD.
rate of at least 65–70% (Barkley 2014). It is esti-
mated that only one in ten adults with ADHD in the
USA is diagnosed. Many of these adults are cur-
rently misdiagnosed with depression, anxiety, or Theoretical Context for Concept
other conditions. Couples wherein one or both part-
ners have ADHD often experience excessive con- Until recently, ADHD was considered primarily
flict and negative interactions that threaten or even a disorder of attention, impulse control, and
Attention Deficit Hyperactivity Disorder (ADHD) in Couple and Family Therapy 185
hyperactivity. Now researchers know that et al. 2012), imbuing them with ADHD-specific
ADHD is fundamentally a disorder of self- treatment interventions:
regulation of executive functions and that the A
18 DSM-5 ADHD symptoms can be considered 1. Alter views of the relationship: Couples are
akin to executive functions (Barkley 2014). provided with psycho-education regarding
Executive functions are higher-order processes ADHD, its causes, how it impacts relation-
of the brain that guide an individual’s behavior ships, and how changing their view of the
over time, analogous to the chief executive offi- nature of their relationship’s challenges
cer of a company or the conductor of an orches- reduces blame and sets the stage for positive
tra. To use the latter metaphor, the conductor change.
selects the musicians and music, rehearses the 2. Modify dysfunctional interactions: Targeted
orchestra, and leads the musicians during the interventions address dangerous and destruc-
concert. If the conductor does a good job, the tive behaviors that ADHD partners may
music sounds fine. If not, it sounds exhibit (e.g., violence, anger outbursts, abusive
mediocre – or even cacophonous. In adult remarks, denial).
ADHD, the brain is inconsistently “conducting” 3. Decrease emotional avoidance: Clinicians
the person’s daily functioning; core executive employ techniques such as consciousness rais-
functions are not efficiently operating in a ing and motivational interviewing to cut
purposeful, task-oriented direction. through denial and low self-awareness of
Neuroimaging research has identified deficits ADHD as well as the associated tactics around
in areas of the brain associated with the execu- blame and avoidance that some individuals
tive functions of inhibition, attention, distracti- with ADHD have developed as poor coping
bility, organization, time, self-awareness, responses.
emotional self-control, and motivation in peo- 4. Improve communication: Direct communica-
ple with ADHD, compared to those without tion training and the modified Imago Dialogue
ADHD (Pera and Robin 2016). These areas help couples improve their interpersonal
include the frontal lobe, the basal ganglia, and exchanges.
the cerebellum. Intrinsically interesting tasks 5. Promote relationship strengths: The thera-
such as the Internet and video games produce pist continually emphasizes the importance of
higher reactivity in these areas of the brain and partners praising each other’s efforts, increas-
more task completion for everyone, regardless ing positive activities, using rewarding incen-
of the presence of ADHD. Intrinsically less tives for habit and behavior change, and
interesting tasks – such as doing chores, listen- rekindling romance.
ing to another person speak, and paying
bills – require more brain stimulation for the From evidence-based treatment for adult
person to complete. The neurogenetic brain def- ADHD, the therapist further incorporates these
icits found in adults with ADHD interfere with elements:
such tasks. As a result, many aspects of ADHD-
challenged relationships suffer. 1. Interventions designed to teach the ADHD
Adult ADHD-Focused Couple Therapy partner how to get the most out of
addresses this situation by blending evidence- medication
based marital therapy with evidence-based 2. Cognitive restructuring designed to replace the
treatment for adult ADHD, including a specific distorted thinking developed over the years
cognitive behavior therapy model and medica- when ADHD had not been identified with
tions shown to mitigate ADHD symptoms. This more reasonable thinking
model incorporates five principles derived from 3. Behavioral interventions that improve time
more than 40 years of published research and management, organization, planning, and
practice on effective couple therapy (Benson follow-through
Description professional boundaries, the knowledgeable

therapist can provide critically needed help in
Adult ADHD-Focused Couple Therapy proceeds informing about medication; guiding the cou-
through seven steps: ple to select meaningful, medication-sensitive
targets for change (e.g., attentive listening, effi-
1. Educate the Couple about ADHD. The ther- cient follow-through, and enhanced emotional
apist provides the couple with a scientifically self- control); employing a simple system for
based explanation of ADHD as an executive monitoring medication effects; and helping the
function disorder, summarizes the evidence for couple work as a team in giving feedback to the
its genetic/neurobiological etiology, describes physician.
how it impairs individuals and couples, sum- 4. Acquire New Habits and Improve Coping
marizes how a diagnosis is made, and outlines Behavior. The therapist teaches the couples
the various treatment strategies available to the “nuts and bolts” strategies for behavior change.
couple. Each partner is encouraged to ask ques- These include reliably adopting physical sup-
tions and to fully process their reactions to the ports (e.g., calendar planners, prioritized “to-
diagnosis in joint or individual sessions. do” lists, and reminder systems) and cognitive
2. Clarify the Partners’ Cognitions. Prior to strategies around “getting things done” (e.g.,
learning about ADHD, couples often harbor managing time, breaking down complex tasks
misattributions or distorted cognitions about into small steps, overcoming procrastination
each other’s behaviors, responses, and and distractibility, and utilizing positive incen-
counter-responses. The non-ADHD partner tive systems). The couple learns how to work
often attributes the ADHD partner’s actions to as a team in applying these techniques to their
malicious motives or not caring about the rela- important household and family projects. In
tionship, leading to depressed and angry affect experiencing successful task completion
and poor coping behavior. The ADHD partner around these projects – typically for the first
often views the non-ADHD partner’s actions time – couples gain new optimism in improv-
as over controlling and hypercritical. It is ing other aspects of their life together.
important to remember that sometimes both 5. Communicate Attentively and Empathic-
partners have ADHD, manifesting in perhaps ally. The couple learns to identify and replace
very different ways; these dual-ADHD couples negative communication habits with positive,
experience patterns similar to the ADHD and solution-oriented habits. The result: They can
“non-ADHD” partner. listen to each other without interruption, express
The therapist uses adult ADHD-focused their thoughts and feelings with dignity and
cognitive restructuring to help the couple iden- respect, and mutually problem-solve disagree-
tify their dysfunctional coping responses and ments. The highly structured Imago Therapy
reframe their challenges through the lens of technique called The Dialogue serves as the
ADHD as a neurobiological disorder. This centerpiece of communication training, chosen
new perspective promotes less toxic and more because it reduces impulsivity, increases
neutral cognitions, establishing a stable foun- sustained attention, and fosters empathy.
dation for more positive affect and teamwork 6. Co-parent Effectively. Adults with ADHD
in learning coping behaviors and improving typically experience extreme difficulty in con-
their ability to problem-solve long after sistently implementing the rules, routines,
therapy ends. structure, incentives, and punishments needed
3. Optimize Medication. Many physicians con- to parent effectively. This is true whether or not
duct only brief medication monitoring visits. their children also have ADHD. (Given the
They do not provide couples with the knowl- high heritability of ADHD, however, chances
edge or tools to access, much less optimize, the are good that biological children will also have
benefits of medication. While respecting ADHD, which only increases demands around
creating consistent routines and structure, not chores. After her many tearful breakdowns,
to mention regulating tempers.) As a result, Michael would always once again agree to help
their partners perform more than their fair more with laundry, dinner preparation, or with the A
share of the parenting, especially when it kids’ homework. But he never followed through
comes to discipline. Moreover, they come to for long, and he cannot explain why. Rose said the
consider the ADHD partner to be “like another reason is clear: He doesn’t care; he does only what
child to be parented.” The therapist helps the he wants to do. Over the years, Rose coped by
couple “get on the same page” with regard to dreaming of “Plan B” – that is, the time when their
evidence-based parenting strategies. They also children were living on their own, and she could
apply to parenting the lessons learned from finally make decisions based on her happiness.
step 4, Behavior and Habit Change. That “empty nest” time has come. Their youngest
7. Address Other Challenges. ADHD- just moved out.
challenged couples grapple with various spe- One day at work, Rose confided to a staff
cific issues around sexual intimacy, money psychologist that she was filing for divorce. The
management, cyber addiction, and denial of more the psychologist listened, however, the more
ADHD. Distinct modules in Adult ADHD- she perceived “red flags” for ADHD. Rose
Focused Couple Therapy address each of responded with incredulity. On the drive home,
these challenges. however, she had time to think. The description
fit. Michael has his good qualities; they were just
The therapist typically goes through these so overwhelmed by the problematic behaviors. If
steps in the order described above, but the therapy it is possible that their long-running conflicts are
is flexibly tailored to the needs of each couple. due to a treatable condition, she decides she owes
Both partners attend most sessions, but the thera- it to him and their marriage to pursue the
pist may at times choose to meet individually with possibility.
each partner. This can be especially helpful when In preparation to deploying “Plan B,” Rose had
the adult with ADHD needs to be “brought up to in recent months turned her attention to sprucing
speed” on many basic personal habit-change and up and then selling their 1960s home. Michael,
cognitive-restructuring techniques before they currently out of work, possesses the “sprucing up”
can be expected to implement cooperative skills but not the follow-through. He has always
strategies. started renovation projects with great enthusiasm.
He eventually loses steam, however, and returns
to other more interesting, passive activities, such
Application of Concept and Clinical as watching YouTube videos on random topics.
Example When it came to issues such as the months-long
unfinished bathroom tile, Michael minimized with
Michael and Rose have been arguing for most of quips such as “Grout is over-rated” and promised
their 26-year marriage, with conflicts centering on “I’ll get to it.” Just last week, Rose declared, “I’m
spending, chore sharing, and co-parenting. done with your lame excuses.” She accused him
Michael has worked off and on as a carpenter for of being a “do-nothing who does not care about
a home-building company. Rose works as the your marriage, just like your father.” He retorted
longtime billing manager in a busy psychiatric that she is “a controlling bitch, just like your
clinic. The couple allowed the more intimate mother.” That’s when Rose gave up on renovating
aspects of relationship to fall by the wayside the house. The next day, she confided in the clinic
years ago, due to the historical futility at improv- psychologist her plans for divorce.
ing these areas. Rose earns the more reliable sal- Now, Rose wants to give their marriage one last
ary, acted as primary caregiver for the children, try. She presented the possibility of ADHD to
and, having finally given up on inspiring Michael and asked him to pursue an evaluation.
Michael’s cooperation, performs most household Initially, he balked. Clearly sensing, however, that
a refusal would mean the end of his marriage – and Clarify Cognitions. Using the figure detailing
being vaguely aware that ADHD might explain his the Adult ADHD-Focused Dysfunctional Interac-
lifelong struggles – he made the appointment. Once tion Cycle (Pera and Robin 2016, p. 66), the
evaluated and diagnosed, he half-heartedly agreed therapist explains to Rose and Michael that they
to couple therapy. Rose knew that the therapist aren’t alone. Other couples dealing with
would need to provide reason for optimism quite unrecognized ADHD predictably develop tightly
quickly, to keep Michael “in the game.” Their one held and toxic misperceptions about each other’s
attempt at couple therapy, years ago, failed because behaviors, reactions, and counter-reactions. For
the therapist kept delving into Michael’s dysfunc- example, the therapist reframes Michael’s poor
tional family of origin without offering any strate- follow-through on various promises as a natural
gies for addressing the couple’s domestic problems, consequence of his ADHD brain turning off repet-
leaving him feeling hopeless and defeated before he itive or tedious tasks, not laziness or lack of
got started. regard. Likewise, Rose’s critical statements
ADHD Education. The therapist thoroughly become better understood as the natural frustra-
explains what ADHD is, the variable ways in tion of a partner who has for years had no viable
which it can manifest, and how the diagnosis is explanation for her spouse’s repeated failure to
made. “This explains a lot about my dad,” said finish what he agrees to do and who forgets impor-
Michael, after learning of ADHD’s high heritabil- tant agreements – and always finds a way to avoid
ity. “It explains a lot about Michael’s approach to important discussions.
work, too,” said Rose. One the one hand, Michael Optimize Medication. Michael expressed a lot
could easily sell customers on his plans for of anxiety about “Big Pharma” and the possible
remodeling, and they would be impressed with negative effects of medication – a bit odd for a
his enthusiastic “blaze of glory” start. But as person who smokes two packs of cigarettes per
time went on, they grew frustrated that he would day. Nonetheless, the therapist provided him with
“hyper-focus” on small details and loses focus clearly explained scientific information about stim-
toward more monotonous tasks, such as measur- ulant medication and urged him to attend an adult
ing and hanging doors. Too many times, he simply ADHD support group meeting on this topic. After
stopped showing up, thus forfeiting payment for talking there with other adults, including men
work completed. Michael was relieved to learn Michael’s age, who benefitted greatly from medica-
that his lifelong pattern of avoidance was common tion, Michael reluctantly agreed to try it.
for late-diagnosis adults with ADHD – and that The couple chose two medication targets for
there was hope for change. change: (1) Michael conversing attentively with
Also like many other adults with ADHD, Rose during dinner and (2) Michael following
Michael’s attention darts to the new and excit- through on three simple, mutually agreed-upon
ing. Left in the dust: the “daily tasks of living” household tasks each day. After the prescribing
and nurturing a relationship. To put simply one physician gradually increased Michael’s dosage
aspect of ADHD, the associated neurobiology of stimulant medication over 3 weeks, the couple
can lead a person to crave the stimulation of concurred in seeing great improvement in both
exciting or novel tasks but shut down when the target behaviors. Again, it is emphasized, a team
task becomes mundane. Michael learns to view approach helps both partners stay on track and
his ADHD as a challenge to be coped with, not optimistic about making further improvements.
an excuse. Rose comes to understand that the As part of the treatment team, the physician
underlying issues are biomedical in nature, not agreed that Rose should accompany Michael to
intentional. Both partners learn that in order to his medication follow-up visits.
have a more satisfying relationship and Acquire New Habits and Improve Coping
smoother-running domestic life, they need to Behavior. Michael acknowledges that he wants to
cooperate in implementing ADHD-targeted be more actively engaged in his marriage and their
strategies and altering their mindsets. “team effort.” He expresses a desire to complete
the household renovation, one that promises to the next day’s goals. Now, the therapist assigned
give their marriage a beautiful “fresh start.” them the task of using part of that time to practice
Simultaneously, though, he feels hamstrung by new elements of The Dialogue learned in session. A
doubts, reinforced by past failures. The list Co-parenting. Because their children were
seems overwhelming. He dreads Rose having to now grown and on their own, this component of
endlessly nag him to finish. The therapist the intervention was no longer needed. Yet, given
explained the importance of acknowledging and the pileup of years spent arguing about
problem-solving around those fears, especially co-parenting, the therapist found it important to
around making and completing plans. review how ADHD, left unrecognized, can pre-
First, he prompted the couple to list on paper sent co-parenting challenges. Rose now better
all the steps of the renovation, sequence the steps, understood why Michael was always the “fun”
break them down into small steps, note them on a parent, leaving her to be the “heavy.” As the
calendar spanning several months, and detail how children grew, the constantly changing rules and
they would carry out the first step. During the next guidelines were too much for Michael to keep
few weeks, the therapist directed the couple to sit track of. He also did not trust himself with meting
down each evening for 10 min, reviewing the out discipline, fearful of repeating his own father’s
day’s work and remaining tasks. They used their violent punishments.
smartphones to structure daily and weekly to-do Address Other Challenges. Michael and Rose
lists, set reminders, and reward their progress. had not been sexually intimate for 3 years at the time
They selected motivating rewards such as dinner that they entered therapy. They had grown so angry
out or movies for completing each phase. To their and distant from each other. Yet, the therapist took
surprise, they steadily accomplished a great deal no direct steps to help them restart sexual intimacy.
without deteriorating into “screaming meanies.” After they started attributing their entrenched prob-
Communicate Attentively and Empathic- lems to ADHD as the “elephant in the room,” and
ally. Michael and Rose called it a “freeing experi- found new success in working cooperatively, they
ence.” That is, their gradually learning to reframe naturally rekindled their desire and again enjoyed
their challenges through the neurobiological lens of sexual intimacy. This couple fortunately had no
ADHD rather than Michael being “lazy and never comorbid addictive behaviors that also needed
listening” and Rose being “hypercritical and con- intervention.
trolling.” This breakthrough led to improved posi- Other couples of course will need targeted help
tive regard, further solidified by ongoing progress in improving patterns around managing income
on shared goals at home. Between these events and and outgo, curbing electronic overuse, tackling
Michael’s ongoing medication treatment, he showed ADHD challenges related to sleep, and nurturing
more active engagement with Rose – listening, physical and emotional intimacy. Throughout,
remembering more, and being more thoughtful. practical strategies typically lay the foundation
For her part, Rose had dropped the incessant inflam- for success. After all, even physical intimacy typ-
matory criticism. ically relies on cooperation in the rest of life,
With this more positive foundation established, including both partners being in bed at the same
the therapist worked to strengthen the pair’s com- time instead of one staying up until the wee hours
munication beyond the chore list. Using the struc- checking social media.
ture of the Imago Couple Dialogue, Michael and
Rose learned how to have more respectful conver-
sations about intimate issues and practical problem- Conclusion
solving. They practiced sharing appreciations for
each other and dealing with grievances. Under Each couple challenged by adult ADHD is differ-
their therapist’s direction, the couple had been ent. ADHD itself is a syndrome, meaning that
“checking in” with each other for 10 minutes daily, symptoms are variable individual to individual.
primarily to note renovation progress and coordinate Moreover, most adults with ADHD will have a
190 Attneave, Carolyn L.
second coexisting condition. The poor coping Introduction

responses to unrecognized ADHD take myriad
shapes as well, influenced by socioeconomic Carloyn L. Attneave was one of the best known
backgrounds, culture and ethnicity, educational American-Indian psychologist due to her contri-
levels, and other aspects of personality. The part- butions in cross-cultural issues and network ther-
ners of these adults might also have ADHD – or apy in the field of family therapy.
any other human foible. Family-of-origin issues
always form a part of the picture. Yet, when
ADHD is challenging the relationship, predictable Career
patterns can ensnare even the most mutually lov-
ing partners and lead to a mistakenly dire progno- In 1940, Attneave completed her Bachelor’s degree
sis for the more troubled couples. ADHD- in English and Theatre at California State Univer-
informed strategies can provide the all-important sity, Chico. Attneave returned to school shortly after
foundation for healing ADHD-challenged graduating to pursue a second baccalaureate in ele-
relationships (Pera and Robin 2016). mentary education. Attneave put her teaching career
on hold and joined the Coast Guard during World
War II, which made her one of the first female
officers. While in the Coast Guard, Attneave
References
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New York: Guilford Publications. After the war was over, Attneave returned
Benson, L. A., McGinn, M. M., & Christensen, A. (2012). to Stanford in 1947 to begin her doctoral work
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Pera, G. A. (2014). Counseling couples affected by adult received her Ph.D. from Stanford. Attneave spent
ADHD. In R. A. Barkley (Ed.), Attention-deficit hyper- several years in Texas teaching at various institu-
activity disorder: A handbook for diagnosis and treat- tions such as Texas Technical College and Texas
ment (4th ed., pp. 795–825). New York: Guilford Press.
Pera, G. A., & Robin, A. L. (2016). Adult ADHD-focused Woman’s University. Attneave moved to Oklahoma
couple therapy: Clinical interventions. New York: and began a new position as the coordinator of
Routledge. community guidance services for the Oklahoma
Snyder, D. K., Schneider, W. J., & Castellani, A. M. State Department of Health, which serviced seven
(2003). Tailoring couple therapy to individual differ-
ences. In D. K. Snyder & M. A. Whisman (Eds.), different American Indian tribes. In 1968, Attneave
Treating difficult couples: Helping clients with moved to Philadelphia, Pennsylvania, to work at the
coexisting mental and relationship disorders Child Guidance Clinic where she began to focus on
(pp. 27–52). New York: Guilford Press. network therapy. For the next 6 years, Attneave
collaborated with physicians, civic organizations,
tribal and federal agencies, tribal leaders, and med-
icine men and women by providing mental health
Attneave, Carolyn L. services. Attneave began her teaching career at Har-
vard University’s School of Public Health in 1973
Heather Colquhoun then later joined the faculty of the University of
Couple and Family Therapy, Alliant International Washington for the remaining 15 years of her career.
Contributions to Profession
Name
Attneave developed network therapy when
Carolyn L. Attneave, Ph.D. (1920–1992) her interest in an individual’s support network
Australian and New Zealand Journal of Family Therapy 191
beyond one’s family offered an alternative to LaFromboise, T. D., & Fleming, C. (1990). Keeper of the
hospitalization for mental health concerns. fire: A profile of Carolyn Attneave. Journal of Counsel-
ing & Development, 68(5), 537–548.
Throughout Attneave’s career, she worked LaFromboise, T. D., & Trimble, J. E. (1996). Obituary: A
with leaders within the health care field to Carolyn Lewis Attneave (1920–1992). American
increase mental health services for individuals Psychologist, 51(5), 549.
of variously diverse backgrounds. Attneave Speck, R. V., & Attneave, C. L. (1973). Family networks:
Retribalization and healing. New York: Pantheon.
strived to gain a better cultural understanding
of the cultural contexts of her clients. Attneave
developed a stage model for network therapy
and created a map for patients and professionals
to help identify people and relationships of a Australian and New Zealand
network. In 1973, Attneave released her book, Journal of Family Therapy
Family Networks, coauthored by Ross Speck,
which provided a comprehensive guide to Glenn Larner
using network therapy. Australian and New Zealand Journal of Family
A year later, Attneave moved to Boston, Therapy, Sydney, NSW, Australia
Massachusetts, and founded the Boston Indian
Council. The Boston Indian Council became
known to be one of the largest Indian Centers Name of Organisation
in North America. Attneave also developed a
newsletter to exchange information about ser- The Australian and New Zealand Journal of Fam-
vices available to Indian communities called the ily Therapy
Network of Indian Psychologists. During her
time at the Harvard School of Public Health,
Attneave produced a nine-volume document
on the mental health needs, service networks, Introduction
and utilization patterns for the Indian Health
Service. During the last 15 years of Attneave’s Since its foundation in 1979, The Australian
career, she dedicated herself to educating others and New Zealand Journal of Family Therapy
at the University of Washington as a professor (ANZJFT) has played a central role in the devel-
of psychology and director of the American opment of family therapy in Australia and
Indian Studies Program while she continued New Zealand. The journal is a quarterly
her work in network therapy and involved her- peer-reviewed professional journal that pub-
self in community services. lishes relevant, innovative, and original articles
on the theory, research, teaching, and practice of
family therapy. The journal is overseen by an
editorial board under the auspices of the
Cross-References Australian Association of Family Therapy and
published by Wiley. The current Editor-in-
▶ Network in Family Systems Theory Chief is Dr. Glenn Larner with the editorial
team including Associate Editors Liz
Forbat (research) and Kristof Mikes-Liu
References (in practice).
Attneave, C. L. (1976). Family network map. Boston:

Boston Family Institute. Location
Attneave, C. L. (1990). Core network intervention: An
emerging paradigm. Journal of Strategic and System-
atic Therapies, 9, 3–10. Sydney, Australia
192 Authoritarian Parenting
Prominent Associated Figures/ June 2016 issue by Guy Diamond, Ingrid Wagner,
Contributions and Suzanne Levy (the USA and Brisbane,
Australia) had the theme of Attachment-Based Fam-
Michael White from Adelaide, well known with ily Therapy: Adaptation and Dissemination.
David Epston as the originator of narrative ther- In summary, ANZJFT has an international rep-
apy, was the foundation editor of ANZJFT from utation for publishing articles on a wide variety of
1979 to 1984. Under Michael’s tutelage, the jour- topics in couple and family therapy in the areas of
nal provided a much needed bedrock for the theory, practice, research, pedagogy, and training.
evolving family therapy movement “down It hopes to provide a journal with an appeal to both
under.” From 1985 to 1996, ANZJFT was edited academics and practitioners.
by Max Cornwell with contributions from leading
figures in the family therapy field such as Tom
Anderson, Karl Tomm, Luigi Boscolo, and References
Harlene Anderson. The many achievements of
this period included a significant contribution to Brown, C., & Larner, G. (1992). Every dot has a meaning.
Australian and New Zealand Journal of Family Ther-
indigenous family therapy from Colleen Brown apy, 13, 175–184.
on the Stolen Generation in Australia (Brown and Crago, M. (1997). Editorial: A journal for the workplace.
Larner 1992) and an exploration of social justice Australian and New Zealand Journal of Family Ther-
in the Just Therapy approach in New Zealand apy, 18(2), iii–iiv.
Crago, H., & Crago, M. (2007). The ANZJFT: Snapshots
(Waldegrave and Tamasese 1993).
from the history of an evolving journal. Australian and
From 1997 to 2008, coeditors Hugh and New Zealand Journal of Family Therapy, 28(1), 11–20.
Maureen Crago oversaw the development of a pro- Waldegrave, C., & Tamasese, K. (1993). Some central
fessional journal for the workplace (Crago 1997) ideas in the ‘Just Therapy’ approach. Australia and
New Zealand Journal of Family Therapy, 14(1), 1–8.
with articles on a range of clinical themes. As the
Crago and Crago (2007) noted in a snapshot of the
Further Reading
journal’s history, ANZJFT offers a practitioner
Australian and New Zealand Journal of Family Therapy.
friendly and less academic alternative to other fam- Wiley Online Library: http://onlinelibrary.wiley.com/
ily therapy publications with an appeal to both journal/10.1002/(ISSN)1467-8438
beginning and experienced family therapists and is
“distinguished by its continuing attempt to include
humour and provocative ideas, alongside more seri-
ous theoretical exploration and research” (p. 11). Authoritarian Parenting
From 2009 to 2010, coeditors Paul Rhodes, Glenn
Larner, and Alistair Campbell introduced a more Jessica L. Chou1, Shannon Cooper-Sadlo2 and
mainstream journal with a focus on theory, practice, Agnes Jos3
1
diversity, and innovation. Queen of Peace Center, St. Louis, MO, USA
2
In September 2010, the helm was taken by Glenn School of Social Work, Saint Louis University,
Larner, the current editor-in-chief. In this time St. Louis, MO, USA
3
ANZJFT has become the publication journal for Community Treatment, Inc. (COMTREA),
the Australian Association of Family Therapy and Comprehensive Health Center, St. Louis,
developed its current format as a Wiley journal. An MO, USA
exciting regular feature is a series of groundbreaking
special issues on contemporary approaches to fam-
ily therapy compiled by local and international guest Introduction
editors. For example, in March 2015, Judith Brown
and Kristof Mikes-Liu (Sydney) compiled a special Parents play an integral role in child development
issue on Dialogical Practices including contribu- over the lifespan (National Center on Parent, Fam-
tions from Peter Rober and Jaakko Seikkula. The ily, and Community Engagement 2013).
Authoritarian Parenting 193
Parenting style has been a well-studied phenome- warm and nurturing disposition. Parents who
non in relation to child outcomes. Through the utilize authoritarian parenting tend to be more
studies of parenting the authoritarian parenting rigid and narrow in rule setting while being A
style has emerged as a more disciplinary style of more punitive in disciplinary measures
parenting compared to the authoritative and per- (Woody 2003).
missive styles (Woody 2003). To fully understand From a developmental perspective, parenting
different parenting styles, developmental and cul- styles need to be taken into consideration. Since
tural perspectives must be considered. authoritarian parents tend to control the child and
expect the child to follow directions, children can
have difficulty developing the autonomy needed
Theoretical Context for Concept to formulate their own ideas and beliefs as they get
older (Fernandez et al. 2013). Since the child is
Diana Baumrind (1971) developed one of the most rarely provided with an explanation for expected
widely used theories of parenting typology. behaviors, he or she is unable to understand why
Through her extensive work of observing children behaving a certain way aligns with one’s beliefs.
from elementary school through adolescents, Instead, a child behaves based on an existing
Baumrind created three parenting styles: authoritar- power differential and fear of consequences.
ian, authoritative, and permissive (Pellerin 2005). Goals are not created collaboratively, rather they
Maccoby and Martin then expanded Baumrind’s are dictated. It is not unusual for children in these
theory and provided further detail of different par- homes to struggle with poor self-esteem and have
enting styles (Wang and Fletcher 2016). behavior concerns. Intrinsic motivation to suc-
The different parenting styles are based on ceed is rare for a child raised in an authoritarian
intensity of two dimensions, responsiveness and home and consequently impact academic achieve-
demandingness. The two dimensions are not ment (Fernandez et al. 2013).
mutually exclusive rather they interact together Consideration must be given to the fact that
and are used to typify each parenting style parenting styles are culturally driven and the
(Minaie et al. 2015). Parents who are low on authoritarian parenting style was developed and
demandingness and high on responsiveness has been rooted in Western culture (Van Campen
are classified as permissive, while parents who and Russell 2010). Though the authoritative
are high on responsiveness and high on demand- parenting style has been observed as yielding the
ingness are considered authoritative. Parents who most ideal outcomes for children, the authoritar-
are low on responsiveness and high on demand- ian parenting style should be understood in the
ingness are characterized as utilizing the authori- cultural context in which it exists before stigma-
tarian style of parenting (Pellerin 2005). tizing this style of parenting.
Description Application of Concept in Couple

and Family Therapy
Authoritarian parenting favors demandingness
over responsiveness. Parents who are low in The therapist should take time to gain an under-
responsiveness lack empathy and warmth standing of the context for which the authoritar-
toward their child(ren). While parents who are ian style of parenting developed and was
high in demandingness are able to set bound- maintained. Understanding cultural influences
aries, limits, and age-appropriate expectations can provide insight into how parenting styles
tailored toward healthy child developmental tra- manifest and can be viewed as beneficial in
jectories (Pellerin 2005). Thus, an authoritarian certain cultures. For example, some cultures
parent is generally described as a parent who may adhere to authoritarian parenting practices
prioritizes enforcing rules but often lacks a as it aligns with cultural values (Kotchick and
194 Authoritarian Parenting
Forehand 2002). Navigating cultural expecta- away from the home. If Tracy does not complete
tions regarding parenting should be done in the chore list Georgia has created for each day,
collaboration with the parent, and the therapist Tracy loses her phone for 1 week for each day
should remain supportive in assisting parents in chores are left uncompleted. In addition, Tracy
adapting old parenting styles into new ones that is not allowed to have friends to the home or
work within the family unit. leave the home when Georgia is at work.
Communication about authoritarian parenting Recently, Tracy has begun talking back to Geor-
style is key in gaining insight into how this style of gia, and Georgia discovered that Tracy has
parenting is impacting the child, as well as the snuck out of the house on more than one occa-
parent-child relationship. Children who are sub- sion. Although Tracy maintains good grades at
ject to harsh disciplinary measures and strict rule school, Georgia is concerned about Tracy’s
enforcement can become rebellious and exhibit behaviors. Georgia’s reaction to Tracy’s recent
other unintended consequences. Therapeutic tech- behavior is to continue punishment through tak-
niques can be utilized to discuss disciplinary mea- ing things away from Tracy and limiting inter-
sures and how to adapt a parenting style to achieve action with friends at all times.
the desired behaviors in children. For a parent During family therapy, the therapist explores
who uses an authoritarian style this may warrant with Georgia and Tracy how the isolation Tracy
a discussion on balancing discipline with warmth is experiencing may be contributing to her
and flexibility. Additionally, the therapist can behaviors. Georgia reports she is not interested
explore age-appropriate expectations with the par- in the therapist’s explanations for Tracy’s
ent and child in an effort to support healthy behaviors and believes that her granddaughter
development. should respect her enough to listen. The thera-
The therapist should be attentive of how the pist continues to validate aspects of Georgia’s
authoritarian style of parenting may present in the parenting style while exploring where it devel-
session. As this style of parenting focuses more on oped. After several sessions, Georgia reveals
disciplinary measures and rigid boundaries, a par- she wishes she had enforced more rules when
ent may enter therapy wanting to control the flow Tracy’s mother was growing up and reveals that
of the session. Engaging in a power struggle hin- she was raised in a culture that highly valued
ders the ability to build rapport and can be an discipline and control. This disclosure enables
obstacle for engaging the parent. The therapist the therapist to understand Georgia’s authoritar-
must remain empathetic towards this style of par- ian parenting style with Tracy and acknowledge
enting and focus on validating positive aspects of Georgia’s concerns for her granddaughter’s
this parenting style. Consistent discipline and safety as well as her future. The therapist and
monitoring of behaviors has been linked to buff- Georgia discuss alternative ways to address
ering against stressors (Kotchick and Forehand Tracy’s behaviors in order to elicit change such
2002). Likewise, the therapist should remember as setting boundaries and limits for sneaking out
that this style of parenting is a reflection of care of the house while still letting Tracy know she
and consideration for the child’s well being. cares.
Clinical Example Cross-References
Georgia is the guardian of her 16-year old ▶ Authoritative Parenting

granddaughter, Tracy. Georgia has been raising ▶ Building Strong Families
Tracy since Tracy’s mom went to jail 11 years ▶ Children in Couple and Family Therapy
ago. Due to financial struggles, Georgia works ▶ Family of Origin
long hours and Tracy is often alone. Georgia has ▶ Nurturing Parenting Enrichment Program
firm expectations of Tracy while Georgia is ▶ Parenting Wisely Enrichment Program
Authoritative Parenting 195
References experience and for many, are influential over the

course of a lifetime. More specifically, parent-
Baumrind, D. (1971). Current patterns of parental author- child relationships can determine various aspects
ity. Developmental Psychology, 4, 1–103. A
of family functioning. Different parenting styles
Fernandez, I. T., Schwartz, J. P., Chun, H., & Dickson,
G. (2013). Family resilience and parenting. In can promote or hinder child development. Author-
D. S. Becvar (Ed.), Handbook of family resilience itative parenting style has been deemed the ideal
(pp. 119–136). New York: Springer. parenting style that offers healthy child adjust-
Kotchick, B. A., & Forehand, R. (2002). Putting parenting in
ment (Minaie et al. 2015).
perspective: A discussion of the contextual factors that
shape parenting practices. Journal of Child and Family
Studies, 3, 255–269.
Minaie, M. G., Hui, K. K., Leung, R. K., Toumbourou, J. W., Theoretical Context for Concept
& King, R. M. (2015). Parenting style and behavior as
longitudinal predictors of adolescent alcohol use. Journal
of Studies on Alcohol and Drugs, 76, 671–679. Diana Baumrind (1971) developed one of the
National Center on Parent, Family, and Community most widely used theories of parenting typology.
Engagement. (2013). Understanding family engage- Through her extensive work of observing children
ment outcomes: Research to practice series. Retrieved
from elementary school through adolescents,
from ncpfce@childrens.harvard.edu
Pellerin, L. A. (2005). Applying baumrind’s parenting Baumrind created three parenting styles: authori-
typology to high schools: Toward a middle-range the- tarian, authoritative, and permissive (Pellerin
ory of authoritative socialization. Social Science 2005). Maccoby and Martin then expanded
Research, 34, 283–303. https://doi.org/10.1016/j.
Baumrind’s theory and provided further detail of
ssresearch.2004.02.003.
Van Campen, K. S., & Russell, S. T. (2010). Cultural differ- different parenting styles (Wang and Fletcher
ences in parenting practices: What Asian American fam- 2016).
ilies can teach us. Frances McClelland Institute for The different parenting styles are based on inten-
Children, Youth and Families. ResearchLink, 2, 1–4.
sity of two dimensions, responsiveness and
The University of Arizona.
Wang, D., & Fletcher, A. C. (2016). Parenting style and demandingness. The two dimensions are not mutu-
peer trust in relation to school adjustment in middle ally exclusive rather they interact together and are
childhood. Journal Child Family Studies, 25, 988–998. used to typify each parenting style (Minaie
https://doi.org/10.1007/s10826-015-0264-x.
et al. 2015). Parents who are low on demandingness
Woody, D. J. (2003). Early childhood. In E. D. Hutchinson
(Ed.), Dimensions of human behavior: The changing and high on responsiveness are classified as permis-
life course (pp. 159–195). Thousand Oaks: Sage. sive, while parents who are low on responsiveness
and high on demandingness are considered author-
itarian. Parents who are high on responsiveness and
Authoritative Parenting high on demandingness are characterized as author-
itative parents (Minaie et al. 2015). Authoritative
Jessica L. Chou1, Shannon Cooper-Sadlo2 and parenting style is identified as having the most opti-
Agnes Jos3 mal outcomes for children. Parents who utilize an
1
Queen of Peace Center, St. Louis, MO, USA authoritative style often have children who are better
2
School of Social Work, Saint Louis University, adjusted socially, academically, (Cowen and Cowen
St. Louis, MO, USA 2003) behaviorally, and psychologically (Minaie
3
Community Treatment, Inc. (COMTREA), et al. 2015), compared to the other two parenting
Comprehensive Health Center, St. Louis, styles.
MO, USA
Description
Introduction
Authoritative parenting balances the qualities of
Family relationships are some of the most reward- responsiveness and demandingness. Parents who
ing and complex relationships a person can are high in responsiveness demonstrate the ability
196 Authoritative Parenting
to exercise empathy, warmth, acceptance, and discussion of parenting styles can feel accusatory
love toward their child(ren). While parents who or punitive, thus cognizance about the sensitive
are high in demandingness are able to set bound- nature of parenting is pertinent to building trust
aries, limits, and age-appropriate expectations tai- and rapport in session. In alignment with author-
lored toward healthy child developmental itative parenting, the therapist should model
trajectories (Pellerin 2005). Thus, an authoritative empathy and warmth toward the parent and the
parent has the ability to nurture their child while child, while maintaining boundaries with
also enforcing healthy rules. Parents who utilize the dyad.
authoritative parenting are flexible and reasonable The therapist is responsible for utilizing tech-
with their child(ren). They provide positive rein- niques to elicit awareness into current parenting
forcement while enforcing firm expectations that methods as well as parenting expectations. During
are clearly rationalized and communicated with this process, the therapist can begin a discussion
their child(ren) (Woody 2003). on balancing responsiveness and demandingness;
From a developmental perspective, parenting these techniques can also be reinforced in session
styles need to be taken into consideration. with a parent and child. The therapist should offer
Authoritative parenting is associated with therapeutic interventions consistent with authori-
healthy development for children and adoles- tative style of parenting and guide parents in
cents. This style of parenting encourages a adapting these interventions to work within the
child to think about their behaviors and reflect family unit. Boundary setting can be difficult for
on how the behaviors tie to their values some, and a therapist should assist parents in
(Fernandez et al. 2013). Parents, who are understanding how to set boundaries among dif-
attuned and supportive, are able to create an ferent family processes.
environment that fosters this type of critical The role of the therapist should be one of
thinking. In turn, behaviors become much consideration for the parenting context and cul-
more meaningful for the child. Authoritative tural influences that shape different parenting
parenting by its virtue buffers some of the risk styles. Though authoritative parenting style has
factors that are tied to adolescence resulting in largely been favored in the Western culture
more positive outcomes associated with this (Woody 2003), the therapist should consider
parenting style than authoritarian or permissive. how cultural beliefs shape parenting styles
Child and adolescent outcomes are tied to (Kotchick and Forehand 2002). Consideration
adjustment and educational success (Fernandez should also be given to how responsiveness and
et al. 2013). demandingness are interpreted and applied in dif-
Consideration must be given to the fact that ferent cultures. The therapist needs to be willing to
parenting styles are culturally driven (Van support parents and children when applying con-
Campen and Russell 2010). Though the authori- cepts of authoritative parenting.
tative parenting style has been observed as yield-
ing the most ideal outcomes for children, an effort
should be made to understand the cultural influ- Clinical Example
ences on parenting styles regardless of style in
order to ensure best fit for families. Georgia is the guardian of her 16-year old grand-
daughter, Tracy. Georgia has been raising Tracy
since Tracy’s mom went to jail 11 years ago. Due
Application of Concept in Couple to financial struggles, Georgia works long hours
and Family Therapy and Tracy is often alone. Georgia has firm expec-
tations of Tracy while Georgia is away from the
When integrating parenting styles into family home. Recently, Georgia and Tracy entered ther-
therapy, therapists must consider communication apy. Georgia was becoming increasingly
and education about various parenting styles. The concerned about the defiant behaviors she was
Autonomy in Families 197
seeing from her granddaughter. Although Tracy is References

the model student she has started “getting an
attitude” with Georgia and has become more argu- Baumrind, D. (1971). Current patterns of parental author-
ity. Developmental Psychology, 4, 1–103. A
mentative. Tracy insists that if Georgia would just
Cowen, P. A., & Cowen, C. P. (2003). Normative family
“leave me alone” that things would be okay, but transitions, normal family processes, and healthy child
Georgia experiences this as Tracy not obeying her development. In F. Walsh (Ed.), Normal family pro-
rules or respecting her as a parent. Georgia is cesses: Growing diversity and complexity (3rd ed.,
pp. 424–459). New York: The Guildford Press.
concerned she is headed down the same path as
Fernandez, I. T., Schwartz, J. P., Chun, H., & Dickson,
her mother. G. (2013). Family resilience and parenting. In
The therapist first inquired about the context D. S. Becvar (Ed.), Handbook of family resilience
in which Georgia’s parenting style developed. (pp. 119–136). New York: Springer.
Minaie, M. G., Hui, K. K., Leung, R. K., Toumbourou,
After several sessions, Georgia finally reveals
J. W., & King, R. M. (2015). Parenting style and
that she felt she was too permissive with her behavior as longitudinal predictors of adolescent alco-
own daughter and decided to parent her grand- hol use. Journal of Studies on Alcohol and Drugs, 76,
daughter the way she was parented. Georgia 671–679.
Pellerin, L. A. (2005). Applying baumrind’s parenting
described her own parents as strict and control-
typology to high schools: Toward a middle-range the-
ling. In expressing guilt over daughter’s current ory of authoritative socialization. Social Science
situation, Georgia acknowledges that her cur- Research, 34, 283–303. https://doi.org/10.1016/j.
rent parenting style may not be effective either. ssresearch.2004.02.003.
Van Campen, K. S., & Russell, S. T. (2010). Cultural
The therapist guides Georgia to reflect on how
differences in parenting practices: What Asian Ameri-
the two different parenting styles, as varied as can families can teach us. Frances McClelland Institute
they are, may be eliciting similar behaviors. In for Children, Youth and Families. ResearchLink, 2,
offering Georgia another perspective, the thera- 1–4. The University of Arizona.
Wang, D. & Fletcher, A. C. (2016). Parenting style and
pist explained how Georgia can nurture Tracy
peer trust in relation to school adjustment in middle
and at the same time enforce age-appropriate childhood. Journal of Child and Family Studies, 25
rules. Tracy was present in the session while 988-998. https://doi.org/10.1007/s10826-015-0264-x.
the parenting discussion was happening, which Woody, D. J. (2003). Early childhood. In E. D. Hutchison
(Ed.), Dimensions of human behavior: The changing
allowed for Tracy to be an active participant in
life course (pp. 159–195). Thousand Oaks: Sage.
therapy and gain an understanding of Georgia’s
current parenting practices.
In the coming weeks, the therapist worked with
Georgia and Tracy in session to assist Georgia in Autonomy in Families
utilizing a more flexible and responsive approach
to parenting with Tracy. The therapist noted that Brad Sachs
there was a reduction in conflict and that Tracy Stevens Forest Professional Center, Columbia,
was no longer displaying the behaviors that ini- MD, USA
tially brought the family to therapy. The therapist
was able to utilize an authoritative parenting
approach to create the balance needed to support Synonyms
the needs of both Georgia and Tracy.
Independent; Individuation; Self-determination;
Self-directed; Self-reliant
Cross-References
▶ Authoritarian Parenting Introduction

▶ Children in Couple and Family Therapy
▶ Family of Origin Autonomy is one of the three cornerstones of a
▶ Nurturing Parenting Enrichment Program healthy identity, along with competence and
198 Autonomy in Families
relatedness, and entails individuals’ capacity to be Application of Concept in Couple

personally effective in adapting to, and producing and Family Therapy
changes in, their environment (Deci and Ryan
1985). The problems bringing clients into treatment usu-
ally have to do with either stunted or misguided
autonomy on the part of one or more family mem-
bers, so family therapy often revolves on the axis
of facilitating healthy autonomy. The clinician
will emphasize the importance of children explor-
While autonomous functioning was initially
ing their environment, becoming aware of their
envisioned as a quality inhering within an indi-
own desires and motivations, and being allowed
vidual, resulting from a sequential mastery of
to make and learn from their own mistakes. Par-
developmental tasks, contemporary theorists
ents will be encouraged to respect interpersonal
and clinicians find it more useful to view auton-
boundaries, value their children’s unique perspec-
omy as bi-directionally connected with the
tive, and accept them for being who they are rather
capacity for relatedness (McGoldrick
than who they “should” be. Parents who are
et al. 2011). In other words, the more comfort-
overly controlling, permissive, or neglectful,
able one feels about being separate, the better
and/or who burden the child with their own
one can connect with others, and vice versa.
unmet needs, unresolved conflicts, and unfulfilled
From a family development standpoint, the pro-
ambitions will be more likely to raise children
cess of differentiating from one’s family of ori-
who struggle to achieve autonomy.
gin creates the space for autonomy, leading to an
Successful couple therapy will also rely on
increasingly elective and nimble movement into
promoting autonomy, being that, as noted above,
and out of family ties, as opposed to those ties
the capacity for autonomy corresponds closely
becoming stagnant, entrapping, or severed
with the capacity for intimacy.
(Bowen 1978; Stierlin 1981).
If one of the primary goals of treatment is to
promote autonomy within the family crucible, it
behooves therapists to simultaneously promote cli-
Description ents’ autonomy within the treatment crucible, too.
This requires many of the same autonomy-
Autonomy is distinguished by the establishment supportive tactics noted above, as well as a careful
of personal intentions, goals, and preferences consideration of clinical presence so that the thera-
while taking responsibility for one’s thoughts, pist eventually becomes less necessary to the family.
feelings, and actions and their ramifications.
Evidence of thwarted autonomy is seen when
an individual is committed either to a rigid com- Clinical Example
pliance with, and/or a reactive defiance of, the
expectations of others. The Pak’s entered treatment due to the parents’
While autonomy is a universal constituent of concerns about their 17-year-old daughter
psychological well-being, the pursuit and defini- Mi-Sook, who was preparing to enter senior year
tion of autonomy may differ cross-culturally of high school, and who had begun engaging in
(Minuchin 1974). For example, exerting individ- sexually promiscuous behavior that was in stark
ual choice with one’s personal priorities primarily contrast to her family’s moral code.
in mind might characterize autonomy in an The family immigrated to the United States when
Anglo-American family, but submerging individ- Mi-Sook was 2 years old, and their second child,
ual choice in the service of collective priorities So-Yi, was born 1 year later, with Down’s syn-
might characterize autonomy in an East Asian drome. Mi-Sook was recruited to play numerous
family. pseudo-adult roles in the family, such as handling
Autopoiesis in Family Systems Theory 199
business-related phone calls for her parents as a McGoldrick, M., Carter, B., & Garcia-Preta, N. (2011). The
result of her fluency with English and providing expanded family life cycle:Individual, family and social
perspectives. Boston: Allyn and Bacon.
childcare for So-Yi, made necessary by the parents’ Minuchin, S. (1974). Families and family therapy. Cam- A
work schedules. bridge, MA: Harvard University Press.
However, while Mi-Sook became quite com- Stierlin, H. (1981). Separating parents and adolescents.
petent on many levels, her sense of self- New York: Jason Aronson.
determination was being compromised by the for-
midable family responsibilities she was shoulder-
ing. This reached crisis proportions when her
parents told her she was expected to continue Autopoiesis in Family Systems
living at home to maintain these responsibilities Theory
after she graduated and to attend community col-
lege rather than the 4-year residential college she Michelle A. Finley
had set her sights on. Antioch University Seattle, Seattle, WA, USA
The clinician hypothesized that Mi-Sook’s pro-
miscuous behavior provided her with a narrow
channel for autonomous behavior since no other Name of Concept
avenues of independence appeared to be open to
her. “I am not allowed to physically and psycho- Autopoiesis
logically depart from my family,” she may have
reasoned, “but at least I will allow myself to
morally depart from my family.” Synonyms
Treatment focused on helping the parents
understand how their reliance on Mi-Sook was Living system; Self-regulating system
quashing her efforts to separate in developmen-
tally appropriate ways and contributing to her Introduction
engaging in a maladaptive form of separation.
A parallel component of treatment explored the In the early development of family therapy, gen-
possibility of creating more autonomy for So-Yi eral systems theory offered a mechanistic view for
despite her limitations. Assisting the entire family explaining interactions among family members
in achieving functional separation yielded a ces- (Bateson 1972). Early family therapy work also
sation of Mi-Sook’s worrisome behavior and laid was based on first-order cybernetics, which
the groundwork for all four family members con- viewed families as self-stabilizing systems by
tinuing to evolve. employing homeostasis and feedback (Jackson
1957; Weiner 1948). These ideas focused on
how family systems stabilize and organize. Fam-
Cross-References ily therapy underwent further refinement through
the inclusion of second cybernetics, which
▶ Authoritarian Parenting focuses on processes such as positive feedback
▶ Authoritative Parenting and deviation-amplification to explain how family
systems are dynamic (Maruyama 1963). Auto-
poiesis originated in biology and was then
References adapted to other fields including family therapy
(Mingers 1995). Family therapy theorists Dell
Bowen, M. (1978). Family therapy in clinical practice. (1982a, b, 1985), Keeney (1982), and Watzlawick
New York: Jason Aronson.
Deci, E., & Ryan, R. (1985). Intrinsic motivation and self-
(1984) brought the concept of autopoiesis to fam-
determination in human behavior. New York: Plenum ily therapy, which underscored a core feature of
Press. family systems (Mingers 1995). The emergence
200 Autopoiesis in Family Systems Theory
of autopoiesis refined the idea that family systems other systems by their self-made boundaries
are self-regulating, autonomous systems and that (Dell 1985; Leyland 1988).
changes to the system from external sources such Finally, language connects Maturana’s descrip-
as a therapist only occur via perturbations through tions of autopoiesis and social systems to how
the therapist’s conversations with the family autopoiesis is viewed in family systems theory.
(Mingers 1995). Maturana and Varela (1980) viewed language as
fundamental to being human, and they posited
that the outcome of language is determined within
Theoretical Context for Concept the cognitive domain of the listener such that the
listener’s behavior is ultimately determined by his
Autopoiesis has its roots in the work of biologist and or her own structure and organization and not the
cybernetics theorist Humberto Maturana who speaker directly. This concept was expanded to
sought to distinguish between living and nonliving the family system whose response to language is
systems with the former being “self-referred” and determined by the structure and organization of
the latter being “other-referred” (Maturana and the family system itself in addition to the
Varela 1980; p. xii.). Autopoiesis, which is derived corresponding cognitive domains of each family
from Greek, literally means “self-making” and can member (Mingers 1995).
be broken into its constituent parts: auto meaning
“self” and poiesis meaning “making” or “creation”
(Capra and Luisi 2014). Maturana and Varela (1980) Description
coined the term “autopoiesis” in their pursuit to
understand and define what the essential character- Autopoiesis is the process where a living system
istics of a living system are, and they postulated that internally responds to messages from all compo-
the main characteristic of life is the ability to achieve nents of itself in order to preserve its organization
self-maintenance through internal processing and enabling the system to exist and remain identifi-
networking that continuously reproduces itself able (Leyland 1988). Any changes living systems
within a self-made boundary. The most basic exam- make are determined by their own structure and
ple of a biological autopoietic process would be the how they are organized rather than due to external
cell, which is an autonomous entity that has a cell triggers, which Maturana refers to as “structural
membrane or boundary enclosing the cell’s various determinism” and “non-instructive interaction.”
structures and components (e.g., nucleus, mitochon- Structural determinism is the idea that a living
dria). Crucially, the cell is able to produce and be system’s structure and organization informs how
produced by nothing other than itself. These quali- a living system is configured and responds to
ties comprise an autopoietic process that defines perturbations external to the living system. Non-
what it means to be a living system (Maturana and instructive interaction is the notion that living
Varela 1980). systems respond differently to the same external
Varela extended Maturana’s work on auto- perturbation because the system itself determines
poiesis to include social systems, which he termed how it will behave, not the external perturbation
“autonomous systems” meaning any system com- or information. Maturana further notes that if liv-
prised of elements that may or may not themselves ing systems were instructable, then they would all
be autopoietic (Varela 1979). Many family ther- achieve the same state under the same external
apy theorists influenced by constructivism and perturbations.
Maturana’s ideas viewed family systems as auto- Maturana recognized that autopoietic sys-
poietic in the sense that families maintained them- tems exist within a medium through which the
selves through rules and patterns formed over system interacts with other systems. This process
time, and families distinguish themselves from of interaction is called “structural coupling.”
Autopoiesis in Family Systems Theory 201
Although the autopoietic system’s structure deter- The existing structural coupling of the family
mines how it will respond to a given external undergoes change during crisis or at critical
perturbation, autopoietic systems interact recipro- junctures such as a birth, death, or divorce lead- A
cally with other entities in their environment ing to a new pattern or view of reality that must
(structural coupling), which can also lead to struc- emerge as the system evolves (Leyland 1988).
tural change that alters the future behavior of the This notion is similar to the Milan view that a
autpoietic system (Goolishian and Winderman family presents symptomatically in therapy
1988; Leyland 1988; Mingers 1995). when its view of reality has become outdated
and no longer fits the current system. Thus, the
therapist is to facilitate change that allows the
Application of Concept in Couple and family to create a new reality for itself. This
Family Therapy facilitation best occurs when the nature of struc-
tural coupling between the therapist and the
Autopoiesis is most relevant to the ideas promul- family is such that the therapist enters the family
gated within the constructivist schools of family system as though she were an equal member
therapy (Goolishian and Winderman 1988) and who gains permission to question the family’s
autopoietic-like concepts can be seen in the current reality and introduces new connections
Milan School of family therapy (Mingers 1995). to facilitate the family’s ability to extend its
The specific framing within the Milan School is cognitive and behavioral patterns, which is
to see families as “self-regulating systems” that also known as taking a second-order cybernetics
maintain control via rules and patterns formed stance (Hoffman 1985; Leyland 1988).
over time (Selvini Palazzoli et al. 1978; p. 3).
Further, the Milan School, like Maturana and
Varela’s view of social systems, sees family sys- Clinical Example
tems as noninstructive to external triggers such
that perturbations by a therapist do not automati- A husband, wife, and their 14-year-old daughter
cally produce changes in the family system. enter therapy for help with their daughter’s fre-
Leyland (1988) defined the family as a complex quent outbursts and truancy. Both parents feel
system consisting of two or more autopoietic helpless to change the situation and have “tried
structurally determined individuals who are struc- everything.” The therapist employs “positive
turally coupled to one another. connotation” (therapist offers a positive view
In the context of therapy, a therapist would see of the effects problematic behavior has on fam-
herself as only triggering a response in the family, ily members) to effect change. The therapist
not directing one. When a family receives the states that the teen’s behavior has brought
message that it should be different, it will likely together her parents in a way that has not hap-
respond by maintaining itself as it is, which is pened since she was a little girl. The interven-
traditionally labeled as “resistance.” However, tion helps the family shift their perspective and
when considering that a family is autopoietic and frees them to consider alternative paths toward
structurally determined, this process can be seen connection apart from the symptomatic behav-
instead as the structurally coupled system trying ior (changing their structural coupling). Using
to be itself (Leyland 1988). Autopoiesis offers a positive connotation is likely most effective
framework for understanding the paradox of with the therapist entering the family system as
change and stability among family systems such an equal with no urge to directly change anyone
that a family therapist would see herself as some- because to do so would likely lead the family to
one who helps facilitate rather than directs change double its efforts to maintain itself (structurally
in families. determined).
202 Aversive Control in Couple and Family Therapy
Cross-References
Aversive Control in Couple
▶ First Order Cybernetics and Family Therapy
▶ Maturana, Humberto
▶ Perturbation in Couple and Family Therapy Kyle C. Horst and Patrick S. Johnson
▶ Second-Order Cybernetics in Family Systems California State University, Chico, Chico,
Theory CA, USA
▶ Varela, Francisco Department of Psychology, California State
University, Chico, Chico, CA, USA
References
Name of Concept
Bateson, G. (1972). Steps to an ecology of mind.
Aversive Control in Couple and Family Therapy
Capra, F., & Luisi, P. L. (2014). The systems view of life:
A unifying vision. Cambridge: Cambridge University
Press.
Dell, P. (1982a). Beyond homeostasis: Towards a concept Synonyms
of coherence. Family Process, 21, 407–414.
Dell, P. (1982b). Family theory and epistemology of
Humberto Maturana. Family Therapy Networker, Coercion; Punishment
6(4), 26, 39–41.
Dell, P. (1985). Understanding Bateson and Maturana:
Towards a biological foundation for the social sciences.
Journal of Marital and Family Therapy, 11, 1–20.
Introduction
Goolishian, H. A., & Winderman, L. (1988). Constructiv-
ism, autopoiesis, and problem determined systems. Aversive control refers to the use of aversive
The Irish Journal of Psychology, 9(1), 130–143. events to manipulate another’s behavior. Punish-
Hoffman, L. (1985). Beyond power and control: Toward
ment* is a form of aversive control used to
and “second order” family systems therapy.
Family Systems Medicine, 3(4), 381–396. decrease the frequency of unwanted behavior
Jackson, D. (1957). The question of family homeostasis. and commonly involves either the presentation
The Psychiatric Quarterly. Supplement, 31, 79–90. of an undesirable consequence (positive punish-
Keeney, B. (1982). What is an epistemology of therapy?
ment*) or the removal of a desirable consequence
Family Process, 21, 153–168.
Leyland, M. L. (1988). An introduction to some of the (negative punishment*). Aversive control may
ideas of Humberto Maturana. Journal of Family Ther- also refer to the use of aversive antecedent stimu-
apy, 10, 357–374. lation. This process, known as negative reinforce-
Maruyama, M. (1963). The second cybernetics: Deviation-
ment, typically results in an increase in the
amplifying mutual causal processes. American Scien-
tist, 51, 164–179. frequency of behaviors that allow the individual
Maturana, H., & Varela, F. J. (1980). Autopoiesis and to avoid or escape from aversive stimulation.
cognition: The realization of the living. Dordrecht/
Boston/London: Reidel Publishing.
Mingers, J. (1995). Self-producing systems: Implications
and applications of autopoiesis. New York: Theoretical Context for Concept
Plenum Press.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & An initial conceptualization of aversive control
Prata, G. (1978). Paradox and counterparadox.
within psychology was the law of effect, which
Varela, F. J. (1979). Principles of biological autonomy. stated that behavior that led to an “annoying state
New York: North-Holland Press. of affairs” was likely to be weakened (Thorndike
Watzlawick, P. (1984). The invented reality. New York: 1913, pg. 1–4). Behaviorists – most notably the
Norton Publishing.
radical behaviorist school founded by B. F.
Weiner, N. (1948). Cybernetics: Or control and communi-
cation in the animal and the machine. New York: Skinner – subsequently reconceptualized this
Wiley. environment-behavior relation as “punishment*”
Aversive Control in Couple and Family Therapy 203
and operationalized it in terms of an observed According to systems theory, the pattern of

decrease in behavior resulting from the presenta- interaction observed in the use of aversive control
tion or withdrawal of a consequence (Skinner is consistent with the concept of “reciprocal influ- A
1938). As mentioned previously, aversive control ence” in understanding the continuation of aver-
may also occur through antecedent manipulations. sive control patterns. In the example above, a
Skinner theorized that any behavior that allowed spouse might withhold affection to control their
the individual to avoid or escape from an aversive partner’s behavior, only to find the spouse resent-
stimulus would increase in frequency through a ful and further disengaged from the relationship.
process known as negative reinforcement. In the context of relationships, the use of aversive
Two primary processes are thought to be behaviors to control a partner or family member
involved in aversive control. First, through classi- often leads to a decrease in couple or family
cal conditioning, the association of a non-aversive relationship quality in the long run. Thus, the
or neutral stimulus with an aversive stimulus may couple and family therapist is careful to observe
lead to conditioned emotional responding in the the interactions between couples and family mem-
presence of the newly conditioned stimulus. An bers, considering how each member’s use of aver-
example may involve feelings of anxiety or fear sive tactics might be reinforcing unwanted and
in the victim of spousal abuse when in the presence dysfunctional behavior.
of their abuser. Because conditioned emotional
responses in these instances may be incompatible
with previously punished responses (e.g., Application of Concept in Couple and
approaching one’s abuser), the latter may be Family Therapy
reduced in frequency. Second, through operant
conditioning, a stimulus previously associated Aversive tactics have been used as a means of
with an aversive consequence may “set the occa- treatment in therapy. Most notably, electric shock
sion” for an avoidance or escape response. In the or other unpleasant aversive stimuli are paired with
earlier example, the victim of past abuse may leave a desirable stimulus or behavior in what is often
the room or avoid meeting their abuser entirely. referred to as “aversion therapy.” Although these
These behaviors are negatively reinforced because techniques have often been used to curb habitual,
they decrease or eliminate the occurrence of aver- addictive, or (as seen in Kubrick’s film A Clock-
sive consequences and are more likely to occur in work Orange) violent behavior, there are questions
the presence of aversive stimuli (e.g., the sight of regarding their effectiveness and ethical use.
one’s abuser). No notable examples exist of aversion therapy
being used in the context of family or couple
treatment. Therapists considering the use of aver-
Description sive control in therapy are advised to consider
alternate techniques as no evidence suggests
Aversive control in couple and family relation- their efficacy. Therapists working with parents,
ships is present when one member of the family however, may find themselves discussing aver-
attempts to alter another’s behavior through aversive tactics for disciplining their child. Even in
sive means. Aversive tactics have varied effects these instances, therapists and parents should be
but are widely used. For example, most parents made aware of the potential side effects these
use punishments* such as time-out or spanking as tactics may have on the parent-child relationships.
a means of child discipline. In couples, one part-
ner might withhold affection or sex as a means of Aversive Control in Couples
control in the relationship. Although often imme- In couple relationships, aversive control is typi-
diately effective, aversive tactics have many cally seen as strategically withholding positive
potential side effects that may outweigh potential experiences (e.g., positive affect, sexual intimacy)
benefits. or using aversive antecedent stimuli (e.g.,
204 Aversive Control in Couple and Family Therapy
nagging, threats) or consequences (e.g., physical relationships, where violent acts are usually met
violence) to curb undesired behavior. Within the with a “honeymoon” phase of immense positive
couple system, more aversive control generally reinforcement. This further entrenches the victim
results in more aversive behavior. Both behavioral and perpetrator in a cycle where violence is
and systems theories suggest that the use of aver- reinforced by both aversive and positive means.
sive control in romantic relationships is at best Couple therapists are highly encouraged to assess
ineffective and at worst toxic to the overall satis- for IPV and coercion* when aversive tactics have
faction and functioning of the relationship. Some been utilized in the relationship.
have suggested that the use of these tactics may
result in the formation of “triangles,” most likely Aversive Control in Families and Children
with children, which are further damaging to rela- The use of aversive control through punishment*
tionships outside of the couple. is a common child-rearing practice in the USA.
Common aversive strategies used in intimate The use of aversive control as a means of disci-
relationships include emotional distancing/with- pline for children involves parents presenting
drawal, withholding affection/sex, nagging, some sort of aversive stimulus to either increase
threats, or violence. Behavioral couple therapists wanted behavior or decrease unwanted behavior.
have noted that aversive control strategies are Popular aversive tactics include threats/yelling,
often the product of failed conflict resolution spanking (corporal punishment), time-out, restric-
(Jacobson and Margolin 1979). More recent tion, or abuse. In order for punishment* through
research by Gottman (1999) has further supported aversive means to be effective, several conditions
the potential pitfalls of aversive control. He notes must apply. The punishment* should be delivered
four particularly destructive aversive tactics, contingently, immediately, consistently, and with-
which he calls the “four horsemen,” and studies out strong emotion.
how the presence of these tactics early in a rela- Aversive tactics are often considered in con-
tionship can help to predict the later dissolution of trast to positive reinforcement techniques of child
the same relationship. discipline. Aversive tactics (especially positive
One of the more well-known, documented, and punishment) are often less advisable, as they are
deleterious aversive tactics used in couples is inti- often associated with undesired side effects. For
mate partner violence (IPV). Perhaps an extreme example, spanking a child may decrease their
example of aversive control, IPV is unfortunately a unwanted behavior, but it may also instill fear
common experience for couples, with some data for the context in which the aversive control was
indicating one in four women and one in ten men used (referred to as “spread” or stimulus general-
experiencing relationship violence in their lifetime ization). Furthermore, because punishment* is
(Black et al. 2011). IPV includes not only physical immediately effective, parents may be inclined
violence but many types of behavior aimed at con- to use aversive tactics in other situations. This
trolling one’s partner through aversive means. For limits the repertoire of parenting techniques, mak-
example, a partner may decide to limit or restrict a ing aversive tactics more prominent. Some have
partner’s access to financial resources in an attempt argued, however, that aversive tactics for behavior
to keep them from leaving the relationship. change are not necessarily a “bad practice” and
The use of aversive tactics to control a partner is unavoidable (Perone 2003). Other evidence sug-
also often referred to as coercive control. A hallmark gests, however, that the use of aversive control
of coercion* is the degree to which one partner tactics on children is associated with outcomes
controls or manipulates the other partner as an exer- such as poor school performance, difficulty with
tion of power. From a behavioral theory perspective, interpersonal relationships, and increased likeli-
a perpetrator’s use of IPV is reinforced through their hood of depression and anxiety (see Gershoff and
partner’s compliance, increasing the likelihood of Grogan-Kaylor 2016).
further coercion* and violence. Many have noted Much has been written about the use of corpo-
the cyclical pattern that develops in violent ral punishment as a means of child discipline. The
Aversive Control in Couple and Family Therapy 205
majority of Americans report their parents using by the thought, “He shouldn’t have to know where
spanking as a means of punishment* as a child, I am twenty-four hours a day,” which in turn pre-
and the use of corporal punishment remains a vents her from letting him know of her situation. A
common technique (Watts-English et al. 2006). This results in Ben becoming increasingly irate,
Although much debate still exists, many behavioral eventually leading him to drive to Abby’s place
researchers have argued that corporal punishment of work. Fuming, Ben storms into her work,
is a generally ineffective means of discipline. Fur- demanding she leave with him, telling her
thermore, data indicates that the use of corporal co-workers, “I can’t believe you would keep a
punishment may have negative long-term conse- pregnant woman here this long. . .well, you can
quences, although much debate about these find- consider this her resignation!” Abby, embarrassed,
ings persist (Gershoff and Grogan-Kaylor 2016). leaves quickly and responds “I cannot believe you
Scholars have argued that corporal punishment as a would do that. I am sick and tired of you trying to
means of aversive control fails to teach the child control my life. I think I need some space from you
why their behavior is wrong, elicits a physiological right now.”
response that prevents the child from construc- It would be advisable for a therapist working
tively learning, and establishes a negative and fear- with this couple to consider the aversive control
ful relationship between the parent-child that will tactics and their impact on the overall relationship
ultimately make other attempts at discipline more dynamic. In particular, the therapist might note
difficult. Additionally, some scholars have argued Ben’s controlling strategies and follow this up with
that using this method of aversive control unwit- an assessment for IPV. If violence is not present, the
tingly models violence as an acceptable means of therapist could bring to light the destructive recipro-
relating to others. cal pattern of aversive control, paying particular
attention to Ben’s suspicions. The couple therapist
might want to encourage Ben to find a more posi-
Clinical Example tively reinforcing way to elicit reassurance from
Abby about their relationship status.
In order to illustrate the impact of aversive control
strategies in a romantic relationship, consider the
following fictional case study. Ben and Abby have Cross-References
been married for 3 years and are expecting their first
child. Although the couple is excited about the ▶ Behavioral Couple Therapy
addition, Ben has unfounded concerns that Abby ▶ Couple Violence in Couple and Family
will leave him after the baby is born. He finds Therapy
himself suspicious of the time Abby spends away ▶ Family Violence in Couple and Family Therapy
from him and is overly critical of anything she does ▶ Reciprocity in Couples and Families
without him. He recently suggested she quit her ▶ Violence in Couples and Families
part-time job to focus on getting the house ready
for the baby. Ben’s suspicions, however, are making
Abby increasingly uncomfortable. She finds his References
constant inquiry into her whereabouts as intrusive
and unnecessary and has felt less desire to include Black, M. C., Basile, K. C., Brieding, M. J., Smith, S. G.,
Walters, M. L., Merrick, M. T., et al. (2011). The
Ben in her day-to-day experiences. She has even National Intimate Partner and Sexual Violence Survey
begun to sneak out of the house at times to avoid (NISVS): 2010 summary report. Atlanta: National Cen-
Ben’s inquisition. This, of course, only further fuels ter for Injury Prevention and Control, Centers for Dis-
Ben’s suspicions and attempts at control Abby. One ease Control and Prevention.
Gershoff, T. E., & Grogan-Kaylor, A. (2016). Spanking
evening, Abby gets caught up at work and ends up
and child outcomes: Old controversies and new meta-
staying an hour later. Her initial impulse to contact analyses. Journal of Family Psychology, 30(4),
Ben to let him know she is running late is contrasted 453–469.
206 Avis, Judith
Gottman, J. M. (1999). The marriage clinic: A scientifically Contributions to the Profession

based marital therapy. New York: W. W. Norton.
Strategies based on social learning and behavior Dr. Myers Avis is best known for being one of the
exchange principles. New York: Brunner Mazel. pioneers in the family therapy field, introducing
Perone, M. (2003). Negative effects of positive reinforce- feminist concepts into family therapy and family
ment. The Behavior Analyst, 26, 1–14 therapy training. In the late 1970s and early
Skinner, B. F. (1938). The behavior of organisms: An
experimental analysis. New York: Appleton-Century- 1980s, a handful of woman began to publish and
Crofts. lecture about the absence of critical analysis of the
Thorndike, E. L. (1913). Educational Psychology. Vol 2. hierarchical imbalance of gender in the family and
The psychology of learning. New York: Teachers Col- the role that sexism plays in family and the family
lege, Columbia University.
Watts-English, T., Fortson, B. L., Gibler, N., Hooper, S. R., therapy field in general. Together they implored
& De Bellis, M. D. (2006). The psychobiology of the field to re-evaluate and challenge the gender
maltreatment in childhood. Journal of Social Issues, hierarchy in families. Her 1985 publication in the
62, 717–736. Journal of Marital and Family Therapy entitled,
“The politics of functional family therapy:
A feminist critique” was a groundbreaking analy-
sis of one of the leading evidence-based therapy
Avis, Judith models and led to a call for all researchers and
practitioners in the field to pay attention to the
Linda Stone Fish ways in which sexism permeates our conscious-
Syracuse University, Syracuse, NY, USA ness and has the potential to do real harm to
families in our care. The article was provocative
enough that the editor asked for a response from
Introduction functional family therapy’s founding theorists to
which Dr. Myers Avis responded.
Judith Myers Avis, Ph.D., is professor emerita of Since that germinal article, Dr. Myers Avis has
couple and family therapy at the University of written over a dozen articles and multiple book
Guelph in Ontario Canada. As an educator, clini- chapters with the intent to infuse feminist
cian, and researcher, her work has focused on informed thinking about gender into training and
gender, trauma, resilience, and re-storying in cou- practice in the field. Not afraid to constructively
ple and family relationships, and draws on narra- critique founding family therapy theories through
tive, feminist, and mindfulness ideas. a feminist lens, she challenged dichotomous
thinking, and urged the field towards a form of
activism whose seeds bear fruits today.
Career Her work has been recognized by awards from
the American Association for Marriage and Fam-
Dr. Myers Avis graduated with a Ph.D. from ily Therapy for Outstanding Contributions to
Purdue University in 1986 and taught at the Uni- Family Therapy, the American Family Therapy
versity of Guelph in the Family Relations and Academy for Innovative Contributions to Family
Applied Nutrition Department until her retirement Therapy, and the Hincks-Dellcrest Institute for
in 2004, directing the couple and family therapy Significant Contributions to the Field of Psycho-
program for 2 years. She went on to a productive therapy. In 2003, she was made an Honorary
career as a professor, therapy consultant, supervi- Fellow of St. Thomas University in Fredericton,
sor, and practitioner in Guelph. Author or New Brunswick in recognition of her contribu-
co-author of more than 40 journal articles and tions to social work knowledge, education, and
book chapters, Dr. Myers Avis has given confer- practice. During her career, she has been on the
ence presentations, keynote addresses, and invited editorial board of multiple journals in the field
workshops throughout the world. (Contemporary Family Therapy, Journal of
Avis, Judith 207
Feminist Family Therapy, Journal of Marital and Avis, J. M. (1985b). Through a different lens: A reply to
Family Therapy) and on the Board of Advisory Alexander, Warburton, Waldron and Mas. Journal of
Editors to Family Process. She has held numerous Avis, J. M. (1988). Deepening awareness: A private study A
positions of leadership in the American Family guide to feminism and family therapy. In L. Braverman
Therapy Academy (AFTA) as well. She currently (Ed.), Women, feminism and family therapy. New York:
provides supervision, consultation, and workshop Haworth Press.
Avis, J. M. (1991). The politics of empowerment. Journal
training to therapists and agencies, therapy to of Feminist Family Therapy, 3, 141–153.
individuals and couples, and teaches mindfulness Avis, J. M. (1992). Violence and abuse in families: The
meditation. problem and family therapy’s response. Journal of
Marital and Family Therapy, 18(3), 223–230.
Avis, J. M. (1994). Advocates versus researchers – A false
dichotomy? A feminist, social constructionist response
Cross-References to Jacobson. Family Process, 33, 87–91.
Avis, J. M. (1996a). Deconstructing gender in family ther-
▶ American Association for Marriage and Family apy. In F. P. Piercy, D. H. Sprenkle, & J. Wetchler
(Eds.), A family therapy sourcebook (2nd ed., p. ##).
Therapy (AAMFT) New York: Guilford Press.
▶ American Family Therapy Academy (AFTA) Avis, J. M. (1996b). Feminist-informed training in family
▶ Feminism in Couple and Family Therapy therapy: Approaching the millenium. In K. Weingarten,
▶ Functional Family Therapy & M. Bograd (Eds.), Reflections on feminist family
therapy training (p. ##). New York: Haworth Press.
▶ Gender in Couple and Family Therapy Avis, J. M. (2006). Escaping narratives of domination:
▶ Journal of Marital and Family Therapy Ideas for clinical practice with women oppressed by
relationship violence. In R. Alaggia and C. Vine (Eds.),
Cruel but not unusual: Violence in Canadian families –
A sourcebook of history, theory & practice (p. ##).
References Waterloo: Wilfrid Laurier Press.
Spitzer, B., & Avis, J. M. (2006). Recounting graphic
Avis, J. M. (1985a). The politics of functional family sexual abuse memories in therapy: Impact on women
therapy: A feminist critique. Journal of Marital and survivors’ healing. Journal of Family Violence, 21(3),
Family Therapy, 11, 127–136. 173–184.
B
Bacigalupe, Gonzalo and Family Therapy from the School of Educa-

tion, University of Massachusetts Amherst in
Peter Fraenkel 1995, and an MPH in Family and Community
The City College of New York, New York, Health, Department of Society, Human Develop-
NY, USA ment, & Health, Harvard University School of
Public Health in 2007. He became a registered
psychologist in Chile in 1986, was licensed in
Name Massachusetts as a Marriage and Family Thera-
pist (LMFT) in 1993, and received designation as
Gonzalo Bacigalupe, Ed.D., M.P.H. an AAMFT Approved Supervisor in 1996. He is
a member of several professional organizations
both in Chile and the USA, including the Red
Introduction Chilena de Psicología Política and Scientific Psy-
chologist Society of Chile; the Society for Par-
Gonzalo Bacigalupe is a Chilean-American ticipatory Medicine (Founding Member); the
family psychologist who has made major contri- American Psychological Association (Fellow
butions in the areas of theory, research, and prac- since 2012); AAMFT where he has been a Fellow
tice, with a focus on utilization of emerging since 1993; and the American Family Therapy
technologies in promoting health, mental health, Academy since 1996, serving as a member and
and resilience for individuals, families, and com- chair of several committees and on the Board of
munities struggling with chronic illness and in Directors, and where he was the first (and only,
disaster response. He is also an innovative leader to date) international and Latino professional to
in the area of online/distance learning, qualitative serve as President (2013–2015). Bacigalupe has
research, and intimate and political violence. received numerous awards, research grants (27 in
all), and fellowships, including a Career Devel-
opment Award from the Department of Health &
Career Human Services and Inter-University Programs
of Latino Research, 1999–2000; a Fulbright
Bacigalupe received a B.S. in Psychology from Senior Research Scholar Award in 2004; an
Pontifical Catholic University of Chile in 1984, NIH P-60 award (2012–2016); and the 2016
an M.Sc. (Equivalent) in Clinical Psychology Carolyn Attneave Diversity Award from the
from Catholic University of Chile in 1986, an APA’s Society for Couple and Family
Ed.D. in Consulting and Counseling Psychology Psychology.
https://doi.org/10.1007/978-3-319-49425-8
210 Bacigalupe, Gonzalo
Bacigalupe began his academic career at well as other oppressed and marginalized commu-
Nova Southeastern University in 1994 and has nities. He has documented and advocated for
been a faculty member since 1996 (Full Profes- the impact of online communities for chronic ill-
sor, 2012) in the Department of Counseling & ness patients. One special focus has been on the
School Psychology, College of Education and usefulness of emerging technologies in health
Human Development, University of Massachu- interventions for adolescents. His stance is that
setts Boston, where he served as Director of technologies can be vehicles of empowerment
the Family Therapy Program (2005–2010, for persons and communities to be full partici-
2011–2017), as Department Chair pants in their healthcare, and to be active in pro-
(2007–2009), and is Principal Investigator, moting their resilience and wellbeing. Through
Communication and Emergent Technologies for his participation and leadership in international
Disaster Risk Reduction, Research Center for research and medical treatment communities out-
Integrated Disaster Risk Management side of family therapy, he has brought a systemic
(CIGIDEN), in Santiago, Chile. He has been and social justice perspective to collaborative
a Visiting Professor in Chile (Doctoral Program, healthcare practice and public policy. He has
School of Psychology, Catholic University of also influenced emerging practices in the use
Valparaiso, 2015–2016; School of Engineering, of technology to aid transnational families in
Catholic University of Santiago, Chile, maintaining connection. Through his numerous
2016–2018) and in Spain (Universidad Nacional leadership positions in academia and professional
de Educación a Distancia, Madrid, Spain, organizations, Bacigalupe has guided the field
2006–present, and Department of Psychology, towards integrating concerns about social justice
University of Deusto, Bilbao, 2010–2014) and in research and interventions. He has mentored
has been a Research Collaborator and Program many colleagues and organizations as they enter
Evaluator on numerous projects in both coun- the digital, online world of research, treatment,
tries, as well as in the USA, focusing mostly on and online/distance learning. He has also made
community mental health. He also serves on major contributions to qualitative research meth-
several editorial boards for leading journals. odologies, especially in the use of analysis soft-
Bacigalupe is also in private practice in Boston ware. In addition to these seminal contributions,
and Santiago. Bacigalupe has contributed to the field of intimate
and political violence, especially in the Chilean
context; the study of masculinity; and critical
Contributions to Profession appraisal of social constructionist family therapy
theory and practice. Importantly, he has argued
Bacigalupe has authored or co-authored one book, that many so-called natural disasters occur due
62 peer-reviewed articles, 21 book chapters, to sociopolitical conditions that put oppressed
4 white papers, 13 research monographs, 33 news- communities at greater risk.
letter articles, and 21 editorials for Spanish- Bacigalupe has also pioneered the use of film
and English-language publications, as well as and the arts in family therapy. A talented abstract
16 audiovisual products (videos and photogra- painter in his own right, he draws upon visual
phy) and has presented world-wide. He has representations of families’ struggles and solu-
made wide-ranging contributions to the fields tions in his therapeutic work.
of family therapy and public health. He is one of
the world’s leading experts in the application of
emerging technologies to intervention in commu- Cross-References
nity health, emergencies and disaster relief, as
well as technological advances in education. ▶ Couple and Family Therapy in the Digital Era
Bacigalupe has focused greatly on issues of health ▶ Global Mental Health with Couples and
disparities for Latino individuals and families, as Families
Bandler, Richard 211
▶ Immigration in Couple and Family Therapy Career

▶ Latino/Latinas in Couple and Family Therapy
▶ Resilience in Couples and Families Bandler attended the University of California (UC),
Santa Cruz, where he received his Bachelor of Arts
in philosophy and psychology in 1973. Two years B
References later, he earned his Master of Arts in psychology
from Lone Mountain College in San Francisco.
Bacigalupe, G. (2011). Is there a role for social technologies Earlier in his career, Bandler worked with a number
in collaborative healthcare? Families, Systems & Health,
of notable figures including Virginia Satir, Milton
29(1), 1–14. https://doi.org/10.1037/a0022093.
Bacigalupe, G., & Askari, S. (2013). E-health innovations, Erickson, and Robert Spitzer. His work in the
collaboration, and healthcare disparities: Developing neurolinguistic field began when he met John
criteria for culturally competent evaluation. Families, Grinder who was a professor at the time when
Systems & Health, 31(3), 248–263. https://doi.org/
Bandler was a student at UC Santa Cruz. In 1974,
10.1037/a0033386.
Bacigalupe, G., & Lambe, S. (2011). Virtualizing intimacy: Grinder and Bandler started creating a model of the
Information communication technologies and transna- language patterns used by Fritz Perls, Virginia Satir,
tional families in therapy. Family Process, 50(1), 12–26. and Milton Erickson. This model was published in
https://doi.org/10.1111/j.1545-5300.2010.01343.x.
their books The Structure of Magic, Volumes I & II
Bacigalupe, G., & Plocha, A. (2015). Celiac is a social
disease: Family challenges and strategies. Families, Sys- (1975a, b) and Patterns of the Hypnotic Techniques
tems & Health, 33(1), 46–54. https://doi.org/10.1037/ of Milton H. Erickson, Volumes I & II (1976; 1977).
fsh0000099. These co-authored books by Grinder and Bandler
Bacigalupe, G., Velasco, J., Rosenberg, A., &
served as the foundation of the field of
Berríos, P. (2017). Medios sociales en la emergencia:
Evidencia y recomendaciones para la gestión de neurolinguistic programming.
desastres [Social media for emergency: Evidence and
recommendations for disaster management] Spanish
Edition. Santiago: CIGIDEN. ASIN: B01NAPL2AC.
Bandler has made significant contributions to the

Bandler, Richard field of couple and family therapy through the crea-
tion of his models, trainings, and writings, which
Shalini Lata Middleton have all facilitated clinicians’ ability to better under-
Alliant International University, Sacramento, stand and help people. Specifically, he is best known
CA, USA for codeveloping NLP, which is comprised of
models and methods used to understand human
communication and behavior in order to elicit
Introduction change. Two major models that arose from Bandler
and Grinder’s work with NLP include the meta-
Richard Bandler is a psychologist, philosopher, and model and the Milton model. The metamodel docu-
a self-help author who has contributed significantly ments language patterns through a series of
to the field of neurolinguistics. He is the cofounder questions that allow the individual to identify think-
of the field of neurolinguistic programming (NLP) ing patterns in another person. It responds to the
and has also helped codevelop other models and distortions, generalizations, and deletions in the
techniques, including the metamodel, the Milton speaker’s language. This can be useful to individuals
model, anchoring, the swish pattern, reframing, the in various roles, including therapists, who are work-
belief change, nesting loops, chaining states, sub- ing to identify their clients’ thinking patterns in order
modality applications, and timelines. Along with his to understand, modify, and/or change them. The
various published books and articles, Bandler con- Milton model is also helpful for therapists, as it can
tinues to contribute to the field through his work- assist in shifting a listener into a more receptive state
shops, seminars, and consulting work. by using language that guides the clients from detail
212 Bateson, Gregory
and content to deeper levels of cognition. NLP is Bandler, R., & Grinder, J. (1975b). The structure of magic
widely used as a technique to elicit behavior change II: A book about communication and change. Palo
Alto: Science & Behavior Books.
in the mental health field. Bandler continues to train Bandler, R., & Grinder, J. (1976). Patterns of the hypnotic
individuals and clinicians in NLP and other self-help techniques of Milton H. Erickson, M.D. Volume I.
techniques that he has developed over the years. Cupertino: Meta Publications.
Bandler has over four decades of work that is Bandler, R., Grinder, J., & Delozier, J. (1977). Patterns of
the hypnotic techniques of Milton H. Erickson, M.-
available to those in the field of psychology as D. Volume II. Cupertino: Meta Publications.
well as the general public. His work includes Bandler, R., Fitzpatrick, O., & Roberti, A. (2013). The
published books, articles, audios, and videos. He ultimate introduction to NLP: How to build a success-
has developed numerous workshops and seminars ful life. London: HarperCollins.
Bandler, R., Fitzpatrick, O., & Roberti, A. (2014). How to
which include neurohypnotic repatterning, design take charge of your life: The user's guide to NLP.
human engineering, persuasion engineering, per- London: HarperCollins.
sonal enhancement, charisma enhancement, and
hypnosis. He has also continued to write books to
help progress the work of NLP. Bandler’s book Bateson, Gregory
How to Take Charge of Your Life (2014) discusses
the importance of self-belief and how to change Douglas C. Breunlin1 and Rajeswari
beliefs, how to control your emotions and nega- Natrajan-Tyagi2
1
tive thinking, and how to create the life you that The Family Institute at Northwestern University,
want in order to create change. In the book, The Center for Applied Psychological and Family
Ultimate Introduction to NLP (2013), readers are Studies, Northwestern University, Evanston,
given the tools to change their life by overcoming IL, USA
2
things such as phobias, depression, habits, psy- Couples and Family Therapy Masters and
chosomatic illnesses, and learning disorders. Doctoral Programs, California School of
Bandler’s book Get the Life You Want (2008) Professional Psychology at Alliant International
discusses simple NLP exercises the readers can University (Irvine), Irvine, CA, USA
do to transform their lives. Bandler’s work con-
tinues to live on through his students and the
licensed institutes worldwide. Introduction
Gregory Bateson was born into a highly acclaimed

academic family in England in 1904. Bateson’s
father, William, was the founder of the prestigious
Cross-References
Cambridge School of Genetics. Bateson was named
“Gregory” by his father after the famous geneticist,
▶ Erickson, Milton
Gregor Mendel who is known as the father of genet-
▶ Hypnosis in Couple and Family Therapy
ics. While Bateson received his undergraduate
▶ Metacommunication in Couple and Family
degree in biology, he is also known as an anthropol-
Therapy
ogist, cybernetic theorist, and a philosopher. He was
▶ Reframing in Couple and Family Therapy
known as a great cross-disciplinary thinker. He had a
▶ Satir, Virginia
profound impact on the field of mental health, par-
ticularly the incorporation of cybernetic and systemic
thinking into the field that led to the birth of family
References
therapy. Bateson died in 1980.
Bandler, R. (2008). Get the life you want: The secrets to
quick and life change with neuro-linguistic program- Career
ming. London: HCi.
Bandler, R., & Grinder, J. (1975a). The structure of magic
I: A book about language and therapy. Palo Alto: Bateson obtained a Bachelor of Arts degree in
Science & Behavior Books. biology in 1925 from St. John’s College,
Bateson, Gregory 213
Cambridge. He then went on to teach linguistics at the critical impact Bateson’s direction would have
the University of Sydney in 1928. He was on mental health and the yet to exist field of family
recruited by the Anthropology chair at Cambridge therapy. Bateson did receive his funding to study
to do field work in the South Pacific where he communication of schizophrenic patients and
spent several years. There he met and married began the Palo Alto project in 1952. The research B
Margaret Meade in 1936. He then moved to Cal- team he assembled included himself, Jay Haley,
ifornia. He worked at Saybrook University in San John Weakland, and Don D. Jackson. It should be
Francisco and at the University of California, noted that only Jackson, a psychiatrist, had any
Santa Cruz. He never settled into a discipline or formal training in mental health. The team’s first
into a tenured position. When he died, he was publication, Toward a Theory of Schizophrenia
a scholar-in-residence at Esalen Institute in (1956), would become one of the most influential
California. papers in the field of family therapy. In this paper,
the team introduced the concept of the Double Bind
which is a form of paradoxical communication. The
Contributions to the Profession article suggested that such paradoxical communi-
cation accounts for the bizarre communication of
Bateson’s work in anthropology led to the publi- schizophrenics. The double bind theory was subse-
cation of an important book, Naven in 1936. This quently investigated in many research studies and
book had a huge impact on the practice of anthro- found not to be a causal factor in schizophrenia;
pology as it argued that the anthropologist as nevertheless, it remains seminal as a classic exam-
observer does not report raw data but rather infer- ple of early theorizing that would evolve into the
ences about behavior viewed through the lens of interactional view and the importance of family
the anthropologist’s theory. The book also pro- context in the formation and maintenance of
posed ideas about sequences of interaction or human problems. The team was highly generative
vicious cycles, mutual influence or recursiveness, for a decade, publishing dozens of articles, many of
and the mutual roles of the observer and the them still considered classics.
observed. These were seminal ideas that would The team disbanded in 1961. Evan though
later shape the epistemology that Bateson advo- Bateson had deeply touched the field of mental
cated for a paradigm shift in the field of mental health and the early beginnings of family therapy,
health. he wasn’t interested in therapy. Some of these views
One of Bateson’s early forays into the field of affected the relationship between him and Haley
mental health occurred through his participation who was already writing about therapy. Haley and
in the set of famous Macy conferences devoted to Weakland would become highly acclaimed in the
cybernetics (1946–1953). The purpose of these field of family therapy. Jackson also contributed to
conferences was to establish a foundation for the emergence of family therapy. He founded the
studying how the mind works. A rich multi- Mental Research Institute (MRI) in 1958 but suf-
disciplinary group of giants in their respective fered an untimely death in 1968.
fields grappled with this topic. They employed Although Bateson no longer moved in the cir-
cybernetics, systems theory, mathematics, biol- cles of mental health, he continued to be viewed as
ogy, and anthropology to name a few. The Macy a visionary and many in the field of family therapy
conferences advanced the understanding of cyber- continued to follow his work closely. Two books
netics and systems theory and laid the foundation by Bateson, widely popular among family thera-
for the new field of cognitive science. pists, are Steps to an Ecology of Mind (1972) and
Excited by these ideas and their application to Mind and Nature: A Necessary Unity (1979).
the state of the art of mental health, Bateson did two These books captured Bateson’s understanding
things. He co-authored a book with Jurgen Ruesch of the foundational concepts that underpinned
titled: Communication: The Social Matrix of Psy- the enormous paradigm shift that had taken place
chiatry (1951) and he sought funding to study during the previous quarter century and gave birth
human communication. It is impossible to measure to the field of family therapy.
214 Baucom, Donald
Bateson’s writing has always been dense and Bateson, G. (1979). Mind and nature: A necessary unity
challenging; hence, some have avoided it. In (Advances in systems theory, complexity, and
the human sciences). Hampton Press. ISBN 1-57273-
2011, his younger daughter, Nora Bateson, pro- 434-5.
duced a wonderful documentary DVD that Bateson, N. (2011). An ecology of mind: A daughter’s
beautifully captures what she believed were portrait of Gregory Bateson. Oley: Bullfrog Films.
five of his most essential ideas. The first is Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. H.
(1956). Toward a theory of schizophrenia. Behavioral
relationship. All things exist in relationship to Science, 1, 251–264.
each other. The second is cybernetics. Processes Haley, J. (1981). Development of a theory: The history of a
exist that regulate the nature of any interaction. research project. In J. Haley (Ed.), Reflections on ther-
The third is ecology of mind. The mind is a apy and other essays. Rockville: The Family Therapy
Institute of Washington, DC.
network of ideas and not a thing. The fourth is Lipset, D. (1980). Gregory Bateson: The legacy of a sci-
epistemology. We must always be diligent about entist. Englewood Cliffs: Prentice Hall.
how we know, what we know. Finally, the fifth is Nichols, M. P. (2011). The evolution of family therapy. In
difference. Information is a difference and one The essentials of family therapy (pp. 7–28). Boston:
Pearson.
should always ask: what is the difference that makes Ruesch, J.; Bateson, G. (2009) [1951]. Communication:
a difference? Many other ideas could be added to The social matrix of psychiatry. W.W. Norton &
this list, including systems theory, context, homeo- Company. ISBN 978-1-4128-0614-5. Retrieved
stasis, feedback family rules, circular causality, first- 19 Mar 2013.
Stagoll, B. (2005). Gregory Bateson (1904–1980):
and second-order cybernetics, etc. A reappraisal. Australian & New Zealand Journal of
Bateson was ahead of his times. Today many Psychiatry, 39(11/12), 1036–1045. https://doi.org/
of the ideas that were radical for his time are a 10.1111/j.1440-1614.2005.01723.x.
mainstay of how human systems are viewed. His
genius changed the course of numerous disci-
plines including communications, anthropology
mental health and its subspecialty, family
therapy. Baucom, Donald
Steffany J. Fredman1 and Kristina Coop Gordon2

1
The Pennsylvania State University, University
Cross-References Park, PA, USA
2
University of Tennessee, Knoxville, Knoxville,
▶ Double Bind Theory of Family System TN, USA
▶ Haley, Jay
▶ Homeostasis in Family Systems Theory
▶ Jackson, Donald Donald H. Baucom, Ph.D., is the Richard
▶ Palo Alto Group, The Simpson Distinguished Professor of Psychology
▶ Weakland, John and Neuroscience at the University of North Car-
olina at Chapel Hill (UNC-Chapel Hill) and a
licensed clinical psychologist. He is a pioneer in
References the development and testing of couple-based
interventions for the treatment of relationship dis-
Bateson, G. (1936). Naven: A survey of the problems tress, infidelity, individual psychopathology, and
suggested by a composite picture of the culture of a
New Guinea tribe drawn from three points of view. health concerns, as well as in the dissemination of
Stanford University Press. ISBN 0-8047-0520-8. couple therapies on an international scale.
Bateson, G. (2000) [1972]. Steps to an ecology of mind: Baucom earned his Bachelor of Arts in Psy-
Collected essays in anthropology, psychiatry, evolu- chology (1971) and Doctor of Philosophy in Clin-
tion, and epistemology. Chicago: University of
Chicago Press. ISBN 0-226-03905-6. Retrieved ical Psychology (1976) from UNC-Chapel Hill
19 Mar 2013. and completed his doctoral internship in clinical
Baucom, Donald 215
psychology at the University of Minnesota importance of helping couples form a cogent

(1976). He served as Assistant Professor of Psy- narrative about the affair by exploring both prox-
chology at Texas Tech University from 1976 to imal and distal factors that may have provided a
1980 prior to joining the Psychology faculty at context for the infidelity’s occurrence, consid-
UNC-Chapel Hill, where he has conducted ered essential for both partners’ ability to work B
research, taught, and mentored students since through the negative impact of the infidelity
1980. He is a Professor of Psychology (1990–pre- regardless of whether they remain a couple
sent) at UNC-Chapel Hill, where he also served as going forward.
Director of the Clinical Psychology Program Baucom and colleagues’ work on conceptualiz-
(1993–2003; 2004–2006). ing the treatment of individual distress within a
Baucom’s program of research focuses on opti- couple/family context represented a major concep-
mizing relationship health and individual psycho- tual shift in the approach to the treatment of indi-
logical and physical well-being within a relational vidual psychopathology and health concerns. In the
context, and his primary contributions center on late 1990s, he spearheaded a paper that offered a
the translation of basic cognitive-behavioral novel heuristic for thinking about ways to incorpo-
research to empirically supported couple therapies rate significant others into treatment when one
designed to enhance relational and individual member of a couple or family has a psychological
adjustment. His work has resulted in major para- or medical disorder (Baucom et al. 1998). This
digm shifts with respect to the treatment of rela- framework differentiated between interventions
tionship distress and infidelity, as well as that considered the unit of intervention to be the
conceptual and clinical models for the treatment identified patient versus the couple’s relationship
of individual distress (e.g., individual psychopa- and whether the intervention targeted individual
thology and health concerns) within a couple symptoms, the way individual symptoms intersect
context. with relationship adjustment, or the relationship
His early contributions focused on developing more broadly. The different models for involving
the clinical, theoretical, and empirical basis for family members into care are conceptualized as
behavioral couple therapy to ameliorate relation- (a) partner-assisted interventions, in which the pri-
ship distress. In collaboration with Dr. Norman mary focus is on the identified patient and the
Epstein, this approach was subsequently partner functions primarily as a surrogate therapist
expanded to elevate cognition and affect to equal or coach; (b) disorder-specific interventions, in
importance with behavior in the onset and main- which the focus is on how the couple (or family)
tenance of relationship distress, marking a major interacts focal to the disorder; or (c) generic couple
paradigm shift within the field. This innovation therapy, in which the focus is on improving the
resulted in a seminal text on cognitive-behavioral couple or family’s relationship more generally to
couple therapy (Epstein and Baucom 2002) that improve the emotional climate of the home,
provided both a theoretical and applied clinical thereby reducing the identified patient’s subjective
model of couple functioning with respect to cog- sense of environmental stress. Consistent with this
nition, affect, and behavior, as well as the impor- conceptual model, Baucom has been at the fore-
tance of considering individual differences in front of the development and testing of disorder-
needs, personality, and affect regulation. specific couple-based treatments for individual
Baucom’s work on the treatment of couples psychopathology and health, resulting in innova-
who have experienced infidelity, conducted in tive therapies for conditions including obsessive-
collaboration with Drs. Douglas Snyder and compulsive disorder, eating disorders, depression,
Kristina Coop Gordon (Baucom et al. 2011), breast cancer, and heart disease.
marked a major innovation in the treatment of Baucom’s current work includes the dissemi-
couples in which there has been a history of nation of empirically supported couple therapies
infidelity. Conceptualizing infidelity as a rela- in real-world clinical settings both in the United
tional trauma, the work highlighted the States and abroad, including a national effort to
216 Bava, Saliha
disseminate couple therapy for depression to pro- collaborative-dialogic practices and hyperlinked
viders within Great Britain through the National identity, developing a concept coined from her
Health Service. doctoral research.
References
Career
Abramowitz, J. A., Baucom, D. H., Boeding, S., Wheaton,
M. G., Pukay-Martin, N. D., Fabricant, L. E., Paprocki, Bava graduated with honors from the University
C., & Fischer, M. (2013). Treating obsessive- of Delhi, India. She earned her M.S. in Social
compulsive disorder in intimate relationships: A pilot
Work from the Tata Institute of Social Sciences,
study of couple-based cognitive-behavior therapy.
Behavior Therapy, 44, 395–407. https://doi.org/ India in 1992 and a post masters certificate in
10.1016/j.beth.2013.02.005. Research Methodology in 1997. She moved to
Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., the USA in 1995 to enroll in the Marriage and
& Stickle, T. R. (1998). Empirically supported couples
Family Therapy program at Virginia Polytechnic
and family therapies for adult problems. Journal of
Consulting and Clinical Psychology, 66, 53–88. Institute and State University, where she earned
https://doi.org/10.1037/0022-006X.66.1.53. her Ph.D. in Human Development in 2001. She
Baucom, D. H., Snyder, D. K., & Gordon, K. C. (2011). completed the Executive Program for Nonprofit
Helping couples get past the affair: A clinician’s guide.
Leaders at Stanford University in 2009.
Baucom, D. H., Worrell, M., Corrie, S., & Fischer, M. S. Bava completed a doctoral fellowship at the
(in progress). Engaging couples: Improving well-being Houston Galveston Institute (HGI) 1998–2000
and reducing distress with cognitive behavioural cou- and served as HGI’s Associate Director
ple therapy. London: Routledge.
2001–2009. There, she provided leadership and
Epstein, N., & Baucom, D. H. (2002). Enhanced cognitive-
behavioral therapy for couples: A contextual approach. vision as an administrator, family therapist, clini-
Washington, DC: American Psychological Association. cal supervisor, consultant, and researcher. She
worked closely with families referred by Harris
County Child Protective Services and with
school-based crisis intervention programs. In
Bava, Saliha
2001, she launched improvisation-based, multi-
family workshops for divorcing families funded
Kristen Benson
by the Texas Office of the Attorney General. She
Appalachian State University, Boone, NC, USA
also served as adjunct faculty in the MSc in
Psychology Program at Our Lady of the Lake
University. She has been affiliated with the Taos
Name
Institute (TI) since 2000 developing their online
course offering, serving as faculty in the masters
Saliha Bava, Ph.D. (1969–)
in Relational Leading and doctoral advisor for the
Ph.D. program in the Social Sciences and cur-
Introduction rently their Advisory Board Member.
In 2010, she joined the Marriage and Family
Saliha Bava has offered numerous revolutionary, Therapy Program faculty at Mercy College
creative, and constructionist contributions to the in Dobbs Ferry, NY, where she continues as a
field of couple and family therapy. She is an tenured associate professor. At Mercy, she
innovator of actively engaging the art of exploring has received grants to focus on equitable
play, risk-taking, and improve in clinical work, practices, play, and design thinking in engaging
scholarship, and everyday life. She is a leader in first-generation college students. Bava directs
engaging community leaders and nonprofit agen- the Play Lab NYC to explore the generative
cies in organizing collaborative disaster response. potential of relational play in everyday
Bava addresses identity and social justice through living. Bava maintains a private practice in
Bava, Saliha 217
New York City as a Licensed Marriage and Fam- Bava has contributed to revolutionary change
ily Therapist, supervisor, leadership coach, and in the ways that communities collaboratively
consultant. respond to trauma and disaster. She served as the
Director of Mental Health for Katrina Relief at
George R. Brown Convention Center in Houston, B
Contributions to the Profession TX in 2005. In this role, she led the initiative to
respond to people with mental health needs who
Saliha Bava is known for her focus on creativity in were displaced following Hurricane Katrina. She
life, leadership, research, pedagogy, and therapy developed collaborative mental health response
from a play and performative perspective. She among University of Texas, Mental Health and
identifies creativity as relationally responsive in Mental Retardation Authority of Harris County
actively making/co-creating our identities, our (MHMRA), City of Houston Disaster Mental
social processes, and the world around us (Bava Health Crises Response Team, and volunteers.
2016, 2017, 2019). Bava’s integration of creativ- She then served on the Katrina Behavioral Health
ity in therapeutic healing is emphasized in her role and Emotional Support (KBHES) Network
as a group facilitator for Moving Our Embodied developing and implementing long-term disaster
Stories: Creative Resilience Workshops for response. Her leadership and efforts were recog-
Survivors of Sexual Assault, which is based in nized when she was awarded the Exceptional
New York City. Her playful approach is evident Leadership and Service for the City of Houston
in the book she co-authored with her husband and and to the Citizens of the City of New Orleans by
partner in life, Mark Greene, titled The Relational City of Houston’s Disaster Mental Health Crisis
Book for Parenting (2018). The book focuses Response Team in July, 2006. Bava was the Pro-
on parenting as an ongoing relational activity gram Director for the Community Partnership for
of experimentation and improvisation rather than Resiliency at the Houston Galveston Institute
a scripted or prescriptive role through use of May 2006–January 2007 where she worked
comics, games, and articles to engage families in to connect various communities in an effort
growing their relational intelligence. to strengthen Houston’s resiliency in response to
Bava’s academic contributions emphasizes Hurricanes Katrina and Rita. This led to designing
her questioning of the dominant academic dis- a community-engaged project From Settlement
courses of research methodology, social justice, to Community: A Collaborative Mental Health
and identity through use of performative meth- Model for Immigrants and Refugees, a model of
odologies, socially just dialog, and hyperlinked emotional wellness using social engagement, col-
identities. In this work, she bridges justice and laborative learning and innovative approaches to
identity and encourages a shift to consider how mental health (trauma treatment) design and
people live in a world that feels generative while delivery. Bava again provided leadership as the
there is subjugation happening. This challenge Co-Director of Houston’s Ike Behavioral Health
is reflected in her chapter, Hyperlinked Identity: Response Team in 2009, following Hurricane Ike.
A Generative Resource in a Divisive World Bava’s extensive experience with collaborative
which is published in McGoldrick and Hardy’s response to disaster and trauma is reflected in her
(2019) Re-visioning Family Therapy. Bava is ongoing work, including funded grants, her ser-
pushing for conversation in her stance which vice as an International trainer and authored pub-
acknowledges there is a practice of hegemony lications. In 2010, she was invited to be a faculty
happening regarding knowledge and discourse and research consultant for the International
about social justice, and challenges people in Trauma Studies Program affiliated with Columbia
socially marginalized groups to refuse the bur- University, where she has focused on theater and
den of discussing social justice in ways defined psychosocial programing and served in designing
by the dominant group by instead telling stories a community engagement program for New York
of agency and survival. City’s Mental Health Service Corp.
218 Beach, Steve
She has offered notable service to the profes- trauma: Impact and recovery issues. New York: Nova
sion in various ways. Bava is the Co-Founder & Science Publishers.
Bava, S., Coffey, E., Weingarten, K., & Becker, C. (2010).
Co-Editor of the International Journal of Lessons in collaboration, four years post-Katrina.
Collaborative-Dialogic Practices. In 2009, Family Process, 49(4), 543–558.
she co-founded and serves on the board of Bava, S., Chaveste, R., & Molina, P. (2018). Collaborative-
International Collaborative-Dialogic Certificate dialogic practices: A socially just orientation.
In C. Audet & D. Pare (Eds.), Social justice and
Program. She served on the American Family counseling. New York: Routledge.
Therapy Academy board (2012–2017). Bava is
an AAMFT approved supervisor and Clinical
Fellow.
Beach, Steve
Cross-References Frank D. Fincham

Florida State University, Tallahassee, FL, USA
▶ Collaborative and Dialogic Therapy with
Couples and Families
▶ Creativity in Couple and Family Therapy Name
▶ Houston Galveston Institute
▶ Play in Couple and Family Therapy Steven R. H. Beach
▶ Social Constructionism in Couple and Family
Therapy
Introduction
References Steven R. H. Beach is well known in clinical psy-

chology for his extensive contributions to marital
Bava, S. (2005). Performance methodology: Constructing therapy and particularly the use of marital therapy in
discourses and discursive practices in family therapy the treatment of depression. His many contributions
research. In D. Sprenkle & F. Piercy (Eds.), Research
methods in family therapy (2nd ed.). New York:
to the field include elucidation of self-evaluation
Guilford Press. maintenance processes in relationship contexts;
Bava, S. (2016). Making of a spiritual/religious hyper- work on forgiveness, gratitude, and religiosity, in
linked identity. In D. R. Bidwell (Ed.), Spirituality, marriage; the role of broader family processes, espe-
social construction and relational processes. Chagrin
Falls: Taos Institute Publications.
cially parenting, on healthy psychosocial develop-
Bava, S. (2017). Creativity in couple and family therapy. In ment; and, more recently, examination of the
J. L. Lebow, A. L. Chambers, & D. Breunlin (Eds.), contribution of genetics and epigenetics in combi-
Encyclopedia of couple and family therapy. New York: nation with family and community factors in pre-
Springer. https://link.springer.com/referenceworkentry/
10.1007/978-3-319-15877-8_226-1.
dicting inflammatory and health outcomes.
Bava, S. (2019). Hyperlinked Identity: A generative
resource in a divisive world. In M. McGoldrick &
K. Hardy (Eds.), Revisioning Family Therapy:
Addressing Diversity in Clinical Practice. New York, Career
NY: Guilford Press.
Bava, S., & Greene, M. (2018). The relational book for
parenting. New York: Think Play Partners. Dr. Beach studied under K. Daniel O’Leary at Stony
Bava, S., & Levin, S. (2012). Collaborative therapy: Brook University where he received his Ph.D.
Performing reflective and dialogic relationships. In degree in 1985. He then relocated to the University
A. Lock & T. Strong (Eds.), Discursive perspectives in of Georgia where he has been ever since. His initial
therapeutic practice. Oxford: Oxford University Press.
Bava, S., & Saul, J. (2012). Implementing collective work was in a psychiatric hospital, in a student metal
approaches in mass trauma and loss in western con- health clinic, and in private practice. He began his
texts. In K. M. Gow & M. J. Celinski (Eds.), Mass academic career as an assistant professor at the
Beach, Steve 219
University of Georgia in 1987 and became director self-evaluation needs were supported. As this line
of the Owens Institute for Behavioral Research in of research unfolded, it became clearer that self-
2003, and Distinguished Research Professor in evaluation was commonly and perhaps continu-
2007. Since 2009 he has served as codirector of ously influenced by events involving the partner.
the Center for Family Research at the University Indeed, as a subsequent line of investigation B
of Georgia. showed, romantic partners, particularly marital part-
ners, were especially good at adjusting their self-
definition to fit with their partner. When
Contributions outperformed by the partner in a given area, persons
in committed relationships showed little negative
Dr. Beach’s early work experiences led him to focus affect (unlike persons interacting with strangers),
on issues with the potential to advance both the instead showing an increased tendency to change
practice of clinical psychology and the prevention the importance of the area to their self-evaluation.
of psychological disorder. This led to pioneering Conversely, Dr. Beach discovered that when the
work on depression, particularly the way that marital opportunity to change self-evaluation was blocked,
processes covaried with and influenced the course of it resulted in more negative recollections about the
depressive episodes. Using the large literature on couples’ past together and led to more negative
stress and social support, Dr. Beach developed a problem-solving interactions. Dr. Beach has noted
theoretical framework that both detailed various that many apparently intractable marital disputes
interpersonal provisions related to depression and may be fruitfully conceptualized as resulting from
underscored the likelihood that spouses could play a automatic self-defensive processes like those
central role in recovery from depression. This described by the self-evaluation maintenance
model, later published in book form (Beach et al. model.
1990), received many accolades and garnered con- More recently, Dr. Beach has shifted his
siderable attention. The treatment model presented research again, focusing increasingly on preven-
in the book, Depression in Marriage, helped to tion, the role of biological variables, and ways for
influence the thinking of a generation of researchers families and marriages to protect against the
and changed the practices of clinicians. Dr. Beach’s stresses of disadvantage, poverty, and racism.
success in using marital therapy as a treatment for Building on his earlier work, he has designed
depression underscored the importance of intimate two culturally sensitive programs to enhance cou-
relationships in understanding this disorder. Over ple functioning. These programs are designed to
the course of the ensuing decade, his surprising help sustain couple satisfaction over time, to
findings were replicated across several laboratories enhance co-parenting, and to provide health pro-
in the USA and across national boundaries. tective benefits for both couples and their chil-
Dr. Beach began to expand the focus of his dren. Dr. Beach has provided evidence that
research using the self-evaluation maintenance tra- parenting-based interventions decrease parental
dition as a useful framework for more detailed depression and enhance parental health. Results
examination of the way the interpersonal could to date indicate that positive, constructive marital
affect the intrapersonal. The model is experimental and parenting processes can be promoted by both
and so had the potential to provide a useful counter- “in-home” and “group-based” intervention pro-
point to intervention-based research by allowing grams and that these changes have the potential
identification of causal mechanisms. In this research to promote the health and well-being of parents
Dr. Beach found that married partners tended to and offspring.
divide decision-making in a manner that protects Dr. Beach’s work has provided a conceptual
each partner’s self-evaluation. Further, spouses foundation that has inspired many researchers to
tend to engage more in activities that supported follow in his footsteps and has placed many clin-
each partner’s self-evaluation and are more likely ical practices on a firmer scientific foundation. He
to recall satisfying relationship memories when published seminal papers on the connection
220 Beavers Systems Measures, The
between marriage and depression as well as on

self-evaluation maintenance in marriage and on Beavers Systems Measures,
the role of epigenetic change in understanding The
environmental effects on long-term health out-
comes. He established a well-described program Alan Carr
to help couples dealing with both marital discord School of Psychology, University College Dublin
and depression. Likewise, he has more recently and Clanwilliam Institute Dublin, Dublin, Ireland
developed several programs of preventive inter-
ventions aimed at couples to help them work
together to protect their relationships against the Name and Type of Measure
erosive power of external stressors arising from
financial strain and from society more broadly. The Beavers Systems Measures assess family func-
In brief, Dr. Beach’s research has led the mar- tioning from clinician and client perspectives. The
ital area in a number of new, productive areas and Beavers Interactional Scales (BIS) are a set of rating
continues to do so today. scales for completion by clinicians or researchers
observing family interaction. The Self-Report Fam-
ily Inventory (SFI) is a questionnaire for completion
by literate family members over 11 years.
Cross-References
Introduction
▶ African Americans in Couple and Family
Therapy
Family competence and family style are the two
main dimensions of the Beavers Systems Model of
▶ Depression in Couple and Family Therapy
Family Functioning (Beavers and Hampson 1990,
▶ Research About Couple and Family Therapy
2000). The competence dimension ranges from opti-
mal through adequate, midrange, and borderline to
severely dysfunctional. The style dimension ranges
References
from centripetal to centrifugal. When the two dimen-
Beach, S. R. H., & Sales, J. M. (2016). Refining Preven- sions are combined, they define nine distinct family
tion: Genetic and Epigenetic Contributions. Retrieved groupings, three of which are relatively functional
from http://www.frontiersin.org/books/Refining_Pre and six of which are dysfunctional. A family’s status
vention_Genetic_and_Epigenetic_Contributions/846 on the competence and style dimensions may be
Beach, S. R. H., Sandeen, E. E., & O’Leary, K. D. (1990).
Depression in marriage: A model for etiology and established with the BIS and SFI.
treatment. New York: Guilford.
Beach, S. R. H., Wamboldt, M., Kaslow, N., Heyman, Developers
R. E., First, M. B., Underwood, L. G., & Reiss,
D. (2006). Relational processes and DSM-V: Neurosci-
ence, assessment, prevention & intervention. The BIS and SFI were developed by W. Robert
Washington, DC: American Psychiatric Publishing. Beavers, M.D. Emeritus Clinical Professor of
Beach, S. R. H., Brody, G. H., Barton, A. W., & Philibert, Psychiatry, University of Texas Southwestern
R. A. (2016a). Exploring genetic moderators and epi-
genetic mediators of contextual and family effects: Medical Center, Dallas, Texas, USA.
From GE to epigenetics. Development and Psycho-
pathology, 28(4pt2), 1333–1346. https://doi.org/
10.1017/S0954579416000882. BIS: Description and Psychometric
Beach, S. R. H., Lei, M. K., Brody, G. H., Kim, S., Barton, Properties
A. W., Dogan, M. V., & Philibert, R. A. (2016b). Par-
enting, SES-risk, and later young adult health: Explora-
There are two BISs, one of which assesses family
tion of opposing indirect effects via DNA methylation.
Child Development, 87(1), 111–121. https://doi.org/ competence and the other family style (Beavers and
10.1111/cdev.12486. NIHMSID 739989. Hampson 1990). Ratings are based on observations
Beavers Systems Measures, The 221
of families discussing the question, What would you 4. Appearance to outsiders (from try to make a
like to see changed in your family?, for 10 min. Each good impression to unconcerned)
interactional scale is made up of a number of 5- or 5. Professed closeness (emphasize closeness to
10-point subscales. deny closeness)
The Beavers Interactional Competence Scale 6. Managing assertion (discourage to encourage B
in composed of the following 13 subscales: assertion)
7. Expression of positive and negative feelings
1. Structure of the family (mainly positive to mainly negative)
1.1 Overt power (from chaotic to egalitarian) 8. Global style (from centripetal to centrifugal)
1.2 Parental coalitions (from parent-child coa-
lition to strong parental coalition) The Beavers Interactional Competence and Style
1.3 Closeness (from indistinct boundaries to Scales have good reliability. Kappa inter-rater reli-
distinct boundaries) ability coefficients for subscales exceed 0.75, and
2. Mythology (from congruent to incongruent) Cronbach alpha internal consistency reliability coef-
3. Goal-directed negotiation (from extremely ficients exceed 0.88. With respect to validity, the
efficient to extremely inefficient) competence scale has been shown to discriminate
4. Autonomy between families with hospitalized adolescents and
4.1. Clarity of expression (from very clear to nonclinical families and to correlate above r = 0.6
unclear) with the SFI and the general functioning subscale of
4.2. Responsibility (from regular to rare the McMaster Family Assessment Device (FAD,
acceptance of responsibility for actions) Miller et al. 1985). The family style scale has been
4.3. Permeability (from very open to found to predict internalizing versus externalizing
unreceptive) diagnoses of patients.
5. Family affect
5.1. Range of feelings (from direct expression
of a wide range to little expression) SFI: Description and Psychometric
5.2. Mood and tone (from warm and optimis- Properties
tic to cynical and pessimistic)
5.3. Unresolvable conflict (from severe The SFI is a 36-item questionnaire which measures
unresolved conflict to none) five family domains: health/competence, conflict,
5.4. Empathy (from consistent empathy to cohesion, leadership, and emotional expressiveness
none) (Beavers and Hampson 1990). The health/compe-
6. Global health pathology (from pathological to tence subscale includes 19 items involving family
healthy) affect, parental coalitions, problem-solving abilities,
autonomy and individuality, optimistic
The Beavers Interactional Style Scale evaluates vs. pessimistic views, and acceptance of family mem-
family style, which may range from centrifugal to bers. The conflict subscale includes 12 items involv-
centripetal. Members of centrifugal families look ing overt versus covert conflict. The cohesion
outside the family for their needs to be met, and subscale includes five items dealing with family
members of centripetal families look within the togetherness. The leadership subscale includes three
family for need fulfillment. The family style scale items involving parental leadership, directiveness,
is composed of eight subscales: and rigidity of control. Finally, the emotional expres-
siveness subscale includes six items dealing with
1. Meeting dependency needs (from needs verbal and nonverbal expression of warmth.
ignored to met alertly) Responses to items are given on 5-point Likert scales.
2. Managing conflict (from open to covert) The SFI has high internal consistency reliabil-
3. Use of space (from much space between mem- ity with Cronbach alphas and test-retest reliabil-
bers to very close) ities above 0.8. It also has a good validity with
222 Beavers, W. Robert
correlations above 0.6 with the Beavers Interac- Introduction

tional Competence Scale and the general func-
tioning subscale of the FAD. W. Robert Beavers was a leading figure in fam-
ily systems therapy and made significant contri-
butions to the field. Based on his own research
Example of Application in Couple and
he developed the Beavers System Model of
Family Therapy
Family Functioning, which provides the struc-
ture and tools for assessing families. Addition-
The scores of the mother, father, and 14-year-old
ally, he provided treatment and intervention
depressed daughter of the Burke family on the BIS
techniques for working with families. Beavers
competence scale and the SFI competence scale
also suggested some insights on using a systems
improved after eight sessions of family therapy.
approach in couples’ therapy and supervising
Treatment focused on helping the parents develop
from a family systems perspective. Beavers
a more supportive and less critical relationship with
contributed 3 books and over 40 journal articles
their daughter, who had become withdrawn,
to the field.
depressed, and argumentative in 6 months after the
family moved from the UK to Ireland.
Career
Cross-References
W. Robert Beavers completed medical school at
▶ Family Assessment Device the University of Texas Southwestern Medical
Center in 1953. Following graduation he com-
pleted an internship at the Wayne County General
References Hospital in Eloise, Michigan. He then completed a
fellowship in pharmacology (1954–1955), after
Beavers, W. R., & Hampson, R. B. (1990). Successful which he spent 2 years in the Air Force in the
families: Assessment and intervention. New York:
W.W. Norton. (Contains the BIS and SFI). Arctic, conducting research. He then became an
Beavers, W. R., & Hampson, R. B. (2000). The Beavers assistant professor of pharmacology for 3 years,
Systems Model of family functioning. Journal of Fam- during which time he also completed residency
ily Therapy, 22(2), 128–143. in internal medicine, eventually becoming chief
Miller, I. W., Epstein, N. B., Bishop, D. S., & Keitner, G. I.
(1985). The McMaster Family Assessment Devise: Reli- resident, in St. Paul Hospital, in Dallas, Texas.
ability and validity. Journal of Marital & Family Therapy, W. Robert Beavers completed a residency in psy-
11, 345–356. chiatry at the University of Texas Southwestern
Medical Center from 1960 to 1963. After com-
pleting his residency he joined the faculty of the
Beavers, W. Robert Medical School once again, this time as an assis-
tant professor of psychiatry. He was also a psy-
Ester Yesayan1 and Armine Gevorkyan2 chiatry attending at the Parkland Memorial
1
Los Angeles, CA, USA Hospital and conducted psychiatry consultations
2
California Department of Corrections and at the Terrell State Hospital.
Rehabilitation (CDCR), Los Angeles, W. Robert Beavers founded a nonprofit
CA, USA counseling center in 1973, called the Family-
Studies Center of Dallas, which is dedicated to
advancing family-based approaches to treating
Name mental disorders, and is also a training center for
psychiatry residents, psychology graduate stu-
William Robert “Bob” Beavers, M.D. (born dents, and medical students of the University of
September 27, 1929) Texas Southwestern Medical Center of Dallas.
Beavin, Janet 223
Contributions to Profession which is a non-profit counseling center. The

focus of treatment at the Family Studies Center
W. Robert Beavers has been a prominent contributor is on the interaction between the clients and their
to the field of family psychiatry. He developed sci- families. The center also provides clinical training
entific approaches to family-based therapy and in the application of family interventions for B
extensively examined family dynamics in his future mental health and medical practitioners.
work. Beavers was interested in studying the differ-
ence between healthy and disturbed family dynam-
ics and developed a family model that provided a Cross-References
classification system for family therapists. Beavers
derived the information for identifying healthy and ▶ Family Assessment Device
disturbed families from the research studies of non-
labeled, healthy, “normal,” or functional families
and clinically referred families. From this empirical References
data, he developed the Beavers Systems Model of
Family Functioning, which has been extensively Beavers, W. R. (1977). Psychotherapy and growth:
used in family assessment. The Beavers Systems A family systems perspective. New York: Brunner-
Mazel.
Model of Family Functioning provides a cross- Beavers, W. R. (1981). A systems model of family for
sectional perspective on family functioning on two family therapists. Journal of Marital and Family
dimensions, family competence and family style of Therapy, 7, 299–307. https://doi.org/10.1111/j.1752-
interactions. The Beavers Interactional Scales are 0606.1981.tb01382.x.
Beavers, W. R. (1982). Healthy, midrange and severely
used by a trained rater to classify a family into one dysfunctional families. In F. Walsh (Ed.), Normal
of nine categories or family groupings, including family processes. New York: Guilford Press.
optimal families, adequate families, midrange fam- Beavers, W. R., & Hampson, R. B. (1990). Successful
ilies, borderline families, and severely dysfunctional families: Assessment and intervention. New York:
Norton & Co.
families. A Self-Report Family Inventory (SFI) is Beavers, W. R., & Hampson, R. B. (1993). Measuring
also included in the Beavers Systems Model, which family competence: The Beavers systems model.
measures five family domains – health/competence, In F. Walsh (Ed.), Normal family processes (2nd ed.).
conflict, cohesion, leadership, and emotional New York: Guilford Press. https://doi.org/10.4324/
9780203428436_chapter_20.
expressiveness. Beavers developed this model with Beavers, W. R., & Hampson, R. B. (2000). The Beavers
the intention to help promote systems thinking for systems model of family functioning. Journal of
therapists who were new to family therapy and to Family Therapy, 22, 128–143. https://doi.org/10.1111/
provide a structure for guiding assessment and 1467-6427.00143.
Lewis, J. M., Beavers, W. R., Gossett, J. T., &
therapy. Phillips, V. A. (1976). No single thread: Psychological
Beavers also examined families from a variety health in family systems. New York: Brunner-Mazel.
of different ethnic and socioeconomic back-
grounds to examine differences in family interac-
tions. Based on his studies, he was able to
determine the two separate characteristics that Beavin, Janet
determined functional families, (1) expressed or
implied beliefs and (2) observable patterns. Jasmine Pickens
Finally, Beavers emphasized the importance of Alliant University, Sacramento, CA, USA
the functionality of the family system and its
relationship to psychological disorders. He was a
strong advocate for adequate client care and was Name
devoted to advancing family approaches in
treating mental disorders. Thus, in 1973 Beavers Janet Beavin Bavelas, PhD, F.R.S.C. (February
founded the Family Studies Center in Dallas, 12, 1940–)
224 Beavin, Janet
Introduction 2012, Beavin received the Steve de Shazer

award by the Solution Focused Brief Therapy
Janet Beavin is a pioneer in the field of commu- Association for her work as a researcher.
nication theory and contributed substantially
to the field of Marriage and Family Therapy
(MFT) through her research regarding therapeutic Contributions to the Profession
and interpersonal communication. She authored
several books including Personality: Current Beavin’s contribution to the field began when
Theory and Research and has co-authored Prag- she collaborated with Paul Watzlawick and
matics of Human Communication: A Study of Don Jackson to co-author Pragmatics of
Interactional Patterns, Pathologies, and Para- Human Communication, a book that challenged
dox, as well as the book, Equivocal Communica- traditional communication theory. Prior to the
tion. She has published nearly one hundred publication, the information-transmission
articles in professional journals. Her work model was used as the primary analysis of com-
has been used to develop solution focused brief munication. The purpose of therapeutic commu-
therapy (SFBT) as an evidenced-based practice. nication was to gather information in the form of
monologues between client and therapist. In this
format, the therapist influenced the client and
Career the direction of treatment. Beavin and col-
leagues believed that therapeutic communica-
Beavin began her education at Stanford tion should be more of a dialogue where
University in 1961 where she received her communication is co-constructed between two
Bachelor of Arts in Psychology. Beavin then individuals and involved moment by moment
went on to obtain a Master of Arts in Commu- influence (Beavin and Watzlawick 1967).
nication Research in 1968, and a PhD in Psy- Beavin and fellow authors summarized the
chology in 1970 also from Stanford University. findings on interpersonal communication
Prior to completing her graduate and doctoral in five axioms: (1) it is impossible to not com-
degrees, Beavin was a research assistant municate. Even in silence, communication con-
(1961–1966) and later a research associate tinues to occur. Anti-behavior does not exist.
(1966–1970) for the Mental Research Institute (2) Communication is not just the words
of the Palo Alto Medical Research Foundation, expressed; it also includes how the sender of
commonly referred to as the MRI (Beavin information wants to be understood and how
Bavelas 2007). During this time, she they understand the receiver. (3) The nature of
co-authored Pragmatics of Human Communica- any relationship is dependent on punctuation.
tion, which remains as a foundational text in the Communication is cyclical. Communicants
field of Marriage and Family Therapy and com- structure the interaction and are interpreting
munication theory (Watzlawick et al. 2011). their own behavior based on their reaction to
In the early 1970s, Beavin moved to Canada the other’s behavior. (4) Analog modalities are
where she became an assistant professor at also involved in human communication. Non-
University of Victoria in Victoria, British verbal and analog-verbal communication is just
Colombia (Signorielli 1996). She retired from as vital as digital communication and one can-
this institution in 2005 as Professor Emeritus of not exist without the other. (5) Interactional
Psychology. Beavin continues to research and communication procedures are either symmet-
provide lectures regarding the power of interac- ric or complimentary, which is based upon the
tion and focuses on the study of face-to-face relationship of the communicants (Watzlawick
dialogue through microanalysis. She has et al. 2011).
received several awards for her work as a Beavin views Pragmatics of Communica-
researcher and educator. Most notably, in tions as the turning point of her career and
Becvar, Dorothy 225
paved the way for her future research in the field Signorielli, N. (Ed.). (1996). Women in communication:
of psychology and communication (Beavin A biographical sourcebook. Westport: Greenwood
Press.
Bavelas 2007). Beavin’s focus remains in the Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D.
study of interactional communication and most (2011). Pragmatics of human communication: A study
notably, her research has continued to develop of interactional patterns, pathologies, and paradoxes. B
microanalysis of face to face dialogue (MFD). New York: W. W. Norton & Company.
Beavin defined MFD as a detailed examination
of observable communication as it occurs in the
moment. Beavin’s communication theory places
importance on the here and now interaction Becvar, Dorothy
which has heavily influenced the practice of
SFBT, a major MFT model and is taught in Karen Caldwell
most MFT graduate programs (Bavelas et al. Appalachian State University, Boone, NC, USA
2016). Her current research team includes
prominent practitioners and researchers focused
on SFBT who are using microanalysis to expose Introduction
the power of language in therapy dialogues
(Beavin Bavelas 2012). Beavin’s work has Dorothy Becvar is a licensed marriage and fam-
been essential in helping to define SFBT as an ily therapist and a licensed clinical social
evidenced-based practice. worker whose contributions to the field of fam-
ily therapy include teaching family therapy to
graduate students in university settings and
authoring influential texts. Her contributions
Cross-References also include her many presentations to profes-
sional organizations, service on editorial
▶ Communication Theory boards, and provision of leadership in family
▶ Jackson, Donald therapy associations.
▶ Metacommunication in Couple and Family
Therapy
▶ Solution-Focused Couple and Family Therapy
Career
▶ Watzlawick, Paul
Dr. Becvar completed her MSW degree at Saint
Louis University in 1980 and a PhD program in
References
Family Studies at Saint Louis University in
Bavelas, J., Gerwing, J., Healing, S., & Tomori, C. (2016). 1983. Her professional career began in Philadel-
Microanalysis of face-to-face dialogue. An inductive phia, PA, leading family clusters, enrichment
approach. In C. VanLear & D. Canary (Eds.), groups for whole families in church settings.
Researching interactive communication behavior
She began her academic career at the University
(pp. 129–157). Thousand Oaks: Sage.
Beavin Bavelas, J. (2007). Writings with Paul. Journal of Missouri-St. Louis and subsequently held
of Marital and Family Therapy, 33, 295–297. academic positions at Saint Louis University,
Beavin Bavelas, J. (2012). Connecting the lab to the Texas Tech University (Lubbock, TX), the
therapy room. Microanalysis, co-construction, and
George Warren Brown School of Social Work
solution-focused brief therapy. In C. Franklin,
T. Trepper, W. Gingerich, & E. McCollum (Eds.), at Washington University (St. Louis, MO), and
Solution-focused brief therapy. A handbook of Radford University (Radford, VA). Her final
evidenced-based practice (pp. 144–162). New York: academic position was as Professor and now
Oxford University Press.
Professor Emerita at Saint Louis University.
Beavin, J., & Watzlawick, P. (1967). Some formal aspects of
communication. American Behavioral Scientist, 10(8), She also has maintained a private practice,
4–8. https://doi.org/10.1177/0002764201000802. either full- or part-time, since 1980, and serves
226 Beels, Christian
as president/CEO of The Haelan Centers ®, a References

not-for-profit organization dedicated to facili-
tating growth and wholeness in body, mind, Becvar, D. S. (1997). Soul healing: A spiritual orientation
in counseling and therapy. New York: Basic Books.
and spirit. Created as a memorial to her son,
Becvar, D. S. (2001). In the presence of grief: Helping family
who was killed in a bicycling accident in 1987, members resolve death, dying, bereavement and related
the Haelan Centers help clients regardless of end of life issues. New York: Guilford Press.
their ability to pay. Becvar, D. S. (2007). Families that flourish: Facilitating
resilience in clinical practice. New York:
W. W. Norton.
Becvar, D. S. (Ed.). (2013). Handbook of family resilience.
New York: Springer.
Contributions to Profession Becvar, D. S., & Becvar, R. (1994). Hot chocolate for a
cold winter’s night: Essays for relationship develop-
In addition to her university teaching, she traveled ment. Denver: Love Publishing Co.
extensively, both nationally and internationally, to Becvar, D. S., & Becvar, R. J. (2013). Family therapy:
A systemic integration (8th ed.). Boston: Allyn &
give presentations on a range of topics including Bacon.
spirituality, grief, systems theory, resilience, and Becvar, R. J., Becvar, D. S., & Bender, A. E. (1982). Let us
supervision. Her writings are extensive and first do no harm. Journal of Marital and Family Ther-
include many journal articles, book chapters, and apy, 8(4), 385–391.
Nichols, W. C., Nichols, M. A., Becvar, D. S., & Napier,
books (Becvar 1997, 2001, 2007, 2013; Becvar & A. Y. (Eds.). (2000). The handbook of family develop-
Becvar 1994, 2013; Becvar et al. 1982; Nichols ment: Dynamics and interventions. New York: Wiley.
et al. 2000). Relative to service to the profession,
she was editor of Contemporary Family Therapy:
An International Journal for 5 years. She pro-
vided two decades of service to the American Beels, Christian
Association for Marriage and Family Therapy as
a leader in the state association, as a member of Marjha Toni Hunt
the Board of Directors, and as chair of the Stan- Couple and Family Therapy, Alliant International
dards Committee of the national association. She University, Sacramento, CA, USA
also provided leadership for a decade to the Inter-
national Family Therapy Association serving on
the Board of Directors and as chair of the Interna- Name
tional Accreditation Commission on Systemic
Therapy Education. C. Christian Beels
▶ Ambiguous Loss in Couple and Family C. Christian Beels has been called a “Hero in Com-
Therapy munity Psychiatry.” Beels was a pioneer in training
▶ American Association for Marriage and Family professionals on how to work from a collaborative
Therapy (AAMFT) family perspective in public mental health.
▶ Individual Supervision in Couple and Family
Therapy
▶ International Family Therapy Association Career
▶ Loss in Couples and Families
▶ Resilience in Couples and Families Beels earned a B.A from Harvard University in
▶ Spirituality in Couple and Family Therapy 1953. In 1960, he went on to earn his MD at the
▶ Systems Theory University of Rochester School of Medicine and
Beels, Christian 227
Dentistry. Beels entered residency at an AECOM’s In The Invisible Village, Beels discusses ways
teaching facility, Jacobi Hospital. After residency, in which the culture and the dominant discourse
he began a fellowship at the National Institute for play a role in the trajectory of schizophrenia. He
Mental Health and began his work with individuals suggests that western cultures views can nega-
and families struggling with schizophrenia. Beels tively impact those challenged with this mental B
later joined the Tremont Crisis Center. He later illness. Beels emphasizes that in addition to soci-
became the director of both the in-patient and the etal expectations of the individual at this specific
out-patient services at the Bronx State Psychiatric developmental stage, the person support dimin-
Center and renamed this program Family Service ishes; they often loose a sense of themselves and
Bronx State Hospital. In 1980, he received a Master their place in society. Beels’ work had a major
of Science degree in psychiatric epidemiology from effect on psychoeducational treatments of
Columbia University School of Public Health. In schizophrenia.
1981, Beels created the Fellowship in Public Psy- In Beels’ book A Different Story: The Rise of
chiatry at the New York State Psychiatric Institute Narrative in Psychotherapy, he writes to both
and served as the director of the program through professionals and nonprofessionals an account of
1987. Although he left this position upon retiring in his journey in merging the two – narrative and
1987, this program is still thriving today. He has psychotherapy. He gives personal accounts of his
held numerous positions in the field from family therapeutic work with community members, dis-
therapist, various director positions, many assistant cusses the works and his encounters with those
and associate professor, as well as part-time teaching that influence his views and practices, and pre-
positions. He serves as faculty at Ackerman Family sents his ideas of the many challenges experi-
Therapy Institute. enced in psychotherapy. Included in the latter are
conversations about the division of professionals
through the adherence of schools of thought and
Contributions to Profession professional isolation. He stresses a collaborative
approach not only when working with clients but
Beels has been known for his nontraditional psy- in working with each other as professionals.
chotherapeutic approach. He has a background Beels has made a major impact through his
and interest in anthropology, which underlies his work in being an educator, a family therapist,
focus on social connections and historical impact. and a pioneer in the development of a new way
In creating the Fellowship in Public Psychiatry, he to view and engage in public mental health.
wanted to train early career psychiatrists in
remaining cognizant of the patients’ family sup-
port systems, multistoried accounts, and their his- Cross-References
torical context when working with individuals
diagnosed with mental illness. ▶ Epston, David
Beels was a major moving force in the devel- ▶ Family Process (Journal)
opment of family therapy and the journal Family ▶ Narrative Family Therapy
Process. He brought with him his emphasis in ▶ White, Michael
community psychiatry to the field; most espe-
cially, in promoting humane family treatments
for those with severe mental illness. References
Later, Beels met and instantly made a personal
connection with the developers of narrative ther- Beels, C. C. (1989). The invisible village. New Directions
apy, Michael White and David Epston in 1982. for Mental Health Services, 42, 27–40.
Beels, C. C. (2001). A different story: The rise of narrative
Although he didn’t have a name for it at the time, in psychotherapy. Phoenix: Zeig, Tucker & Theisen.
he had similar ways of thinking that aligned with Beels, C. C. (2009). Some historical conditions of narrative
the values that narrative therapy. work. Family Process, 48(3), 363–378.
228 Behavior Exchange in Couple and Family Therapy
Rationale for the Strategy or

Behavior Exchange in Couple Intervention
and Family Therapy
Previous research suggests that distressed couples
Jennifer Duchschere are less likely to engage in rewarding or positively
University of Arizona, Tucson, AZ, USA reinforcing behaviors and are more likely to
engage in negative or unwanted behaviors
(cf. Birchler et al. 1975). This finding has been
Name of the Strategy or Intervention demonstrated as a general effect as well as within
specific dyadic interactions such as problem-
Behavior exchange in couple and family therapy solving (Birchler et al. 1975). Increased negative
behaviors have been linked to higher levels of
partner avoidance (e.g., engaging in activities
without their partner; Birchler et al. 1975) and
Synonyms lower levels of marital satisfaction (as cited by
Birchler et al. 1975; Gottman 1993).
BE; Contingency contract; Social exchange When behaviors occur without a naturally
rewarding context, they may lead to heightened
reactivity to a partner’s behaviors (Jacobson and
Introduction Margolin 1979). This reactivity is illustrated by
distressed couples responding more intensely to
Behavior Exchange (BE) is a therapeutic tool immediate rewards or consequences as opposed to
which seeks to increase the ratio of positive to delayed rewards or consequences, whereas non-
negative behaviors that occur within a dyad distressed couples may not be as significantly
(Gurman and Jacobson 2002; Jacobson and affected by immediate responses (Jacobson and
Christensen 1996; Jacobson and Margolin Margolin 1979).
1979). A BE model of relationships assumes
that each partner holds some amount of control
or influence over the other’s behaviors, and thus Description of the Strategy or
the dyad is engaged in a continuous cycle of Intervention
interacting behaviors and responses (Jacobson
and Margolin 1979). Partners often respond to In a therapeutic context, BE seeks to resolve the
positive behaviors with positive behaviors, and imbalance of positive and negative behaviors
respond to negative behaviors with negative exchanged by distressed couples. In order to do
behaviors (Gottman et al. 1976). so, reinforcing or rewarding behaviors are identi-
fied (with the therapist) that would increase a
partner’s relationship satisfaction. It is important
to note that these identified behaviors are often
Theoretical Framework unique in that both dyadic and individual differ-
ences must be considered. Even within the dyad,
BE is derived from behaviorism and makes the each partner may desire seemingly unrelated
assumption that small shifts in behavior will behaviors. Examples of target behaviors include
influence the overall dyadic dynamic. It is thus demonstrations of affection, increased verbal
often incorporated into behavior-based thera- communication, or spending more time together
pies, such as traditional behavioral couple ther- (Jacobson and Christensen 1996; Gurman and
apy (TBCT) or integrative behavioral couples Jacobson 2002; Jacobson and Margolin 1979).
therapy (IBCT; Jacobson and Christensen Chosen behaviors should be ones which partners
1996). seek to increase (positive) rather than those they
Behavior Exchange in Couple and Family Therapy 229
want eliminated (negative), so as not to provide behavioral change immediately after the termina-
further effort and attention to the negative behav- tion of therapy. However, after 6 months couples
iors within the relationship (Gurman and receiving only BE lost their gained progress,
Jacobson 2002). Additionally, these behaviors whereas those who received CPT or the combina-
should not generate additional conflict; thus, tion of CPT and BE were more likely to maintain B
behaviors should feasible (low-cost) for a partner their gains or continue to improve. It seems that
to complete as well as require similar effort across although BE can increase positive behaviors at
the dyad (Gurman and Jacobson 2002). home short-term, it does not tend to get at under-
After rewarding behaviors are generated lying relationship issues or help the couple deter-
within the session, therapists often guide the cou- mine how to work through challenges in the future
ple to individually choose a behavior to try at (Jacobson and Christensen 1996). As such, BE
home and notice what the responses are to these is insufficient treatment for a distressed couple.
changed actions. The idea is that if the behaviors The above describes the use of BE within
chosen are truly rewarding, or have the potential romantic relationships because there is existing
to actually increase relationship satisfaction, their and ongoing literature on this topic; however,
partner will respond positively. For example, a BE might also be a successful tactic in other
husband may choose to increase his physical types of relationships in which dyads or families
affection toward his wife by hugging her each are struggling with the presence of rewarding or
day when he comes home from work. If his wife reinforcing behaviors. For example, if a parent
is indeed seeking increased physical affection, she is seeking behavior change in their child but is
may respond by smiling or engaging in conversa- using punishment or consequences as the moti-
tion. These responses are natural and positively vation for the child, shifts in their behavior may
reinforcing for the initial act of hugging. need to reflect those which are rewarding to the
Jacobson and Christensen (1996) provided a child.
simple structure for BE. They suggested that in
session, each partner generate a list of behaviors
they believed their partner would want more or Case Example
less of (rather than create this list about behaviors
they want their partner to change). A behavior is Karen (30) and Justin (32) have been married for
chosen to “try out” during the week without 5 years. They have two young children. They
knowing whether their partner would agree that decided to start therapy due to feeling distant
a given behavior would shift their current level of from one another in the past year. While they do
relationship satisfaction. During the next session, not argue frequently, they both acknowledged that
the behaviors attempted are explored and each their relationship currently feels more like “room-
partner may respond. The partners at this time mates” rather than partners in marriage. Karen
may then review the list and provide feedback as expressed that at times she doubts Justin’s feelings
to why or why not a particular action would be for her because his physical affection and inti-
something wanted. After this, they may continue macy has decreased. She believes this shift has
in the same fashion as traditional BE. resulted in her seeking any affection. Justin
Research on the effects of BE demonstrate that reported feeling stressed from responsibilities
although it generally creates rapid change, it is not related to both work and taking care of their chil-
sufficient for lasting change (Jacobson and dren. He described still being in love with Karen,
Christensen 1996). Jacobson (1984) examined but simply that he “doesn’t have time to show it.”
the components of behavioral marital therapy, Karen and Justin were asked to create separate
including BE and communication/problem- lists of behaviors they could reasonably do during
solving training (CPT). He found that BE demon- the week in attempt to increase their partner’s
strated significant increases in marital satisfaction relationship satisfaction. These lists were not
and positive behaviors, while reducing desires for shown to the other partner. Rather, they were
230 Behavior Exchange Theory
asked to try one of the behaviors on this list during Jacobson, N. S. (1984). A component analysis of behav-
the week and take note of their partner’s response. ioral marital therapy: The relative effectiveness of
behavior exchange and communication/problem-
When Karen and Justin came in for their next solving training. Journal of Consulting and Clinical
session, they reported that the task had gone well. Psychology, 52(2), 295–305.
Karen reported that one evening during the week, Jacobson, N. S., & Christensen, A. (1996). Acceptance and
she prepared lunches for Justin and their children change in couple therapy: A therapist’s guide to trans-
forming relationships. New York: W.W. Norton &
for the next day. When Justin discovered that she Company.
helped with this task generally designated to him, Jacobson, N. S., & Margolin, G. (1979). Marital therapy:
he responded by smiling and giving her a hug. Strategies based on social learning and behavior
Justin indicated that his idea was to come home exchange principles. New York: Brunner/Mazel.
from work, kiss Karen and tell her that he loves
her. The first time this behavior occurred, Karen’s
mood seemed uplifted and she inquired more
about his day at work. Although Justin’s goal Behavior Exchange Theory
was to try this one time, he ultimately did this
several times throughout the week stating that Kathleen A. Eldridge
they actually felt like they were a couple. Graduate School of Education and Psychology,
Pepperdine University, Los Angeles,
CA, USA
Cross-References
▶ Behavior Exchange Theory Name of Theory

▶ Christensen, Andrew Behavior exchange theory
▶ Gottman, John
▶ Gurman, Alan
▶ Integrative Behavioral Couple Therapy Synonyms
▶ Jacobson, Neil
▶ Problem-Solving Skills Training in Couple and Social Exchange Theory
Family Therapy
▶ Social Exchange Theory
Introduction
References Behavior exchange theory is a set of ideas designed

to explain the formation, maintenance, and dissolu-
Birchler, G. R., Weiss, R. L., & Vincent, J. P. (1975). tion of close relationships. The basic principles of
Multimethod analysis of social reinforcement exchange behavior exchange theory are that (a) close relation-
between martially distressed and nondistressed spouse
and stranger dyads. Journal of Personality and Social ships are characterized by interdependent interper-
Psychology, 31(2), 349–360. sonal transactions (behavioral exchanges) between
Gottman, J. M. (1993). The roles of conflict engagement, people, (b) these exchanges provide rewards and
escalation, and avoidance in marital interaction: costs for each person, and (c) people weigh the
A longitudinal view of five types of couples. Journal
of Consulting and Clinical Psychology, 61, 6–15. ratio of rewards and costs against alternative rela-
Gottman, J., Notarius, C., Markman, H., Bank, S, tionships to determine whether to continue or dis-
Yoppi, B., & Rubin, M. E. (1976). Behavior exchange solve the relationship. Based on these ideas, it
theory and marital decision making. Journal of Person- follows that satisfying and stable relationships will
ality and Social Psychology, 34(1), 14–23.
Gurman, A. S., & Jacobson, N. S. (Eds.). (2002). Clinical contain behavioral exchanges marked by favorable
handbook of couple therapy (3rd ed.). New York: reward-cost ratios for each member of the relation-
Guilford Press. ship. Although behavior exchange theory has been
Behavior Exchange Theory 231
of interest across multiple disciplines, this entry will by Neil Jacobson, Andrew Christensen, and col-
emphasize the aspects most pertinent to couple and leagues (Jacobson and Christensen 1998).
family therapy.
Description B
Behavior exchange theory has featured promi-
John Thibaut and Harold Kelley (1959) are often nently in behavioral conceptualizations of couple
cited as the social psychologists who proposed and family relationships and treatment methods.
behavior exchange theory. Other early works on Integrating ideas set forth by sociologists, psy-
behavior exchange are those by social psycholo- chologists, and economists, it describes relation-
gist Kenneth Gergen (1969) and by sociologists ships as social exchanges of rewards and costs. In
George Homans (1961) and Peter Michael any close relationship, each partner experiences
Blau (1964). rewards from being together and costs of being in
After the theory was proposed, it was studied the relationship. Rewards and costs can be tangi-
in the context of couples and families throughout ble or intangible and exist for both the receiver
the 1970s and 1980s by numerous psychologists and the producer of the behavior. Examples of
associated with cognitive-behavioral approaches. rewards include companionship, emotional and
Early examples of these studies include Weiss instrumental support, pleasant emotions, income,
et al. (1973), Birchler et al. (1975), and Gottman social approval, and physical intimacy. Con-
et al. (1976). Their goal was to identify frequen- versely, costs might include, among others, com-
cies, correlates, and consequences of rewarding promises, disagreements, unpleasant emotions,
and aversive behavioral exchanges among couple financial costs, time and energy costs, or social
and family dyads experiencing varying levels of disapproval.
distress. Presuming that people are motivated to maxi-
Psychologists also developed treatment mize rewards and minimize costs, behavior
methods based partly on the ideas of behavior exchange theory suggests that relationship deci-
exchange theory, such as operant-interpersonal sions around mate selection and relationship
treatment presented by Richard Stuart (1969), rec- maintenance or dissolution are based, in part, on
iprocity counseling for couples introduced by the level of rewards experienced and costs
Nathan Azrin and colleagues (1973), and the incurred in the relationship. An individual con-
Gottman Method developed by John Gottman siders the rewards and costs of the current rela-
and colleagues (Gottman 1999). Examples of tionship in comparison to the rewards and costs of
treatment approaches that contain some behavior alternative relationships and to no relationship. If
exchange methods and have been established the current relationship offers a better reward-cost
empirically over decades include the Prevention profile than the alternatives, the relationship is
and Relationship Education Program developed more likely to continue. Conversely, if alternative
by Howard Markman, Scott Stanley, Susan relationships or no relationship offers a better
Blumberg, Galena Rhodes, and colleagues profile, the relationship is more likely to end.
(Markman et al. 2010); Behavioral Parent Train- Some versions of behavior exchange theory
ing developed by Gerald Patterson and colleagues emphasize parallels with economic or market
(Forgatch and Patterson 2010); Behavioral Cou- forces. As individuals seek to immerse themselves
ple Therapy developed by Neil Jacobson, Gayla in relationships that offer more advantages than
Margolin, and colleagues (Jacobson and Margolin disadvantages, they also consider supply and
1979); Cognitive Behavioral Couple Therapy demand. If supply of a reward is generally low
developed by Norman Epstein, Donald Baucom, in the population (extreme wealth or attractive-
and colleagues (Epstein and Baucom 2002); and ness; excellent listening and deep, meaningful
Integrative Behavioral Couple Therapy developed conversation) but provided by one’s partner, that
reward may be valued more than one that is pro- whereas those from more individualist cultures
vided but in high supply elsewhere as well may place a higher value on tangible rewards gar-
(physical affection). Likewise, costs that are nered in exchanges. Similarly, those with collectivist
incurred in the current relationship but also likely orientations may find the time and energy costs of
incurred in other relationships (time and energy; relationships less burdensome than those from an
minor disagreements) may be experienced less individualist orientation.
negatively than costs incurred in the present rela-
tionship but unlikely in other relationships Exchange Ratios and Satisfaction
(violent behavior). Another economy metaphor Of interest to therapists and clinical researchers is
offered in the context of behavior exchange theory the ratio of rewards to costs in the behavior
is the “bank account” model of marriage exchange of relationships. This ratio can be favor-
(Gottman et al. 1976). In this metaphor, positive able, with high rewards and low costs, or it can be
exchanges are described as investments or unfavorable, with high costs and low rewards.
“deposits” that maintain a favorable emotional Psychologists have attempted to understand how
balance and ensure stability and satisfaction of this reward-cost ratio relates to satisfaction in the
the relationship, while negative exchanges are relationship, how an unfavorable ratio develops,
considered “withdrawals” from that account that and how treatment can improve the ratio.
disrupt a favorable balance. As the balance In support of behavior exchange theory, studies
declines and tensions rise, couples are more apt have found that a higher ratio of rewards to costs
to scrutinize the rates of deposit and withdrawal is associated with more relationship satisfaction.
and become increasingly reactive to withdrawals. In behavioral terms, this is assumed to be due to
This increased reactivity creates a higher level of the high rate of reinforcement experienced in rela-
negative reciprocity in behavioral exchanges, in tionships that have a favorable rewards-to-costs
which partners increasingly respond to negative ratio, as compared to the low rate of reinforcement
behaviors with subsequent and escalating negativ- experienced when an unfavorable rewards-to-
ity (Jacobson and Margolin 1979). costs ratio exists. John Gottman and colleagues
Early studies of behavior exchange theory exam- have attempted to determine the specific numeric
ined behavioral exchanges in dyads using question- ratio of benefits to costs necessary during conflict
naire methods, such as the Spouse Observation discussions for a relationship to be stable and
Checklist (Wills et al. 1974), or observational satisfied. Their work suggests that a 5:1 ratio of
methods, using objective coders who observed the positivity to negativity is necessary, even during
recorded conversations of couples and made judg- disagreements. An example of this would be five
ments about what would be considered positive or positive behaviors such as compliments, expres-
negative. Later, researchers understood that part- sions of empathy, careful listening, appropriate
ners’ subjective perceptions of the level of reward humor, or affection for every one negative behav-
or aversion they experience in response to specific ior such as criticism, withdrawal, or defensive-
behaviors would represent a more accurate reflec- ness. On the other hand, unhappy couples
tion than just behaviors alone or evaluations of headed for divorce display a ratio closer to 0.8:1,
behaviors from an outsider’s frame of reference. while they are discussing problems in the relation-
They discovered a difference between the intended ship. Their ratios demonstrate slightly less posi-
impact of a behavior and the actual impact, particu- tivity than negativity (Gottman 2011).
larly for distressed partners who received behaviors
more negatively than nondistressed partners. In Development of Unfavorable Exchange Ratios
addition to associations with distress, it is important Early on, dating relationships are often character-
to note that what each partner regards as a reward or ized by rewarding behavioral exchanges as part-
cost is also culturally informed. Hence, those from ners display their most pleasing behaviors. Rarely
collectivist cultures may place higher value on the are these uniformly positive exchanges sustained
rewards of interdependent behavioral exchanges, throughout the relationship. In behavioral theory,
two processes are thought to contribute to the or disadvantageous. Being more responsive to
development of unfavorable behavior exchange negative exchanges creates a spiral of negative
ratios over time. One process is reinforcement reciprocity between partners, while responsive-
erosion. In every relationship, partners habituate ness to positive exchanges can lead to a power-
to the rewarding behaviors each one displays ful response of positive reciprocity when B
toward the other. Over time, behaviors that were treatment methods increase positive behaviors.
once highly reinforcing gradually become less so
as each person becomes accustomed to them. Behavioral Reinforcement in Exchanges
Even though the exchanges are positive, they In behavior exchange theory, principles of posi-
carry less reinforcement value over time as their tive and negative reinforcement are an important
impact wears off. If couples aren’t intentional component in explaining the maintenance and
about refreshing these behaviors by adding new intensification of exchanges. Positive behavioral
ones, or bringing back ones that have fallen away, exchanges are experienced as rewarding and are
their relationship begins to have less reinforce- therefore more likely to continue. Negative
ment. Another process that contributes to unfa- behavioral exchanges on the surface would appear
vorable behavioral exchanges is skill deficit or to be distressing and non-rewarding and therefore
decline. Many skills are helpful in the effective less likely to continue. However, a closer look at
functioning of relationships, such as communica- the specifics of these exchanges reveals the central
tion, parenting, budgeting, and decision-making. role of negative reinforcement in their continua-
If these skills are not learned, practiced, or used, tion. For example, when one partner criticizes the
relationships are likely to have higher rates of other, the responding partner sometimes changes
negative exchanges and fewer positive ones. in a favorable way to stop the criticism. Doing so
provides intermittent negative reinforcement for
Interdependence and Reciprocity both partners. In other words, the criticizing part-
Studies of behavior exchange theory have also ner gets the criticized partner behavior to stop
considered the extent to which behavioral (negative reinforcement), or gets new positive
exchanges are reciprocal or interdependent. If behavior in its place (positive reinforcement),
reciprocity exists, behaviors are contingent on and is therefore more likely to criticize again in
prior and subsequent behaviors of the partner. the future. The criticized partner, in making the
For example, one partner is more likely to changes desired by the partner, ends the criticism,
behave in rewarding ways if the other partner at least temporarily (negative reinforcement), and
has recently done so. Each person’s behavior is therefore is likely to respond with similar changes
in response to and provokes the partner’s behav- upon future criticism. The downside to this behav-
ior, in a cyclical pattern, so that exchanges that ioral exchange pattern is that problems are not
are positive tend to bring about more positive often discussed or resolved in a meaningful or
exchanges immediately and over time (positive sustainable way. Instead, temporary changes are
reciprocity), whereas negative exchanges foster made to stop the unpleasant behaviors, but inef-
more negativity (negative reciprocity). fective patterns of aversive control or coercion are
Research tends to indicate that distressed and reinforced and repeated over time. Similarly, if
nondistressed couples alike tend to engage in heated exchanges involving both partners yelling
positive reciprocity, whereas distressed rela- and arguing are followed shortly thereafter by
tionships are uniquely characterized by negative declines in intense emotional arousal, these
reciprocity, particularly escalating negativity. behaviors are negatively reinforced and likely to
These patterns hold true for both day-to-day continue in future exchanges. These types of rein-
exchanges as well as lengthier time frames forcement patterns in behavioral exchanges are
(Jacobson and Margolin 1979). When reciproc- described further by coercion theory (Patterson
ity exists, suggesting that partners are more and Reid 1970) and escape conditioning theory
reactive to one another, this can be beneficial (Gottman and Levenson 1986).
Relevance to Couple and Family Therapy improving the behavior exchange ratio provides
a clear rationale for including skills in the
The clinical implications of behavior exchange treatment plan.
theory are clear in assessment, psychoeducation, Behavior exchange theory also guides goal-
and treatment planning. In relying on these ideas, setting and treatment planning. The theory and
therapists start with careful assessment of the research suggest that improving the ratio of
rewards and costs in the relationship, gathering rewards to costs will improve the quality and
specific details about positive and negative behav- stability of the relationship. This provides a clear
iors displayed and their precipitants and conse- path for improving relationships by helping cou-
quences. Therapists also ask partners about their ples improve this ratio. Note that improving the
perceptions of those behaviors, to ensure their ratio involves addressing both elements of the
subjective experience is considered, instead of equation, reducing the negatives and increasing
making assumptions about how behaviors are the positives. Mathematically speaking, if the goal
experienced based on one’s own frame of refer- is a 5:1 ratio or higher, it will clearly be necessary
ence. Therapists can use the Spouse Observation to help distressed couples who are closer to a 0.8:1
Checklist in specific ways that provide both objec- ratio to increase their rewarding behavior, espe-
tive and subjective measurement of behavioral cially during attempts to resolve conflict.
exchanges and their impact on partners (Wills Behavior exchange methods, such as develop-
et al. 1974; Jacobson and Margolin 1979). ing lists of positive behaviors each partner will
Therapists may provide psychoeducation demonstrate, are intended to escalate rewarding
about behavior exchange ratios and processes exchanges. In these methods, the goal is to deter-
like reinforcement erosion and skill deficits that mine behaviors that maximize rewards for the
bring about unfavorable ratios. For example, the recipient and minimize costs to the giver. Thera-
fact that some negative exchanges do exist in the pists ensure that partners plan to engage in posi-
5:1 ratio of stable and happy marriages indicates tive behaviors that are new or renewed, instead of
that not all negativity is detrimental to relation- routine, so that they will carry ample reinforce-
ships, as long as it is not extensive and exists in ment value. Therapists also ensure the behaviors
combination with ample positive exchanges. An are within the partners’ current abilities, so they
overall positive experience in the relationship, can be implemented with ease instead of requiring
termed positive sentiment override, provides a practice or preparation. Often, couples who have
buffer for those negative exchanges. This infor- been immersed in problems appreciate the initial
mation may be helpful for partners who believe focus on building back positivity in the relation-
that all conflict is harmful and seek to avoid it at all ship, and this initial focus builds their hope, con-
costs. It is also helpful for partners to understand fidence, and willingness to collaborate as they
the role of reinforcement erosion in reducing the engage in the more difficult skill-building work
potential for positive behaviors to impact the rela- of therapy.
tionship. For example, in describing the positive Treatment methods that strengthen skills in
behaviors displayed, partners may feel communication and conflict resolution are also
unappreciated for those they have been engaging designed to improve the behavior exchange
in, finding them to be fruitless in improving the ratio. In addition to helping couples constructively
relationship. Particularly if those positive behav- work on problems throughout therapy, another
iors have been displayed routinely, they may no benefit is that these skills can continue to be
longer hold much reinforcement potential. Cou- used long after therapy has ended, particularly
ples appreciate understanding why their positive when difficult problems arise, to maintain a favor-
behavior attempts are not being met with the able behavior exchange ratio. Generally, research
anticipated positive outcome, which then reduces does show that skill acquisition and ratio improve-
their discouragement and hopelessness. Lastly, ments occur over the course of couple treatments
explaining the utility of skill building for that encourage skill building. In addition, these
improvements in positive behavior and reductions increase in negative ones. The therapist also con-
in negative behavior are associated with expected sidered whether the ratio of positive to negative
improvements in relationship satisfaction. during disagreements was closer to the 0.8 to
1 expected of distressed or divorcing couples or
to the 5:1 ratio of stable and satisfied marriages. B
Clinical Example of Application of The therapist discussed the possibility of inviting
Theory in Couples and Families Amira to sessions, asking the Rehmans if they
would like to do this. Together, the therapist and
Jamil and Maya Rehman have been struggling in the Rehmans decided to make initial progress in
their relationship for quite some time. They are a the marriage and then begin to incorporate other
dual-career couple with three children ranging in members of the family system. They ended up
age from 8 to 15. While their initial dating years holding three sessions over the course of treat-
were characterized by high levels of affection and ment in which Amira attended with her parents.
rare disagreements, their marriage is now marked The behavioral exchanges between Maya and
with occasional heated exchanges followed by Amira were assessed in the same ways as the
days of tense silence and minimal exchanges parental dyad, asking about both positive and
needed to carry out the functions in their family. negative exchanges and gathering specific details.
Jamil feels ignored by Maya on a daily basis, and Psychoeducation about ratios in satisfied and
Maya sees the relationship more like roommates dissatisfied relationships, the processes of rein-
who co-parent than a marriage based on Jamil’s forcement erosion, positive and negative rein-
lack of physical affection and involvement with forcement, skill deficits that contribute to
her. Both have silently considered divorce but unfavorable ratios, and the methods for improving
have decided to attempt marital therapy before the ratio was shared with Jamil and Maya and then
giving up, for the sake of their children. In addi- later with Amira as well. For example, the thera-
tion, Maya and the eldest daughter, Amira, report pist informed them that the aim would not be to
frequently occurring and rapidly escalating eliminate conflict, since even happy couples and
behavioral exchanges in which Maya blames and family dyads experience negativity, but to help
criticizes, while Amira gets defensive and them respond to it in more constructive ways
countercriticizes. Maya initiated treatment for while also increasing their positive exchanges so
the martial relationship and also expressed con- that the overall balance was skewed toward
cern about the quickly deteriorating relationship rewarding exchanges. In addition, the therapist
with her daughter. explained the reinforcement process that gets
In early meetings with Jamil and Maya, the them stuck in their negative behavioral
therapist attempted to gather specific details exchanges. For example, the therapist helped
about the early behavioral exchanges in their rela- Maya understand that her criticism and blame
tionship, bringing back pleasant memories and toward Amira, while unpleasant for both, con-
providing some initial hope and encouragement. tinues in part because it sometimes gets rewarded
The therapist also assessed the details of their by changes in Amira’s behavior. Psychoeducation
current behavioral exchanges, asking for specific also helped the Rehmans understand that rein-
behaviors and listening carefully for their percep- forcement erosion, a natural process, contributes
tions of those behaviors. Since Jamil and Maya’s to decline in satisfaction even when positive
descriptions were mainly negative, the therapist behavioral exchanges have been maintained for
intentionally asked about current positive many years.
exchanges. While observing the Rehmans and The goal of treatment was straightforward in
listening to their descriptions and perceptions, theory, although not always simple to accomplish,
the therapist considered whether processes like and entailed increasing rewards and decreasing
reinforcement erosion and skill deficits contrib- costs through shifts in behavioral exchanges.
uted to the decline in positive exchanges and The first treatment method was closely tied to
behavior exchange theory and was in fact called some preplanned contingencies, such as encour-
behavior exchange. The Rehmans were encouraging Jamil to initiate physical affection
aged to write a list of kind, considerate, affection- through hugs each evening, which would then
ate interpersonal behaviors they were willing to prompt Maya to ask about his day. Initially, the
do toward their partner. The therapist helped them therapist chose to forego specified days, based
include items that were worded positively (“I will on the unpredictability of their daily lives with
make eye contact and ask how he is doing each dual careers and three children. Instead the ther-
day” instead of “I won’t ignore him”), specific (“I apist started with approaches that maximized
will hug her” instead of “I will show affection”), the probability of the Rehmans experiencing
daily interpersonal behaviors (“I will make her early success in treatment while minimizing
coffee when I make mine” instead of “I will buy the potential for disappointment. The therapist
a new coffee-maker”), behaviors already in their also encouraged the Rehmans to notice the
repertoire (not requiring newly learned skills), and behaviors initiated, the impact they have, and
behaviors unrelated to highly sensitive unresolved the level of pleasure experienced both as
issues (such as longstanding absence of sexual receiver and giver.
activity). It was quite helpful to have them make The therapist then began the subsequent ses-
their lists focused on what they were willing to do sion with a review of the behavioral exchanges
for their partner, instead of the reverse direction of demonstrated by Jamil and Maya, their experi-
what they want from their partner. As the ences doing the behaviors, and the receiving part-
Rehmans entered therapy, they were highly ners’ experiences of them. Over time, as
focused on what they wanted their partner to do collaboration and satisfaction improved, the
for them and had become less aware of the behav- Rehmans were encouraged to provide input to
iors they could demonstrate toward their partner their partners’ lists, thereby including the behav-
to improve the relationship. Early in therapy, part- ioral exchanges that were likely to carry the stron-
ners are often more willing to produce rewarding gest reinforcement value. Jamil and Maya were
behaviors that are self-initiated instead of partner also encouraged to brainstorm activities they
imposed. could partake in together that were mutually
The therapist also considered variations in rewarding, each making a separate list then com-
how to implement these behavioral changes. paring to see where there was overlap. Jamil’s list
The Rehmans could be encouraged to initiate included enjoying the outdoors, and Maya’s list
the specified behaviors in an unscheduled way included going on a family picnic, so together
by doing them as it occurred to them, or in a they decided to spend Saturday afternoon at the
prescheduled way by designating specific “love local park, picnicking and enjoying time together
days” or “caring days” when they intensify their and with their children. The therapist also helped
number of pleasing behaviors (Stuart 1980). them work out the details of food preparation, age-
They could also be encouraged to do the behav- appropriate activities and responsibilities for each
iors in a non-contingent fashion, regardless of of the children, communicating the plan with the
how the partner behaves, or use contingency children (particularly Amira who they anticipated
contracting or quid pro quo agreements in would express displeasure at the idea), backup
which each behavior is tied to another behavior plans in case of inclement weather, and methods
in the partner, therefore creating reciprocal or for maintaining pleasant exchanges during the
interdependent behavioral exchanges between activity. The therapist also had them design the
Jamil and Maya (Azrin et al. 1973; Stuart details of a rewarding time together for just the
1969). In collaboration with the Rehmans and two of them without the children, involving a
based on their input, the therapist encouraged a short hike and picnic of their favorite foods.
combination of these methods, allowing them As the Rehmans experienced initial success in
some flexibility in choosing when and how to escalating rewarding exchanges, they were then
engage in the behaviors while also specifying taught skills for maintaining them with less
involvement of the therapist. They were encour- ▶ Positive Reinforcement in Couples and
aged to make requests in effective ways that are Families
assertive and non-demanding. For example, they ▶ Quid Pro Quo in Couple and Family Therapy
were encouraged to start requests with phrases ▶ Quid Pro Quo in Social Exchange Theory
such as “I would appreciate it if you. . .” or ▶ Social Exchange Theory B
“Would you please. . .” or “I would like you
to. . .” followed by specific behaviors, not vague
prompts. Jamil was able to change “You should
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me” to “I would like you to ask me about my day Azrin, N. H., Naster, B. J., & Jones, R. (1973). Reciprocity
and listen with eye contact for 5–10 minutes each counseling: A rapid learning-based procedure for marital
evening.” In addition, the therapist encouraged counseling. Behavior Research and Therapy, 11,
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by expressing interest and appreciation toward Multimethod analysis of social reinforcement exchange
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Although these methods were not designed to cognitive-behavioral therapy for couples. Washington,
reduce negative exchanges, they also had that DC: American Psychological Association.
Forgatch, M. S., & Patterson, G. R. (2010). Parent man-
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Service.
BCT is based on behavioral exchange principles.
Drawing from behaviorism, it focuses on the fre-
quency of positive and negative behaviors, how
Behavioral Couple Therapy these behaviors get reciprocated between part-
ners, and how partners’ responses either intention-
Justin A. Lavner ally or unintentionally reinforce these behaviors
University of Georgia, Athens, GA, USA (Stuart 1969; Jacobson and Margolin 1979). Gen-
erally, the model argues that happy marriages can
be distinguished from unhappy marriages by the
Name of Model ratio of positives to negatives in the relationship,
such that this ratio is favorable in happy relation-
Behavioral couple therapy (BCT) ships and unfavorable in unhappy relationships;
that distressed couples are especially likely to
reciprocate negative behavior; and that distressed
Synonyms couples are more likely to use punishing behav-
iors to bring about behavior change in their part-
Behavioral marital therapy (BMT); Traditional ners, whereas non-distressed couples use positive
behavioral couple therapy (TBCT) reinforcement. The model further assumes that a
lack of positives signifies an absence of key skills
such as providing empathic and supportive com-
Introduction munication and problem-solving/decision-
making (Weiss 1980). Couples’ inability to utilize
Since its development several decades ago, the skills needed to promote happier relationships
BCT has grown into one of the most widely is thought to be due either to couples’ lack of those
used couple therapy modalities and has been skills in the first place (i.e., a skill deficit) or an
the most widely studied form of couple therapy. inability to perform certain skills they do have due
This treatment also forms the basis for later to other factors (e.g., external stressors such as
iterations of behaviorally based couple therapy, work or children; Baucom et al. 2008).
including cognitive behavioral couple therapy, In keeping with these behavioral principles,
enhanced cognitive behavioral couple therapy, BCT emphasizes increasing the frequency of cou-
and integrative behavioral couple therapy. ples’ positive interactions and teaching couples
These later treatments adopt many of the theo- communication and problem-solving skills to
retical tenets and therapeutic strategies decrease the frequency of their negative interac-
described here while also expanding on this tions. The focus is on present interactions and on
Behavioral Couple Therapy 239
specific interventions in and outside of session to Strategies and Techniques Used in

improve couple’s interactional processes. The the- Model
ory of change is that by changing couples’ behav-
iors and their reinforcers, these interventions can BCT takes a skills-oriented, present-focused
shift the overall balance of positives and negatives approach to improving couples’ relationships. B
in the couple’s relationship, ultimately resulting in The therapist plays an active role in treatment as
improvements in couples’ satisfaction. a collaborator, coach, and facilitator. The strate-
The ideas underlying the model – particu- gies and techniques used in BCT fall into two
larly the notion that maladaptive communica- general categories that directly target the theoret-
tion patterns distinguish between distressed ical framework outlined above: (1) behavior
and non-distressed couples – have been exchange strategies designed to increase the ratio
supported by a large body of research spanning of positive to negatives in the relationship and
several decades. Collectively, this work indi- (2) communication and problem-solving skills
cates that the relationships of distressed couples training.
are marked by high levels of negative commu-
nication, low levels of positive communication, Behavior Exchange Strategies
and more negative reciprocity between partners Behavioral exchange strategies can generally be
(Bradbury and Karney 2013). BCT’s focus on thought of as interventions designed to increase
increasing positives in couples’ relationships positivity in couples’ relationships. They are the
and improving their communication to decrease initial focus of treatment so that couples experi-
negatives is thus consistent with this basic ence some positive growth and learn that change
research on some of the factors that characterize is possible (Jacobson and Margolin 1979). Given
satisfied and dissatisfied couples. that couples are generally presenting to therapy
BCT’s sole focus on behavior and how the with some distress – and commonly present with
relationship context serves to shape each partner’s considerable distress – these strategies are aimed
behavior distinguishes it from other behavioral at introducing positivity back into couples’
couple approaches with more expansive foci. For relationships.
example, cognitive behavioral couple therapy Therapists can use a variety of strategies to
addresses how cognitions, values, and beliefs increase positivity in couples’ relationships.
can drive behavior and includes a therapeutic Some of these strategies are directed at improving
focus on these cognitive elements. Integrative an individual partner’s happiness. Initially, cou-
behavioral couple therapy incorporates an empha- ples are encouraged to monitor their behaviors
sis on promoting acceptance in addition to behav- and how their behavior affects their partner’s sat-
ior change. isfaction. This strategy shifts the focus away from
what the partner does not do or does “wrong” and
toward what each individual does that makes the
Populations in Focus partner happier. With the therapist’s assistance,
each member of the couple is then encouraged to
Behavioral couple therapy is widely used with and identify behaviors that they can implement in
appropriate for couples with a range of relation- order to increase their partner’s satisfaction. For
ship difficulties. In addition, it has been shown to example, a partner may take over some of the
be particularly effective for couples with relation- household chores like washing the dishes or
ship distress in which one partner is experiencing tucking the kids in or engage in some pleasurable
clinical depression (Whisman and Beach 2012) as activity like giving the partner a massage. These
well as for couples in which one partner has an types of activities can be enacted on a daily basis,
alcohol or drug use disorder (Powers et al. 2008), such that partners are assigned a certain number of
with adaptations for dealing with the specifics of tasks per day to complete, or they can be
these conditions. implemented in a more targeted manner during
“love/caring days” in which one partner does sev- (1) receive feedback about their current patterns,
eral pleasing activities for the other partner during (2) learn about more adaptive communication
a given day. (e.g., listening skills, positive and negative feeling
In addition to helping romantic partners iden- expression), and (3) practice the new communica-
tify things they can do to make their partner hap- tion patterns (Jacobson and Margolin 1979).
pier, therapists also help couples make and When providing feedback to the couple about
respond to specific requests. Here couples learn their communication, therapists focus on describ-
how to ask for specific things they would like the ing specific aspects of the communication as well
partner to do and how to respond to these requests. as their function; doing so helps the couple
This strategy differs from the previous strategy in become more aware of aspects of their communi-
that the previous set of activities were developed cation that are positive and negative and what role
by Partner A and directed toward Partner B in this plays in the relationship. With this under-
order to improve Partner B’s satisfaction, whereas standing in place, the couple is then in a better
specific requests are made by Partner B to Partner position to learn more adaptive communication
A to improve Partner B’s satisfaction. For exam- patterns. The therapist serves an active role as a
ple, one partner may request that the other partner coach and model, instructing the couple in new
give them 10 min after arriving home in order to ways of interacting. As a coach, therapists may
decompress before having to talk about the day. interrupt a couple when they are speaking,
Behavioral exchange strategies also include directing them to phrase things a certain way
strategies directed at improving the couple’s hap- (e.g., “This time tell her what you think, not
piness. Couples are encouraged to brainstorm what you think she is thinking”). As a model,
activities that they can engage in together that therapists may participate in the interaction by
will be pleasurable for both of them, like going pretending to be one of the partners, allowing
to the movies, going out to dinner, going for a the couple to see firsthand what a more adaptive
walk, or doing arts and crafts. These activities can type of communication looks like. With this foun-
be particularly beneficial in terms of providing dation in place, the couple then focuses on prac-
couples with novel activities that boost their ticing these new skills (behavioral rehearsal).
mood, repositioning them as a team, and breaking Again the therapist plays an active role in shaping
them out of negative routines. the couple’s communication, providing feedback
Taken together, behavioral exchange strategies and instructions throughout. This process is help-
increase the frequency and amount of positivity in ful for teaching couples a range of communication
couples’ relationships. These strategies provide a skills, including empathy and listening skills, val-
much-needed boost for distressed couples and in idation, feeling talk, negative feeling expression,
some cases prove sufficient to solve couples’ pre- positive expressions, and assertiveness (Jacobson
senting problems. However, many couples need and Margolin 1979). Couples may be provided
assistance dealing more directly with their prob- with specific guidelines for speaking and listening
lems, necessitating the next set of therapeutic skills (e.g., Epstein and Baucom 2002).
strategies: communication and problem-solving Problem-solving training is a specific type of
skills training. communication training. It is aimed at helping
couples develop solutions to particular problems
Communication and Problem-Solving Skills in their relationship in a structured way that helps
Training couples avoid some of the maladaptive strategies
Communication and problem-solving skills train- they have used to resolve conflicts in the past.
ing helps couples become more comfortable and Couples are provided with specific guidelines
adept at sharing their thoughts and feelings and and instructions for how they should have these
resolving specific challenges in their relation- conversations (e.g., see Epstein and Baucom
ships. Communication training proceeds in a 2002; Jacobson and Margolin 1979). Generally,
three-part sequential process in which couples these guidelines include instructions for helping
Behavioral Couple Therapy 241
couples better define their problems (e.g., being therapy. In the initial phone call, Lauren explained
specific, discussing feelings about the issue, and that the couple had been arguing more frequently
being brief) as well as for solving problems and and wanted assistance improving their
developing change agreements (e.g., focusing on communication.
solutions, brainstorming, compromising, making a The therapist met with the couple for several B
plan). The magnitude of these issues can range from intake sessions, including an initial conjoint ses-
what to do on a Friday night to whether to have sion, two individual sessions, and a conjoint feed-
children, but the same general guidelines apply. back session. During these sessions, the couple
Therapists often assign couples homework to provided more information about their back-
practice these discussions at home and then ground and presenting problems. The couple
review these conversations during the following was in their late 20s and had a 6-month-old son,
session. Discussions that did not go well can then Max. They reported that their communication
be reattempted in session under the therapist’s problems had been an issue before Max’s birth
guidance. The therapist may need to play an active but had increased significantly since then. They
role in limiting couples’ angry outbursts or reported that they could argue about almost any-
encouraging withdrawn partners to engage, espe- thing. They stated that they had particular diffi-
cially early on, but in time, the therapist’s role culty with navigating household roles now that
becomes less directive and more collaborative as they were a family of three and now that Lauren
couples are better able to self-correct and engage was taking a leave from her job to stay home to
in positive communication on their own. take care of Max. Both partners noted that they did
not have good role models for what healthy cou-
ple communication looked like: Thomas had been
Research About the Model raised by a single mother throughout his entire
childhood, and Lauren had been raised in a family
There is robust research support documenting the who never discussed negative emotions. The cou-
effectiveness of behavioral couple therapy. In a ple also noted that they were no longer engaging
meta-analysis and review of different couple ther- in positive activities together, which was a drastic
apy models, BCT was the only model considered shift for them since this was something that had
“efficacious and specific,” the most stringent always been a strength of their relationship during
criteria for empirically supported treatments the 2 years they’d dated and the 3 years they’d
(Baucom et al. 1998). More than two dozen con- been married. The couple reported a moderate
trolled treatment outcome studies consistently level of marital distress but a high level of com-
showed that BCT was more effective than waitlist mitment to working on their relationship and was
controls or nonspecific treatments. Meta-analyses pleased to hear that behavioral couple therapy
similarly indicate the effectiveness of BCT com- would target increasing positives in their relation-
pared to no-treatment couples, with an average ship and decreasing negatives.
effect size of 0.59 (Shadish and Baldwin 2005). Consistent with the behavioral couple therapy
Recent data on a sample of chronically and model, treatment began with behavioral exchange
severely distressed who received BCT indicated strategies. First, the couple was asked to brain-
that 46% of couples demonstrated clinically sig- storm positive activities they could engage in
nificant improvement 5 years after treatment, and together. The couple greatly enjoyed doing so,
72% remained married (Christensen et al. 2010). reporting that it reminded them of when they
were dating and more carefree. As the couple
completed this activity, the therapist encouraged
Case Example them to identify a range of activities, including
relatively short activities like going for a walk or
Thomas and Lauren Smith presented to a putting together a puzzle together, longer activi-
university-based psychology treatment for couple ties like going to a farmer’s market or cooking a
special meal together, and extended activities like listening techniques such as reflecting and validat-
going out of town on a weekend getaway. The ing, which allowed him to focus more on Lauren
couple understood this distinction and agreed to and demonstrate his care and compassion rather
implement a range of different activities in the than having to be a problem-solver. Lauren liked
upcoming weeks. The therapist then helped the having Thomas listen to and validate her feelings
couple identify caring activities they could do for after a day at home with their son and reported that
the other person to increase their happiness. their improved conversations made her feel closer to
Thomas noted several activities he could do him. She was also able to more clearly express what
around the house to make things easier for Lauren she needed from these conversations (e.g., “I want
and also offered to spend some one-on-one time to vent about my day”), which served to clue
with Max at some point during the evening so Thomas in to her goals and helped them be on the
Lauren could have a break. Lauren stated that same page when they started their discussions.
she could let Thomas have some decompression The therapist then implemented structured
time when he got home from work before asking problem-solving training. Initially the couple was
him to engage with her and Max and also hesitant to embrace the more rigid format of this
suggested giving him a shoulder massage when approach, but agreed to try it to break out of their
he had a particularly long day. The couple was existing patterns. The therapist walked the couple
able to successfully implement these activities, through the various guidelines in the approach
and in subsequent sessions they reported that outlined by Jacobson and Margolin (1979). The
these activities had helped remind them of why couple struggled at first with the problem definition
they became a couple in the first place. phase, lacking clear consensus around exactly what
Thomas and Lauren were able to quickly their problems were and with defining them within a
implement these behavioral strategies and noted clear scope. With practice, however, they were able
a fairly rapid increase in their positivity. They to do so more easily and used the time in therapy to
reported that they continued to argue about a discuss several problems that ranged in difficulty
range of topics but their fights seemed to decrease from moderately easy to more challenging. For
in intensity and they were able to bounce back example, at one point as the holidays were
more quickly, which they attributed to having approaching, the couple chose to spend their time
more overall positivity in their relationship in session discussing whose family they would
again. Nonetheless, they were eager to learn new spend the time with. They were surprised at how
communication strategies to improve how they much more calmly they were able to approach this
handled difficult situations, so the focus of ther- discussion with the guidelines in mind and how
apy transitioned toward these topics. However, much easier coming to a solution was. In time, the
the therapist still continued to periodically check couple was able to add more challenging topics to
in about the couple’s use of behavior exchange their agenda, like if and when Lauren should go
strategies throughout the remainder of treatment back to work. The therapist continued to guide the
to ensure that these did not dwindle. couple during these discussions but took on a less
Communication skills training focused initially active role as the couple became more comfortable
on general communication strategies the couple and proficient in using problem-solving skills.
could use for a range of topics. One of the couple’s Toward the end of treatment, the therapist
biggest challenges was in having a conversation engaged the couple in several discussions about
after Thomas arrived home. Lauren was often relapse prevention and the steps they wanted to
excited to have someone to vent to about her chal- take to ensure that they would maintain their func-
lenges with Max that day, but Thomas often tioning going forward. Both partners expressed
reported feeling overwhelmed by these updates some anxiety about terminating treatment; they rec-
and stated that he did not know how to respond or ognized that they were functioning well, but were
what he could do to help. With the therapist’s guid- concerned about things going downhill when they
ance, Thomas was able to learn and implement basic did not have weekly therapy to ground them. The
Behavioral Parent Training in Couple and Family Therapy 243
therapist encouraged the couple to treat this as a Christensen, A., Atkins, D. C., Baucom, B., & Yi,
problem to solve as well, and they were able to J. (2010). Marital status and satisfaction five years
following a randomized clinical trial comparing tradi-
come up with a plan forward involving slowly titrat- tional versus integrative behavioral couple therapy.
ing treatment (biweekly for 1 month and then a Journal of Consulting and Clinical Psychology, 78,
1 month follow-up after that) and scheduling their 225–235. https://doi.org/10.1037/a0018132. B
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although they had some minor squabbles during Powers, M. B., Vedel, E., & Emmelkamp, P. M. (2008).
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▶ Behavior Exchange in Couple and Family Weiss, R. L. (1980). Strategic behavioral marital therapy:
Therapy Toward a model for assessment and intervention. In J. P.
▶ Caring Days in Couple and Family Therapy Vincent (Ed.), Advances in family intervention, assess-
ment and theory (Vol. 1, pp. 229–271). Greenwich: JAI
▶ Cognitive Behavioral Couple Therapy Press.
▶ Communication Training in Couple and Family Whisman, M. A., & Beach, S. H. (2012). Couple therapy
Therapy for depression. Journal of Clinical Psychology, 68,
▶ Depression in Couple and Family Therapy 526–535. https://doi.org/10.1002/jclp.21857.
▶ Integrative Behavioral Couple Therapy
▶ Jacobson, Neil
▶ Margolin, Gayla
▶ Stuart, Richard Behavioral Parent Training in
▶ Time Outs in Couple and Family Therapy Couple and Family Therapy
▶ Weiss, Robert
Hsinlien Tiffany Tsou and Ryan M. Earl
The Family Institute at Northwestern University,
References Evanston, IL, USA
Baucom, D. H., Shoham, V., Mueser, K. T., Daituo, A. D.,

& Stickle, T. R. (1998). Empirically supported couple
and family interventions for marital distress and adult
Name of the Strategy or Intervention
mental health problems. Journal of Consulting and
Clinical Psychology, 66, 53–88. https://doi.org/ Behavioral Parent Training
10.1037/0022-006X.66.1.53.
Baucom, D. H., Epstein, N. B., LaTaillade, J. J., & Kirby,
J. S. (2008). Cognitive-behavioral couple therapy. In
A. S. Gurman (Ed.), Clinical handbook of couple ther-
apy (pp. 31–72). New York: Guilford Press.
Synonyms
Bradbury, T. N., & Karney, B. R. (2013). Intimate relation-
ships (2nd ed.). New York: W. W. Norton. Parent management training; Parent training
244 Behavioral Parent Training in Couple and Family Therapy
Introduction mediators for childhood behavior problems. BPT

especially emphasizes the role that parents play in
Since its emerging presence in the late 1960s, the development and maintenance of undesired
behavioral parent training (BPT) has been one behaviors in children, and follows the assump-
of the most widely used behavioral interventions tions that: (1) human development serves as a
for parents of children with behavioral problems. function between reinforcement and punishment,
BPT involves clinicians helping parents to define to which humans are constantly interacting with
behavior problems accurately, implementing assess- either one with the environment; (2) undesired –
ment measures that further define the problem and most often antisocial – behavior is learned and
its intensity, and educating parents in the treatment sustained by the positive and negative reinforce-
plans that would be appropriate for the problems ment children receive from social agents,
within their individualized context (Briesmeister most often parents; (3) the goal of therapy is
and Schaefer 1998). Although this approach has to strengthen the desired behavior through posi-
been applied to a variety of child behavioral prob- tive parental reinforcement, while alleviating
lems, it is most commonly focused on antisocial undesired behavioral through ignorance or paren-
behavior, including but not limited to non- tal punishment; (4) maintenance and generaliza-
compliance, temper tantrums, defiance, and aggres- tion of treatment gains are heavily reliant on
siveness (Serketich and Dumas 1996). a process of positive reinforcement through
a newly acquired interactive pattern based on
BPT techniques (Dumas and Lechowicz 1989).
Theoretical Framework Notably, as caretakers, parents are most often
the closest attachment figures for a child. There-
BPT is based upon the principles of beha- fore, training an adult who has a greater and more
vior modification and social learning theory. frequent influence on the child to manage the
A central component of BPT focuses on the role of presenting problematic behaviors will ultimately
parents and pinpoints how their actions are directly increase the likelihood that a positive change will
influencing the child’s targeted behavior. With the occur. Furthermore, the involvement of parents is
aid of a therapist, parents are to proceed with behav- ideal because individual treatment usually does
ior modification techniques, oftentimes with not address parental ability to deal with the child’s
rewards and punishments through the principles of undesired behavior, adding additional distress
operant conditioning during treatments. As illus- that may be more effectively mitigated through
trated by Chronis et al. (2004), parents are taught a direct involvement of parental figures. More-
to identify and manipulate the antecedents and con- over, taking medication solely as the method of
sequences of child behavior, target and monitor therapy also may not be sufficient enough to mit-
problematic behaviors, reward prosocial behavior igate all behavioral problems. Lastly, due to a
through praise (e.g., praising a child for following shortage of mental health practitioners that are
orders), positive attention, and tangible rewards, and thoroughly trained in working with children’s
decrease unwanted behavior through planned ignor- behavioral issues, training parents may be a
ing (e.g., removing parental attention after child more attractive option that can be both cost-
throws a tantrum), time out, and other nonphysical effective and time-saving – a win-win situation
discipline techniques. for both clinicians and clients alike.
Rationale for the Strategy or Description of the Strategy or

Intervention Intervention
Under the umbrella of the social learning theory, BPT treatments usually last for 8 to 12 sessions
BPT is a proponent of utilizing parents as for 3 to 14 year olds, with the majority of
Behavioral Parent Training in Couple and Family Therapy 245
treatment utilizing treatment manuals specifically Oftentimes, BPT treatment programs also collab-
describing the intervention while employing var- orate with the child’s teacher to track the child’s
ious interventions such as social skills training performance at school and link it to the reward
and school interventions (Chronis et al. 2004). system administering at home. Before termination,
In most cases, the training is delivered by a ther- maintenance of progress is addressed to ensure the B
apist and is conducted primarily with parents modified behaviors are continued post-treatment.
(as opposed with the child); however, the child Unanticipated roadblocks in the future are discussed
could be involved in sessions during different and planned ahead in hope for parents to refrain
periods of treatment. from similar pre-treatment situations.
BPT typically starts with a collaborative effort
between the clinician and the parent(s) to assess for
and provide an overview of the child’s presenting Case Example
issues. The therapist may use this opportunity to
psychoeducate, particularly in regard to concepts Angela and Howard brought in Hunter, a 10-year-
such as the social learning theory and the behavioral old soon turning 11 Hispanic boy who has
management principles, and how that could be tied had trouble at home with defiant behaviors and an
into treatment. After mutually agreed upon treat- oppositional attitude. Angela, feeling helpless, men-
ment goals have been established, the therapist tioned dismally how Hunter’s grades at school had
slowly starts to work behaviorally around different been dropping (from an A and B range student to
aspects of the child’s environment (mostly focusing C’s), and how his behaviors at home had “gotten out
on school and home). A clear reward system and of control.” As the therapist continued to inquire
response cost is then established to reinforce “good” what “out of control” entailed for the parents,
behaviors and diminish “bad” ones. Oftentimes, a Angela went about how Hunter constantly yelled
progress chart or a checklist of some sort is intro- and screamed at them whenever he didn’t “get his
duced and acted upon as in-session activities. The way.” When things got worse, Hunter would throw
chart or list may pertain to identified desired behav- around items in the house and physically push and
ior(s) of the child and tracking the progress of such hit his parents (mostly Angela) and then directly go
behaviors on a daily basis. to crying. Hunter’s father, Howard, expressed how
Next, parents are trained to attend to appropriate often he lost his temper because of Hunter’s unac-
behaviors and ignore inappropriate behaviors during ceptable tantrums and would often scold him
sessions, while having the opportunity to practice harshly which would bring about more crying
and track their own success rates for administering from Hunter.
the newly learned BPT at home. The therapist over- The therapist laid out a brief overview for
sees and points out specific areas where parents can the duration of the time the parents (and child)
improve on (e.g., praising the child in a more effec- were in treatment and determined whether both
tive manner) as parents recapitulate the weekly sce- parents were on board with the treatment plan.
narios reflected back at home. Moreover, the After both parents agreed, treatment officially
therapist coaches parents to express more effective began and the therapist started with a mixture
commands and reprimands to mediate the desired of psychoeducation and therapeutic strategies,
responses from the child. New rules are established, adding in frequent inquiries regarding the child’s
enforced, and continually modified based on the specific issue surrounding different techniques
child’s progress, and time-out procedures are often assigned for each week. Due to an inflexible
included in this process. Additional rules and plan- working schedule, Howard was sometimes not
ning for unforeseen misbehaviors outside of home able to join for the sessions, in which case, Angela
may need to take into consideration. Problem solv- would solely work with the therapist with occa-
ing techniques are introduced and discussed to foster sional involvement of Hunter.
effective communications and interactions between In the beginning, the use of a progress chart
parents and child. was introduced that let Angela and Howard
246 Behavioral Rehearsal in Couple and Family Therapy
document the desired behaviors that Hunter ▶ Premack Principle in Social Learning Theory
performed (e.g., picking up his trash, read for ▶ Punishment in Social Learning Theory
20 min before night) through putting “star ▶ Social Learning Theory
stickers” next to the ones he successfully com-
pleted. The therapist then continued on with
coaching the parents for effective ways to dimin- References
ish Hunter’s screaming and crying. Through many
roleplays, planning, and validation, the therapist Briesmeister, J. M., & Schaefer, C. E. (1998). Handbook of
parent training. New York: Wiley.
was able to coach Angela to speak to Hunter in a
Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T.,
clear, concise manner to ask him to stop the pre- & Pelham, W. E. (2004). Enhancements to the
senting “bad” behaviors. The therapist taught behavioral parent training paradigm for families of
Angela to be consistent with her answers and to children with ADHD: Review and future directions.
Clinical Child and Family Psychology Review, 7(1),
“persist on,” even when she confessed that “it is
1–27.
so easy to give in.” After constant encouragement, Dumas, J. E., & Lechowicz, J. G. (1989). When do
the therapist walked Angela through different sce- noncompliant children comply? Implications for family
narios in which she was expected to ignore behavior therapy. Child and Family Behavior Therapy,
11, 21–38.
Hunter’s unreasonable tantrums. Moreover, the
Serketich, W. J., & Dumas, J. E. (1996). The effectiveness
therapist facilitated discussion between Angela of behavioral parent training to modify antisocial
and Howard to establish agreement around behavior in children: A meta-analysis. Behavior
Hunter’s punishment. Therapy, 27(2), 171–186.
Lastly, Angela and Howard were coached
to practice praising in a more natural and direct
manner. Through periodic evaluations, the parents
were asked to assess their progress and modify or Behavioral Rehearsal in
strengthen BPT in certain areas if needed. Overall, Couple and Family Therapy
throughout the treatment period, both parents
expressed seeing slight improvement from Hunter Nicole Ortiz
over the course of treatment. Angela noted Hunter Clinical Psychology, California School of
became more compliant with her orders and felt Professional Psychology, Alliant International
there were fewer tantrums of higher severity in the University, Los Angeles, CA, USA
last month or so of treatment. There were still
some relapses here and there, but both Howard
and Angela were much more confident at han- Introduction
dling Howard’s defiant behaviors and better at
administering effective communication to Hunter. Behavioral rehearsal is a technique that emerged
Before termination, the therapist also provided from social learning theory and operant condition-
space for discussion regarding post-treatment ing and is used to modify current behaviors or learn
and refreshed all the techniques the parents had new behaviors. This technique is particularly effec-
learned. tive in cognitive behavioral models of treatment for
couples and families. It is most effective in learning
behaviors that require practice.
Cross-References
▶ Cognitive-Behavioral Family Therapy Description of the Strategy or

▶ Negative Reinforcement in Social Learning Intervention
Theory
▶ Operant Conditioning in Couple and Family This technique involves the clinician modeling
Therapy behaviors or interactions for the clients, followed
Behavioral Rehearsal in Couple and Family Therapy 247
by the clients imagining or performing the behav- conflict resolution, and relationship satisfaction.
iors and receiving feedback from the clinician. In cognitive-behavioral family therapy, the behav-
This may be covert or overt, such that the clients ioral techniques focus on the parents and helps
can imagine the experience, role plays the experi- provide parental training to help target problems
ence, or discussing future behaviors with the cli- of the children or adolescents. B
nician in preparation for the real experience.
These rehearsals are different from typical thera-
peutic role plays, because they focus on practicing Rationale for the Strategy or
skills rather than evoking emotional responses. Intervention
This technique can be used to modify or teach
responses, behaviors, and social skills in order to In regard to its efficacy in couple’s therapy, it
improve interpersonal functioning. In couple has been found more effective compared to tradi-
and family therapy, this process begins with the tional communication training, likely due to its
clinician observing interactions of the partners or largely collaborative nature (Fischer and Fink
group in order to formulate a conceptualization 2014). Empirical evidence also suggests it is
and determine the target behaviors. The target more effective in fostering more adaptive relation-
behaviors are those that will require rehearsal. ship functioning compared to individual-based
Next the clinician models the chosen behavior treatments (O’Farrell & Schein 2011). Behavioral
for the couple or family and allows them to prac- rehearsal has also been effective in modifying
tice said behaviors and interactions, followed maladaptive behavioral and communicative pat-
by providing feedback based on their perfor- terns within families (Liberman 1970). Specifi-
mance. An important aspect of this technique is cally, it has been utilized as a component
that the clients practice the new behavior often, in of child-focused behavioral therapy, behavioral
order to develop the knowledge and skills to uti- parent training, and family skills training. There
lize in real life settings and situations. is also evidence that these therapeutic interven-
tions have been empirically proven to impact out-
comes including relationship satisfaction, social
Theoretical Framework skills, depression, substance abuse, posttraumatic
stress disorder, obsessive compulsive disorder,
This behavior therapy technique is most often anxiety, and eating disorders.
utilized in cognitive behavioral models of treat-
ment with individuals, groups, couples, and fam-
ilies. In addition to its use for teaching social Case Example
skills within interpersonal relationships, this tech-
nique is also commonly used to foster coping Matthew and Allison presented to couple
skills that can target anxiety, stress, and other therapy in order to address an ongoing conflict
psychological phenomena. Additionally it can be they were experiencing in their relationship.
used to increase a client’s self-efficacy, assertive- The couple had been experiencing conflict, as
ness, and other social skills that can improve their a result of Allison not feeling supported by
interpersonal relationships and daily functioning. Matthew during her new job transition. Allison
More specifically, it is utilized within behavior stated that Matthew would come home late from
couple therapy (BCT) and cognitive-behavioral work and when she talked to him about her day
family therapy (Masters and Burish 1987; and sought support, she felt that he was not actu-
Meichenbaum 1977). In BCT the technique is ally engaged in the conversation, which hurt
has been used to target couples’ communication her feelings. As a result, Allison often told him
patterns as well as psychological functioning that he does not care about her, and they ended up
including depression, substance abuse, post- arguing. There is clearly a lack of communication
traumatic stress disorder, relationship distress, within this couple regarding each of their needs
248 Bell, John
in the relationship. Thus, the therapist’s first goal

was to talk to the couple about the importance Bell, John
of open communication and then to demonstrate
this with Matthew and Allison. Samuel B. Rennebohm
In order to demonstrate this open communica- Seattle Pacific University, Seattle, WA, USA
tion, the therapist acted as Allison and told
Matthew to imagine he just came home, tired
and stressed, and Allison started talking to him Name
about her day. The therapist, acting as Allison,
told Matthew that she felt like he was not really John Edlerkin Bell, Ed.D. (1913–1995)
listening to her, and that this hurt. She proceeded
to tell him how important it was to her to have
his support, and then asked him what they could Introduction
do to work on this together. Matthew responded
that he would like a short amount of time when John Bell is recognized as one of the first clini-
he got home to unwind from his day so that cians in the United States to work systemically
he could be fully present with her when she tells with families as the focus of treatment, rather than
him about her day. Next, the therapist asked the individual. His contributions as a scholar and a
the couple totry having this conversation with practitioner helped to launch family therapy as a
each other, communicating their needs and work- formal approach to clinical work.
ing toward a compromise. Ultimately, following
several practices of this open communication
about their needs across several sessions, Allison Career
and Matthew were able to resolve this conflict
and use those skills to communicate more openly After earning a bachelor’s degree from the Uni-
with each other in other situations. versity of British Columbia and a certificate in
theology from Union Theological College in Van-
couver, Bell began his career as a parish minister.
Cross-References He served churches in British Columbia for
3 years before making the decision to pursue
▶ Cognitive Behavioral Couple Therapy further education. Bell moved to New York City
▶ Cognitive-Behavioral Family Therapy and enrolled in the graduate program in education
at Columbia University. He earned a Master of
Arts degree in 1941 and a doctor of education
References degree in 1942, focusing on educational psychol-
ogy. He spent the next 2 years as an assistant
Fischer, D. J., & Fink, B. C. (2014). Clinical processes in professor of psychology at Park College in Kansas
behavioral couples therapy. Psychotherapy, 51(1),
City, followed by 12 years on the faculty of Clark
11–14.
Liberman, R. (1970). Behavorial approaches to family and University in Worcester, Massachusetts. While at
couple therapy. American Journal of Orthopsychiatry, Clark, Bell also served as director of the psycho-
40(1), 106–118. logical clinic, where he pioneered his approach to
Masters, J. C., & Burish, T. G. (1987). Behavior therapy:
Techniques and empirical findings (3rd ed.).
working with family groups. It was also during
San Diego: Harcourt Brace Jovanovich. this time that Bell published his most influential
Meichenbaum, D. (Ed.). (1977). Cognitive-behavior texts documenting this approach.
modification: An integrative approach. New York: Later in his career, Bell held positions as a
Plenum Press.
regional director for the National Institute of Men-
O’Farrell, T. J., & Schein, A. Z. (2011). Behavioral couples
therapy for alcoholism and drug abuse. Journal of tal Health (1959–1968), Director of the Palo Alto
Family Psychotherapy, 22(3), 193–215. Mental Research Institute (1968–1973), and
Bernal, Guillermo 249
research psychologist at the Palo Alto Veterans insisted that all members of the family be present
Hospital (1973–1979). He also traveled to for each session, and refused to meet with indi-
24 countries in the developing world on behalf vidual members outside of family sessions. While
of NIMH to study family functioning in medical many of these techniques have since become stan-
contexts. He also served terms as president of the dard practice in the field of family therapy, they B
Society for Projective Techniques and president of represented novel innovations at the time, and
the Division of Psychologists in Public Service, were developed through years of trial and error
and in 1970 was honored with the Distinguished in Bell’s work with families. Much of the techni-
Scientific Contribution Award from the Division cal and theoretical basis for contemporary clinical
of Clinical Psychology. work with families has thus been derived from
Bell’s pioneering work and writings.
Cross-References
Bell’s efforts to focus treatment on the family as a
whole emerged from his work with adolescents ▶ Family Therapy
experiencing significant behavior problems. Rec- ▶ Identified Patient in Family Systems Theory
ognizing the limitations of applying adult inter- ▶ Therapist Position in Couple and Family
vention techniques to adolescents, Bell instead Therapy
began experimenting with techniques he had
learned while doing group therapy. He applied
these techniques in sessions attended by the entire References
family and labeled the emergent approach as
Family Group Therapy. In his written text of the Bell, J. (1961). Family group therapy : A method for the
same name, Bell described Family Group Therapy psychological treatment of older children, adolescents,
and their parents, Public health monograph; No. 64.
as consisting of six phases: (1) orientation, Washington, DC: United States Government Printing
(2) child-centered, (3) parent-child interaction, Office.
(4) father-mother interaction, (5) sibling interac- Bell, J. E. (1963). A theoretical position for family group
tion, and (6) family-centered. therapy. Family Process, 2(1), 1–14. https://doi.org/
10.1111/j.1545-5300.1963.00001.x.
Consistent with his emphasis on treating entire Bell, J. E. (1964). The family group therapist: An agent of
families rather than individuals, Bell conceptual- change. International Journal of Group Psychother-
ized psychological problems as the result of dis- apy, 14(1), 72–83.
ruptions in familial relationships rather than Bell, J. (1975). Family therapy (1st ed.). New York:
J. Aronson.
individual-level pathology. Treatment then Bell, J. (1983). Family group therapy. In B. Wolman &
focused on improving communication and inter- G. Stricker (Eds.), Handbook of family and marital
action patterns within the family at-large. The role therapy (pp. 231–245). New York: Plenum Press.
of the therapist, in his view, was to first shift the
focus away from individual level pathology and
towards a system level analysis, then to facilitate
new interactions between members. He structured Bernal, Guillermo
sessions in such a way as to give each member of
the family opportunities to express themselves, Lorna London
particularly the children, in order to create a col- Midwestern University, Downers Grove, IL, USA
laborative environment in which all members
shared ownership of the problem-solving process.
To help facilitate this, Bell would often meet with Name
the parents beforehand to teach them skills for
listening more carefully to their children. He also Bernal, Guillermo
250 Bernal, Guillermo
Introduction work at UPR-RP and has served as the founding

director of the University Center for Psychologi-
Dr. Guillermo Bernal is a licensed clinical psy- cal Services and Research, professor of psychol-
chologist and a prolific researcher who has been ogy, and the director for the Institute for
touted for his contributions to advancing psycho- Psychological Research at UPR-RP (Bernal
logical science and practice. He serves as the 2018).
director of the Institute for Psychological To support his research in the areas of depres-
Research at the University of Puerto Rico, Rio sion with Latino youth, suicide prevention, and
Piedras, and remains active in teaching, research training in biopsychosocial research, Dr. Bernal
and service. Much of his work centers on the has received grants from the National Institute of
impact of the cultural adaptation of psychological Mental Health (NIMH), National Institute on
treatment intervention with ethnic minority Drug Abuse (NIDA), and the Substance Abuse
populations. and Mental Health Services Administration
(SAMHSA).
In his role in academia, Dr. Bernal has been
Career active as a grant reviewer, serving on panels for
various professional agencies, and has also been
Dr. Bernal graduated cum laude with his A.B.. in active on the editorial boards of journals such as
psychology from the University of Miami in the Puerto Rican Journal of Psychology, the Jour-
1972. He earned his master’s degree in clinical nal of Family Psychology and the Journal of Con-
psychology from the University of Massachusetts sulting and Clinical Psychology.
at Amherst in 1975 and completed his thesis enti- A prolific researcher and author, Dr. Bernal has
tled “Vicarious eyelid conditioning in a discrimi- made many contributions to the field of psychology.
nation learning paradigm.” Bernal continued his In particular, he has published widely in the area of
education at the University of Massachusetts at empirically supported treatments for ethnic minori-
Amherst, where he earned his Ph.D. in clinical ties (Bernal et al. 2016). Of mention, he has
psychology in 1978 and successfully defended his published articles discussing the importance of the
dissertation entitled “Couple interactions: A study cultural adaptation of existing treatment interven-
of the punctuation process” (Bernal 2018). tions and the need to establish evidence-based prac-
tice for work with individuals and families (Bernal
et al. 2012). Within the area of family therapy,
Contributions to Profession Dr. Bernal has collaborated with researchers and
published works related to understanding the man-
A clinician licensed to practice psychology in ifestation of clinical issues among Latino families,
Puerto Rico and California, Dr. Bernal’s profes- and ways in which counseling and psychotherapy
sional work has had him involved in clinical, may be utilized in a culturally competent way. Of
research, and academic pursuits. Following note, he was instrumental in devising the Contextual
receipt of his doctorate degree, Dr. Bernal worked Therapy Action Index for use by family therapists in
as a staff psychologist at the Community Organi- their work with culturally diverse clients (Bernal
zation for Mental Health and Mental Retardation, et al. 2016).
Inc., in Philadelphia, PA. He later accepted an A member of a number of professional organi-
appointment as an assistant professor of psychol- zations, Dr. Bernal has held positions of leader-
ogy and the University of California, Department ship including serving as Fellow for the Society
of Psychiatry at San Francisco General Hospital. for Community Research and Action (1992),
He was promoted to associate professor, before President of the American Psychological Associ-
accepting a position in the Department of Psy- ation (1996–1997), and Chair of the Research
chology at the University of Puerto Rico, Rio Committee for the American Family Therapy
Piedras (UPR-RP). Dr. Bernal continues his Association (2007–2011).
Berne, Eric 251
Throughout his lifetime, Dr. Bernal has

received numerous accolades for his profes- Berne, Eric
sional work, including a Lifetime Achievement
Award from the Puerto Rican Psychological Lindsay Dwelley and Marilisa Z. Raju
Association, the Stanley Sue Award from the California School of Professional Psychology, B
Society of Clinical Psychology, the APA Alliant International University, Los Angeles,
Presidential Citation and Distinguished CA, USA
Elder Award, and the Distinguished Contribu-
tion to Family Systems Research Award pre-
sented by the American Family Therapy Name
Academy.
Dr. Bernal’s many contributions to the field Eric Berne (1910–1970)
of psychology have led him to be respected for
his vast works which have blended his commit-
ment to the mental health of Latino families and Introduction
his desire to ensure that family therapy interven-
tions are culturally based and empirically Eric Berne is known in the field of psychotherapy
supported. for his theory of Transactional Analysis (TA) and
his prolific writings, authoring eight books and
over 50 publications. Berne’s work, analyzing
social transactions and disrupting predictable pat-
Cross-References terns between individuals, has extended out to
group work, families, and couples.
▶ Cultural Competency in Couple and Family
Therapy
▶ Culture in Couple and Family Therapy Education/Career
▶ Latino/Latinas in Couple and Family Therapy
▶ Research About Couple and Family Therapy Canadian born, Eric Berne attended McGrill Uni-
versity in 1935 where he earned his degrees, Doc-
tor of Medicine and Master of Surgery. Berne then
References moved to the United States, where he later became
a citizen. He did his psychiatric residency at Yale
Bernal, G. (2018, Sept 10). Guillermo Bernal curriculum University School of Medicine and later a psychi-
vitae. Retrieved from http://guillermobernal.net/
Bernal, G., & Domenech Rodriguez, M. M. (Eds.). (2012).
atric post in New York City at Mt. Zion Hospital.
Cultural adaptations: Tools for evidence-based prac- In 1941, Berne attended the New York Psychoan-
tice with diverse populations. Washington, DC: APA alytic Institute where he began training as a psy-
Press. https://doi.org/10.1037/13752-000. choanalyst; he worked with Paul Federn, whose
Bernal, G., Flores-Ortiz, Y., Rodriguez, C., Sorensen, J. L.,
& Diamond, G. (1990). Development of contextual
ideas were highly influential and shaped Berne’s
family therapy therapist action index. Journal of Fam- personality theory (Stewart 1992).
ily Psychology, 3(3), 322–331. Eric Berne joined the US Army Medical Corps
Bernal, G., Jimenez-Chafey, M. I., & Domenech in 1943 during World War II, eventually becom-
Rodriguez, M. M. (2009). Cultural adaptation treat-
ments: A resource for considering culture in evidence-
ing a Major while serving in several Army hospi-
based practice. Professional Psychology: Research and tals as a psychiatrist. In 1946, he left the Army,
Practice, 40(4), 361–368. moved to the west coast, and resumed his psycho-
Bernal, G., Morales, J., & Gomez, K. (2016). Family analytic training. At the San Francisco Psychoan-
counseling and therapy with diverse ethnocultural
groups. In P. B. Pendersen, W. J. Lonner, J. G. Draguns,
alytic Institute, Berne worked with Erik Erikson
& J. E. Trimble (Eds.), Counseling across cultures for 2 years; his influence illuminates much of
(7th ed., pp. 457–476). Newberry: SAGE. Berne’s work (Stewart 1992). Meanwhile, Berne
252 Berne, Eric
became Assistant Psychiatrist at Mt Zion Hospi- describe how a person is structured psychologi-
tal, San Francisco, in 1950, while also working as cally. The varying ways a person behaves, thinks,
a Consultant to the Surgeon General of the US and feels may be put into three large categories of
Army. Soon after, Berne joined a Veterans Hospi- ego-states called Parent, Adult, and Child (Berne
tal, serving a third psychiatric post, while concur- 1961). Berne’s transactions explains the patterns
rently establishing his private practice and of communication between people and are ana-
maintaining a busy schedule of writing, teaching, lyzed in terms of the ego-states employed. Thus,
and research. according to TA, identifying and changing the
In the early 1950s, Eric Berne began hosting transactions between people is the path to solving
regular seminars where he and fellow clinicians emotional problems (Berne 1964). The games
presented papers and exchanged ideas focusing on within TA refer to the stereotyped, repetitive
social psychiatry. When he was turned down for a sequences of transactions and predictable patterns
formal membership of the psychoanalytic institute that lead to painful outcomes.
in 1956 for allegedly challenging psychoanalytic Berne’s theory of games is what he and TA are
orthodoxy in a formal paper, Berne split from best known for due to the world-wide fame of his
psychoanalysis, marking a departure from the 1964 best-selling book, Games People Play, written
classical theory toward the development of new and intended for a professional audience, but sold to
language and thought. Berne continued to work, a mass market and popularized by the media (Stew-
write, and lecture until his death in 1970. art 1992). Lastly, the concept of script within TA
signifies a person’s wider-life pattern that encom-
passes the smaller expressions of games and trans-
Contributions to the Profession actions; it is based on a person’s decision in
childhood and reinforced by his or her parents and
Eric Berne has several notable contributions to subsequent life events. Finally, Transactional Anal-
the field, including advancing his theory of ysis helps people to succeed in freeing themselves
Transactional Analysis and publishing his first from their script and their predictable relational
full-length book devoted to the theory in 1961, patterns (Berne 1964). Berne’s therapy model has
Transactional Analysis in Psychotherapy. been used with individuals in psychotherapy as well
Berne’s theory of Transactional Analysis (TA), as with couples and families, where interpersonal
while developed from the thinking of earlier disturbances are the focus of treatment. Eric Berne is
writers like Freud, Federn, and Erikson, was also known for his professional interest and writings
rooted in his real-world observations and clini- on the psychotherapy of groups and the comparative
cal experiences (Stewart 1992). In contrast to study of psychiatry, inspired by the different regions
psychoanalytic theory, Eric Berne was deter- where he traveled and wrote about while visiting
mined to create a new approach to psychother- psychiatric hospitals throughout the world (Berne
apy that had practical applications and aimed to 1963).
make change quickly. The cornerstone of
Berne’s theory was that he believed human
behavior was systematically observable thereby References
highlighting transference phenomena and
improving the likelihood for intrapsychic Berne, E. (1961). Transactional analysis in psychotherapy.
change (Stewart 1992). New York: Grove Press.
Transactional Analysis is mapped into four Berne, E. (1963). The structure and dynamics of organiza-
tions and groups. New York: Lippincot.
main divisions: the structural model of ego-states,
Berne, E. (1964). Games people play. New York: Grove
transactions, games, and script (Berne 1961). Press.
Berne’s ego-states are the basis of TA and Stewart, I. (1992). Eric Berne. London: Sage Publications.
Bids and Turning Toward in Gottman Method Couple Therapy 253
affection during conflict (Gottman 2015). Bids

Bids and Turning Toward in can be understood as the smallest units of inti-
Gottman Method Couple macy with these moments of emotional connec-
Therapy tion often brief and seemingly trivial at first glance
(Gottman and Gottman 2015). B
Robert J. Navarra and John M. Gottman Conversely, a failed bid occurs when the bid is
The Gottman Institute, Seattle, WA, USA met with either “turning away” by ignoring the bid
or by responding negatively or “turning against.”
This is akin to a withdrawal from the emotional
Name of Concept bank account. For marriages headed for divorce,
the bank account is in the red and the chances of
Bids and Turning Toward in Gottman Method the partner re-bidding again and partners risking
Couples Therapy. further rejection is almost zero, while in stable
marriages partners re-bid about 20% of the time
(Gottman 2001). With continued failed bids, the
Synonyms number of bids drops precipitously, increasing
emotional disconnection over time. Relationship
Emotional bank account distress and core dysfunctional interactions
are likely to be found in a pattern of failed bids
(Gottman 1999).
Introduction In a hierarchy of needs, bids can range from
low-level to high-level, depending on the amount
Research indicates that a reliable predictor of rela- of emotional vulnerability associated with the bid
tionship satisfaction and stability is found in how (Navarra and Gottman 2011). A low-level bid
couples typically respond to each other’s attempts would be “small talk,” including any comment,
for conversation and connection, referred to remark, or observation. Building on low-level
as “Bids and Turning Toward” (Gottman 2001). bids leads to increased trust – the stepping stone
While heart-to-heart conversations create to bids that reflect increased emotional vulnera-
moments of closeness, a more pervasive sense bility. When high-level bids (e.g., for attention,
of emotional connection is found in nuanced empathy, support, affection, humor, or comfort)
day-to-day interactions that may not seem partic- are responded to positively, partners feel cared for,
ularly significant or even noticeable at the time. important, and that their partner is there for them.
The fundamental law of bids and turning toward
creates either a positive or negative feedback loop;
Theoretical Framework turning towards leads to more turning toward, and
turning away or turning against leads to more
Bids are defined as any attempt a partner makes, turning away or turning against.
verbally or nonverbally, to connect with the other Gottman Method Couples Therapy integrates
partner. The couple’s ability to pay attention to the work of affective neuroscientist Jaak
and effectively respond to these immediate needs Panksepp and his discovery of seven emotional
for connection is defined as “Turning Toward,” command systems and the subcortical structures
which increases positivity and is likened to mak- found in all mammals that he identified as neuronal
ing a deposit in the “emotional bank account.” circuits hardwired for emotional expression. These
An emotional bank account balance in the black emotions (i.e., seeking, rage, fear, lust, care, panic/
is positively correlated with sex, romance, and grief, play) are circuits built into the brain.
expressing positive emotions of humor and Panksepp’s remarkable integration of affective
254 Bids and Turning Toward in Gottman Method Couple Therapy
neuroscience and evolution identifies these emo- emotional command systems. Strategies are
tions as our primary affective command systems. developed on initiating and responding to
They are primary, but they can work together, with expressed needs, so they are not left to chance.
emotions from two or more command systems at Couples are given tools to have conversations
work at the same time. Turning toward the partner’s and make agreements for ritualizing activities,
core emotion-based needs provides and nurtures like date night, going for walks, or sharing
connection at fundamental levels (Gottman 2015). time together, even if briefly. One example of a
Once researchers knew what to look for, pat- ritual is the “stress-reducing conversation,” where
terns emerged that clearly differentiated stable couples take turns talking about and receiving
relationships from distressed relationships (e.g., support for stressful events that are external to
some couples made 200 bids in 10 min while the relationship.
others only made two bids in the same amount
of time). The researchers discovered that they
could quantify how often partners needed to turn Case Example
toward bids for a stable relationship. In a study of
newlyweds and divorce prediction, couples that Debby and James had been married for 2 years
were happily married 6 years later turned towards when they began couples therapy complaining of
each other’s bids about 86% of the time, while continual arguments, lack of emotional support,
couples who ended up divorced turned toward an absence of connection, and increasing with-
each other only 33% of the time (Gottman and drawal. They married several years after meeting
Gottman 2015). in a 12-step program. Both had established, long-
term recovery from substance use disorders at the
time they began therapy, but recovery was the
Rationale only point of connection for them.
Gottman Method Therapy is an affective-
Bids and Turning Toward is one of the levels, or based therapy; emotional connection increases
building blocks, of the Gottman relationship the- likelihood of more effectively managing con-
ory, the Sound Relationship House (SRH), that flict (Navarra and Gottman 2011). By defining
emerged after combining long-term predictive bids and discussing how they each made bids,
studies and proximal studies. Turning away or the therapist helped them establish new ways to
against leads to severe relationship difficulties ask for what they needed and how to turn toward
over time; however, brief interventions can effec- each other, deepening emotional attunement and
tively mediate this trajectory and modify couples’ connection. Over the months, they became
interactions (Gottman and Gottman 2015). much more successful in recognizing, then ritu-
alizing bids and turning toward. They made
commitments to meet regularly, spending time
Description of Strategy or Intervention to talk about the day and hopes for the future.
Strengthening their friendship helped put their
Interventions for strengthening bids and turning relationship back on track to manage conflict
toward and increasing the emotional bank account more effectively.
start with informing the couple about these con-
cepts and discussing and exploring how they cur-
rently make bids and typically respond to bids. Cross-References
Once couples become more aware of bids and
how to respond to them, changes are likely to ▶ Four Horsemen in Couple and Family Therapy
happen very quickly, as the proximal studies sug- ▶ Gottman method couples therapy
gest. Couples learn that turning toward the partner ▶ Negative Sentiment Override in Couples and
needs to occur in all of Panksepp’s seven Families
Biobehavioral Family Model, The 255
▶ Sound Relationship House in Gottman Method Prominent Associated Figures

Couples Therapy
▶ Trust in Gottman Method Couples Therapy The Biobehavioral Family Model was developed
by Beatrice L. Wood, PhD, who was trained in
family therapy at Philadelphia Child Guidance B
References Clinic and has remained active in clinical training
and research in family systems. The BBFM was
Gottman, J. M. (1999). The marriage clinic: inspired and informed by Salvador Minuchin’s
A scientifically-based marital therapy. New York:
Psychosomatic Family Model (Minuchin
W. W. Norton.
Gottman, J. M. (2001). The relationship cure. New York: et al. 1978).
Three Rivers Press.
Gottman, J. M. (2015). Principia amoris: The new science
of love. New York: Routledge.
Gottman, J. S., & Gottman, J. M. (2015). 10 principles for
Description
doing effective couples therapy. New York:
W.W. Norton & Company. This model is not a model of family dysfunction,
Navarra, R. J., & Gottman, J. M. (2011). Gottman but rather a configurational model of seven dimen-
method couple therapy: From theory to practice.
sions of normative family process. Individual emo-
In D. K. Carson & M. Casado-Kehoe (Eds.), Case
studies in couples therapy: Theory-based approaches tional and physiological dysregulation mediates
(pp. 331–343). New York: Routledge. the effects of family relational process on the indi-
vidual’s physical functioning. The dimensional
nature of the model provides for consideration of
both protective and negative effects of family rela-
Biobehavioral Family Model, tions on the individual family member. The seven
The continua include: (1) interpersonal proximity;
(2) generational hierarchy; (3) responsivity;
Beatrice Wood (4) parent-parent relationship quality; (5) family
State University of New York, Buffalo, NY, USA emotional climate; (6) attachment security; and
(7) biobehavioral reactivity. Family relational pro-
cess characterized by the positive ends of each
Synonyms continuum would buffers the effects of stress
(internal and external) on the individual, whereas
BBFM family process characterized by the negative ends
of the continua would transmit internal family
Introduction stress and exacerbate external stress for the indi-
vidual. This model has been used to guide research
The Biobehavioral Family Model (BBFM) is a on the effects of family relational stress on stress-
multilevel systemic biopsychosocial model, posit- related illnesses, to guide treatment, and to guide
ing reciprocal pathways of effect among family and training in family systems intervention.
individual function (Wood et al. 2000, 2008, 2015). The Scope of the BBFM: The BBFM model
This model rests upon assumptions of the originally focused on the child. However, the
interdependence of relational, emotional, and bio- model can be applied to patients across the lifespan.
logical processes consistent with the current “social In principle the model can address the family and
and affective neuroscience” paradigm. The BBFM individual processes affecting any family member
posits that patterns of family relational process influ- (adult or child) suffering from physically and/or
ence one another and collectively either buffer psychologically manifested disease. This inte-
against or potentiate emotional, physiological, and grated interpretation of “disease” is justified by
developmental dysfunction in individual family research developments that increasingly demon-
members (see Fig. 1). strate the mutual contribution of psychological
256 Biobehavioral Family Model, The
Biobehavioral Family
motional Climate
Model, The, Fig. 1 The Family E
biobehavioral family
model 2016 Parental
Generational
FAMILY Proximity Relationship
Hierarchy
Quality
Responsivity
Attachment Security
PARENT-CHILD
Parenting
Biobehavioral Reactivity
PATIENT PSYCHOBIOLOGICAL MECHANISMS
Emotional or Physical
Disorder
and biological factors to both physically and psy- family members. Extremely high levels of
chologically manifested disease. Indeed, it could be responsivity can exacerbate maladaptive emo-
argued that the dichotomy of psychological versus tional/physiological resonance in the family, pos-
physical disease is an outmoded dichotomy. sibly worsening stress-influenced emotional or
physical disorders. Extremely low levels of
responsivity result in neglect or avoidance, leav-
Dimensions of the Biobehavioral Family ing family members unbuffered from internal,
Model familial, or environmental stressors. Family-wide
levels of responsivity reflect family-level emotion
Proximity is defined by who is close to whom regulation or dysregulation. Furthermore, family-
based on the extent to which family members level emotion regulation and individual biobehav-
share personal space, private information, and ioral reactivity are inter-related (Wood et al. 2000).
emotions (Wood et al. 2000). It is analogous to Parent-parent relationship quality refers to
family cohesion. mutual support, understanding, and adaptive dis-
Generational hierarchy refers to the extent to agreement (respectful and resolving) versus hostil-
which caregivers are in charge of children by ity, rejection, and unresolved conflict (Wood et al.
providing nurturance, guidance, and limit setting 2000). Parent-parent relationship quality is a key
through strong parental alliance and absence of component determining family-level emotional
cross-generational coalitions (Wood et al. 2000). climate.
Responsivity refers to the extent to which fam- Family emotional climate refers to the overall
ily members are behaviorally, emotionally, and intensity and valence of family emotional
physiologically responsive to one another. exchange. It colors all aspects of family relational
Responsivity depends, in part, on the biobehav- process, and therefore it is likely a key factor
ioral (i.e., emotional/physiological and behav- contributing to emotional status and outcomes in
ioral) reactivity of each family member. family members (Wood et al. 2008). A negative
Moderate levels of emotional/physiological family emotional climate (NFEC) includes hostil-
responsivity allow for empathic response among ity, criticism, verbal attacks, etc., and it is similar
to the criticism construct of expressed emotion. contribute to ongoing attachment security and
Positive aspects include respect, acceptance, car- empathic attunement.
ing, warmth, support, affirmation, etc. Family The nurturance aspect of generational hierar-
emotional climate is characterized by the intensity chy is also not equivalent to attachment, because
and balance of negative and positive emotional nurturance is a broader construct addressing a B
exchange among family members. This balance or more general fostering of the child’s well-being.
imbalance can be construed as reflecting one Nurturance and attachment are likely to be closely
aspect of family-level emotion regulation or related, however, because secure attachment inter-
dysregulation. actions are unlikely to occur in the absence of a
Attachment refers to the biologically based, nurturing relationship.
lifelong tendency, of human beings under condi- Given the above research findings and theoret-
tions of stress to seek some form of proximity ical rationale, it seems likely that secure attach-
(physical or emotional) with specific other per- ment may buffer, and insecure attachment
sons who are perceived as protective or exacerbate, the impact of stressful family process
comforting, such that one’s emotional and physi- or life events on disease-related psychological and
ological disequilibrium are restored (Bowlby physiological processes in individual family
1969). Patricia Minuchin (Minuchin 1988) has members. Furthermore, the patterns of proximity,
also elaborated family systems frameworks in generational hierarchy, parental relationship qual-
which attachment may be studied. ity, family emotional climate, responsivity, and
There is evidence that secure attachment can biobehavioral reactivity are likely to shape and
buffer a child from difficult life events. In the be shaped by attachment configurations in the
BBFM, attachment mediates and/or moderates family.
the effect of family relational process on individ- Biobehavioral reactivity is the pivotal con-
ual family members (Wood et al. 2000). struct of the BBFM. It mediates the effect of
The construct of attachment overlaps with the BBFM family relational processes on physical
constructs of proximity and generational hierar- well-being or illness in the individual. It is con-
chy in the BBFM. However, the constructs are ceptualized as the degree or intensity with which
distinct, suggesting potentially independent influ- an individual family member responds physiolog-
ence on family member experience and function. ically, emotionally, and behaviorally to emotional
Proximity, as conceptualized in the BBFM, refers stimuli. It is the phenomenological reflection of at
to the amount and intensity of physical and emo- least three psychobiological processes: neurobio-
tional exchange among all family members. In logical aspects of temperament; emotion/affect
contrast, the construct of attachment refers to regulation and dysregulation; and allostasis/allo-
dyadic relations and includes not only an individ- static load.
ual family member’s seeking of closeness and Neurobiological aspects of temperament. The
soothing, when under threat or stress, but also neurobiological aspects of temperament are
the attunement (that is, sensitive attentiveness, reflected in biobehavioral reactivity. Individual
perception, and response) of one to another family differences in infant and child temperament and
member, which helps the individual modulate his stress reactivity have been shown to be related to
or her emotional/physiological response. Thus health outcomes. Infant reactivity and regulation
attachment involves the notion of dyadic are two constituent parts of Rothbart’s model of
empathic attunement safety and emotion regula- temperament (Rothbart and Derryberry 1981).
tion, but proximity, by itself, does not. Proximity Research has shown robust support for an integra-
is analogous to family cohesion. The constructs tion of Rothbart’s behavioral model of tempera-
are related, however. The degree of family prox- ment with the neurobiological processes
imity (or lack thereof) may be a reflection of underlying the model. Thus temperament consti-
attachment security or insecurity among family tutes an important component of biobehavioral
dyads, the family proximity or cohesion may reactivity.
Emotion regulation and dysregulation. Biobe- relational process on the physical well-being or
havioral reactivity in part reflects emotion regula- disorder in a given family member.
tion and dysregulation, because of the Family flexibility is implicit in the BBFM.
neurobiological processes inherent in emotion/ Family flexibility is a dynamic construct. It is
affect regulation and dysregulation. Emotion the family’s ability to change its relational pat-
dysregulation is influenced both by innate and terning according to the demands of the circum-
by external influences, particularly by patterns of stances. Stressful life events, including trauma,
caregiving. Insecure attachment can result in spe- developmental changes, illness, and rapid cul-
cific types of emotion dysregulation: anxiety and tural change and/or migration are some of the
depression, which are the aspects of biobehavioral circumstances in which the family needs to shift
reactivity. Emotion dysregulation is accompanied its patterns of relational process and make nec-
by neurobiological dysregulation. Thus, emotion/ essary changes in order to successfully adapt
neurobiological dysregulation has potential influ- (Akyil et al. 2016). Families that lack such flex-
ence on physical or psychologically manifested ibility have rigid patterns that prioritize
disease by dysregulating neurobiological path- maintaining the status quo, which precludes
ways and mechanisms related to disease. Thus, adapting to the need for change. Families that
biobehavioral reactivity reflects, in part, the abil- are too flexible have a chaotic pattern that makes
ity of the individual to regulate emotion, accom- them vulnerable for dissolution.
panied by the neurobiological underpinnings of
this process.
Allostasis and allostatic load. Allostasis, Relevance to Couple and Family Therapy
which is the body’s physiological response to
stress (McEwen 1998), also reflected in biobehav- Examples of BBFM Configurations in Clinical
ioral reactivity. Several physiological systems and Context
processes underlie and constitute allostasis: car- Adaptive family configuration: A family that is
diovascular functioning, the sympathetic and characterized by positive balance of emotional
parasympathetic nervous systems, the hypotha- climate (more warmth than hostility); moderate
lamic pituitary adrenal axis, immune function, proximity (i.e., age and dyad appropriate sharing
lipid/fat metabolism, and glucose metabolism. of emotions, personal information, physical
When activated by stress, these systems respond space; cohesive but allowing for privacy); moder-
in ways that support the organism’s adaptive ate parental hierarchy (i.e., parents in alliance, age
response to stress, while protecting the body’s appropriate guidance and limits, parents nurturing
appropriate function. However, if these systems children, no-cross generational coalitions; room
are repetitively or chronically called upon to for age appropriate autonomy); moderate
respond to stress, their continual activation can responsivity (i.e., enough responsivity to share
damage the body and result in poor health. This emotions, which promotes bonding, and to
is called “allostatic load,” defined as “wear and soothe, but not reactive in ways that contribute
tear that results from chronic over activity or to the stress level); good quality parent-parent
under activity of allostatic systems” (McEwen relationship (i.e., more positivity than negativity,
1998, p. 171). Allostasis and allostatic load are but negativity permitted); and a secure parent-
important underlying processes contributing to child attachment with both parents. The children
biobehavioral reactivity. or ill adult can turn to a family member for sooth-
These three aspects of biobehavioral reactivity ing and support, and this family member or mem-
(neurobiological aspects of temperament, emotion bers are attuned and provide what is needed. This
regulation, and allostasis and allostatic load) family configuration would support moderate bio-
mediate the effects of the BBFM-identified family behavioral reactivity which would be sufficient to
inform appropriate response to life challenges, but Research Applications of the BBFM
not so extreme as to evoke high levels of psycho- Relevant to Family Systems Theory and
biological stress, resulting in vulnerability to Practice
physical and emotional illness.
Extreme maladaptive configuration A: Children with asthma: The BBFM has been tested B
A family that is characterized by more negative in laboratory-based family interaction studies of
than positive family emotional climate (i.e., more children with asthma. Findings demonstrated that
hostility than warmth); very high levels of prox- the chronic stress of negative family emotional
imity (i.e., intrusive over involvement) among climate, parental depression, parent-parent hostil-
family members; extremely strong generational ity, insecure parent–child relationship, and nega-
hierarchy (i.e., parent(s) overly controlling of tive parenting predicted child anxiety and
child(ren); extreme reactivity (i.e., family mem- depression, which in turn were associated with
bers hyper-emotionally reactive to any stressor or increased asthma disease activity (Lim et al.
challenging family interaction); and insecure 2011). Other studies indicated that chronic family
parent-child attachment and attachment among stress may impact child asthma disease process
family members (i.e., anxious attachment). This through asthma-relevant altered immune function
configuration would leave an individual family and autonomic dysregulation, mediated by child
member highly susceptible to family and or envi- depression. Thus, the results of these studies are
ronmental and social stress, and likely produce suggestive that the BBFM may be useful in spec-
high levels of biobehavioral reactivity and conse- ifying family-psycho-biological pathways by
quent physical or psychologically manifested which family relational stress impacts child phys-
illness. ical well-being and disease. Furthermore, the find-
Extreme maladaptive configuration B: ings suggest that the BBFM, as a dimensional
A family that is characterized by flat family emo- model, may be used to examine how family func-
tional climate (i.e., neither positive nor negative tion may buffer the impact of social stress on child
emotion expressed); low levels of proximity (i.e., asthma by examining the effects of the family
low levels of sharing of feelings, personal infor- configurations constituted by family relational
mation, and personal space among most dyads or patterns at the positive ends of the BBFM
between parent and child); weak generational dimensions.
hierarchy (i.e., parents uninvolved or ineffectual, Adult health: Recently, the BBFM has been
or engage in cross-generational coalitions); low extended to test the model’s pathways for adult
responsivity (i.e., lack of emotional or behavioral family members. Research supports the model
response); flat parent-parent emotional climate in explaining the health of underserved primary
(i.e., emotionally distant); insecure attachment care patients (Woods and Denton 2014). Fur-
patterns (i.e., likely avoidant attachment). This ther, the model has been validated for use in
family configuration could lead to high levels of studying adult health using large, representa-
biobehavioral reactivity, and perhaps would be tive, epidemiological samples, incorporating
more permissive of, or inciting of, behavior social support as an additional exogenous vari-
disorder. able, distinct from family emotional climate
There are many possible BBFM configura- (Woods et al. 2014). Emotion dysregulation
tions, and patterns may differ by individual family (anxiety and depression) and allostatic load
member and dyads. Therefore it is crucial to (two aspects of biobehavioral reactivity) were
assess each family individually based on all of highlighted as distinct mediating pathways in
the BBFM dimensions and to attend to each the model (Priest et al. 2015) Together these
dyad type (parent-parent, parent-child, siblings) studies indicate an indirect pathway from family
as well. emotional climate to disease activity, through
the mediating variable of biobehavioral reactiv- interact about problems, losses, conflicts, and
ity, thus supporting the BBFM’s useful applica- things they like best about each other, without
tion across the lifespan. being distracted by the presence of an interviewer.
The trainees learn how to perceive patterns of
family relational process, characterize a family’s
Clinical Applications of the BBFM strengths and weaknesses according to BBFM
dimensions, and plan intervention accordingly.
Guiding family system-based intervention: The This importantly supplements and enhances the
BBFM can be used to guide family systems inter- more standard interview process, and speeds the
vention in several ways. The BBFM proposes that course of therapy.
all families (healthy and maladaptive) have the
same basic interactive relational dimensions, as Case Example
identified in the BBFM. Families that function at Brian was a white, middle-class, 14-year-old boy
the extremes on these dimensions can be for whom assessment and treatment was
problematic. The BBFM has distinct value: requested because of seizure-like symptoms and
(1) The BBFM can be used to identify the auditory hallucinations, which occurred despite
extremes of family emotional climate, proximity, negative neurologic and EEG findings. The Fam-
hierarchy, responsivity, attachment, and individ- ily Process Assessment Protocol (FPAP) was used
ual biobehavioral reactivity and determine how to assess BBFM patterns of family relational pro-
they are related to an individual patient’s emo- cess, and to determine their relevance, if any, to
tional and/or physical disorder. This can guide the child’s symptoms. The family consisted of
intervention by targeting specific patterns of rela- biological mother and father, Brian, and a younger
tional process that need redirecting; (2) The brother and sister. The FPAP assessment involved
BBFM can be used as a guide within the context having the family engage in six different five-
of most family intervention models (Theodoratou minute discussion tasks designed to evoke a
et al. 2011; Wood 2001); (3) By focusing on range of emotions and interactive patterns. The
enhancing the positive direction of the dimen- family was observed, and BBFM dimensions
sions, the BBFM can be used in family-based were characterized by the patterns of interaction
prevention programs so as to enhance the ability and from subsequent interview.
of the family to buffer family members from The family was characterized by extremely
external stressors; (4) The BBFM has the advan- hostile and anxious expression of emotions
tage of being intentionally developed with con- (negative family climate) and with extreme reac-
structs that are relatively culture-neutral (Akyil tivity to one another’s communications (high
et al. 2016; Theodoratou et al. 2011). responsivity). This responsivity was unmodulated
Teaching family assessment and intervention: by parental guidance (weak parental hierarchy),
The BBFM can be used as a model to organize a because the mother and father could not function
trainee’s learning to observe, perceive, and char- in alliance as parents. Mother was especially hos-
acterize family relational process as it relates to a tile to father who reacted anxiously to her interac-
patient’s presenting problem. A Family Process tions with him (negative quality of parental-
Assessment Protocol (FPAP) was developed to relations). Mother had established a stable coali-
test the BBFM (Wood et al. 2008). The FPAP tion with Brian against father (weak parental hier-
has also been used in clinical work to characterize archy). The coalition of Brian with mother against
families and to direct family intervention father reduced tension between the parents but
according to the BBFM (Wood 2001). It is cur- also resulted in scapegoating of Brian, and in a
rently being used in Child and Adolescent Psy- lack of support and nurturing attitude towards his
chiatry and Family Therapy Training programs. stress and symptoms (weak generational hierar-
The process of trainee and supervisor observation chy). Inconsistent availability from mother and an
(from behind a one-way mirror) allows families to emotionally absent father resulted in insecure
parent-child attachment. Brian’s stress was further but, with therapeutic assistance, they did so in a
fueled by maladaptive levels of proximity (e.g., way that preserved appropriate BBFM dimen-
Brian sleeping with mother “because of his sei- sions of functioning. As a result the children
zures,” being exposed to mother’s suicide remained well connected with both parents, and
attempts and sexual indiscretions). The direct parents were able to coparent adequately. B
experience of maternal mental disorder, parental
conflict (intense proximity) amplified Brian’s
stress. The threat of the father leaving mother, Cross-References
and the already unstable and potentially danger-
ous family context, acutely exacerbated the situa- ▶ Biopsychosocial Model in Couple and Family
tion. The insecure attachment between Brian and Therapy
each parent made the threat of his father’s leaving ▶ Circle of Security: “Understanding Attachment
extremely traumatic. Brian’s anxiety/emotion in Couples and Families”
dysregulation and cognitive fragmentation ▶ Health Problems in Couple and Family
(biobehavioral reactivity) skyrocketed, culminat- Therapy
ing in stress-related seizures and auditory halluci- ▶ Medical Family Therapy
nations. The hallucinated voices stated that they ▶ Medical Model in Couple and Family Therapy
were going to “kill his family or Brian, himself.” ▶ Neurobiology in Couples and Families
An initial family intervention alone with the
parents achieved a commitment from them not to
separate at this time, but to work in therapy on References
their marriage. This arrangement was accom-
plished by evoking positive emotional climate in Akyil, Y., Prouty, A., Blanchard, A., & Lyness, K. (2016).
the room and guiding the parents in exchanging Experiences of families transmitting values in a rapidly
positive expressions of support of one another. changing society: Implications for family therapists.
Hope was instilled by pointing out each of their Bowlby, J. (1969). Attachment and loss: Vol.1 Attachment.
strengths and parents, individuals, and marital New York: Basic Books.
partners. The children were brought into the Lim, J., Wood, B. L., Miller, B. D., & Simmens, S. J.
room, and informed of this plan by their parents. (2011). Effects of paternal and maternal depressive
symptoms on child internalizing symptoms and asthma
There was great relief. Therapy focused on disease activity: Mediation by interparental negativity
reorganizing the BBFM patterns to provide a fam- and parenting. Journal of Family Psychology, 25(1),
ily context that was conducive to healthy func- 137–146.
tioning and development. Engendering hope and McEwen, B. S. (1998). Protective and damaging effects of
stress mediators. N Engl J Med, 338, 171–179.
proving a positive emotional “holding environ- Minuchin, P. (1988). Relationships within the family:
ment” in family sessions improved family emo- A systems perspective on development. In R. A.
tional climate. This allowed family interventions Hinde & J. Stevenson-Hinde (Eds.), Relationships
which focused on reducing stressful proximity within families (pp. 7–26). New York: Oxford Univer-
sity Press.
between Brian and mother, and on increasing Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psycho-
soothing proximity with father. The mother- somatic families: Anorexia nervosa in context. Cam-
Brian cross-generational coalition against father bridge: Harvard University Press.
was interrupted, and parents were guided in work- Priest, J. B., Woods, S. B., Maier, C. A., Parker, E. O.,
Benoit, J. A., & Roush, T. R. (2015). The biobehavioral
ing together as a team, both guiding and nurturing family model: Close relationships and allostatic load.
Brian and their other two children, improving Social Science & Medicine, 142, 232–240.
generational hierarchy, reducing negative emo- Rothbart, M. K., & Derryberry, D. (1981). Development of
tional climate, and improving attachment rela- individual differences in temperament. In M. E. Lamb
& A. Brown (Eds.), Advances in developmental psy-
tions. Brian became less anxious (reduced chology (Vol. 1, pp. 37–86). Hillsdale: Erlbaum.
biobehavioral reactivity) and his seizures and hal- Theodoratou, M., Bekos, V., & Wood, B. L. (2011). Apply-
lucinations ceased. Parents ultimately separated, ing biobehavioral model in a young asthmatic patient:
262 Biopsychosocial Model in Couple and Family Therapy
Case study. Thessaloniki: 2nd International Congress deserved to be viewed from a more comprehen-
on Neurobiology, Psychopharmacology and Treatment sive framework. Engel posited that an individual’s
Guidance.
Wood, B. L. (2001). Physically manifested illness in chil- health experience results from the intersection of
dren and adolescents: A biobehavioral family biological, psychological, and social factors oper-
approach. Child and Adolescent Psychiatric Clinics of ating on multiple levels of the system (i.e., molec-
North America, 10(3), 543–562. viii. ular, individual, interpersonal, cultural, and
Wood, B. L., Klebba, K. B., & Miller, B. D. (2000).
Evolving the biobehavioral family model: The fit of national levels). Engel encouraged the application
attachment. Family Process, 39(3), 319–344. of the BPS model with systems theory in an effort
Wood, B. L., Lim, J., Miller, B. D., Cheah, P. A., Zwetsch, T., to practice medicine from a perspective that
Ramesh, S., & Simmens, S. J. (2008). Testing the biobe- includes attending to the multiple levels of the
havioral family model in pediatric asthma: Pathways of
effect. Family Process, 47(1), 21–40. organization present. This perspective is benefi-
Wood, B. L., Miller, B. D., & Lehman, H. K. (2015). cial for understanding a condition and providing
Review of family relational stress and pediatric asthma: treatment to individuals, couples, and families.
The value of biopsychosocial systemic models. Family In the years since Engel proposed the BPS
Process, 376–389.
Woods, S. B., & Denton, W. H. (2014). The biobehavioral model, there has been debate regarding its appli-
family model as a framework for examining the con- cation. Some have argued that the BPS model
nections between family relationships, mental, and takes away from medicine and could lead pro-
physical health for adult primary care patients. Fami- viders to miss important biomedical issues
lies, Systems & Health: The Journal of Collaborative
Family HealthCare, 32(2), 235–240. https://doi.org/ because of the attention to psychosocial issues
10.1037/fsh0000034. (Herman 1989). However, others have encour-
Woods, S. B., Priest, J. B., & Roush, T. (2014). The aged providers to think of BPS as an orientation
biobehavioral family model: Testing social support as rather than a prescribed approach that relies on
an additional exogenous variable. Family Process,
53(4), 672–685. https://doi.org/10.1111/famp.12086. well-developed interview skills. Borrell-Carrió
et al. (2004) recognize the BPS model as a phi-
losophy for clinical care and a practical clinical
guide. As a philosophy, it is a way to understand
Biopsychosocial Model how illness and disease are impacted and impact
in Couple and Family Therapy multiple levels of the patient’s system. As a prac-
tical guide, a clinician should aim to understand a
Rola O. Aamar1,2 and Irina Kolobova3 client’s subjective experience in order to develop
1
Texas Tech University, Lubbock, TX, USA an accurate diagnosis and develop a client-
2
East Carolina University, Greenville, NC, USA centered treatment plan.
3
Center of Excellence for Integrated Care, Cary, For many the BPS model is seen as a vision of
NC, USA health rather than a manualized guide to practice
(e.g., Hepworth and Cushman 2005). As Engel
suggested, the BPS model prioritizes understanding
Introduction the client’s subjective experience of his or her symp-
toms from a comprehensive and contextual lens
The biopsychosocial (BPS) model was presented rather than focusing on just one factor or dimension
as a challenge to the biomedical model in the late of the individual’s health. Successful implementa-
1970s (Engel 1977, 1980). Per Engel, the biomed- tion of the BPS model is dependent on the pro-
ical model left little room for the social, psycho- vider’s perspective of health, interpersonal skills,
logical, and behavioral aspects of illness and empathetic curiosity, and diagnostic flexibility. Fur-
reduced all symptoms to physiological or bio- thermore, interview skills and the ability to create
chemical origin. Engel commented that the relationships with clients and other healthcare pro-
human experience of illness is not well captured viders are important to successful implementation.
by laboratory results or diagnostic tests often Strong interview skills are important for gathering
employed in the biomedical model and hence relevant health information for each domain (e.g.,
Biopsychosocial Model in Couple and Family Therapy 263
biological, psychological, social) within the context Description

of the client(s)’ story and being able to bring it
together in a way that reflect the client’s reality and Through the use of the BPS model, clinicians and
needs. In conceptualizing the client’s needs, being researchers promote the idea that there are three
able to collaborate with other providers (e.g., doctor, domains of health that need to be collectively B
psychiatrist, school counselor, case worker) is nec- attended to in treatment and research. Prior to the
essary in order to provide comprehensive and cohe- BPS model, the biomedical model was the primary
sive treatment. tool used to explain and manage health. Per the BPS
model, the three domains of health are biological,
psychological, and social. The primary premise of
Prominent Associated Figures the BPS model is that while there are three distinct
domains of health, they are inextricably linked,
George Engel is widely recognized as the devel- meaning that one domain of health cannot be under-
oper of the current biopsychosocial model. He stood, researched, or treated without examining how
was also the major proponent of the model the other domains of health are impacting it or being
through his medical and psychiatric work. While influenced by it. The principal argument made by
Engel is frequently remembered as a psychiatrist, proponents of the BPS model is that overall health is
Engel started his career in the biomedical field and most clearly understood in the space where the three
held a dual appointment in the departments of domains overlap.
psychiatry and medicine at the University of
Rochester Medical Center for the majority of his Biological
career. Many propose that this dual appointment The biological domain of the BPS model is com-
reflects his commitment to attending to the monly associated with physiological and biomed-
biopsychosocial needs of his patients. ical health issues and concerns. Focusing on the
Engel started his work in medicine as a physi- biological domain highlights the importance of
cian and a researcher. Initially, Engel was a strong the physiological experience of an individual’s
proponent of the medical model and advocated for health. This may include addressing a specific
identifying and focusing on physiological causes disease or condition and tracking biomarkers,
and treatments, even for psychiatric problems. medications, or treatments that change an individ-
This is highlighted in his discussion of neuropsy- ual’s physiological response to a disease or to
chiatric disturbances and complications as origi- promote health. An important consideration for
nating in the malfunctioning of the central clinicians is that oftentimes distress in other
nervous system (Engel and Margolin 1942). How- domains can manifest themselves physiologically,
ever, around this same time in the early 1940s, such as stress leading to chronic headaches or
Engel was exposed to the work of his colleagues ulcers. Conversely, issues with physiological
in psychoanalysis at the University of Cincinnati. health can also have a negative impact on the
As a result of this exposure, Engel began to slowly other domains such as struggles with mood regu-
accept and explore alternative explanations to the lation among individuals with poorly controlled
physiological and psychosocial problems of his diabetes. Therefore, clinicians should be aware
patients, initially focusing on gastrointestinal dis- that for some patients the biological domain of
orders (Guillemin and Barnard 2015). This led health may be the first indicator that something is
him to be recognized as one of the foremost wrong or the first signal to which they respond to
experts on psychosomatic illness. Engel’s passion seek treatment or relief.
for and work in integrative healthcare that incor-
porated the multiple domains of health eventually Psychological
culminated in the proposal of his heavily cited The focus of the psychological domain of health
works on the biopsychosocial model for treatment often refers to addressing mental health issues and
as an alternative to the biomedical model. disorders. Engel stressed the importance of the
psychological domain on the patient’s overall social health is impacting the other domains and
health, even drawing the connection between car- what factors to consider when proceeding with
diac patients’ psychological health and heart func- treatment, there may be some aspects of the
tioning, which continues to be a commonly domain that cannot be improved.
accepted and heavily studied relationship in
healthcare (Moravec and McKee 2011). There- A Final Domain to Consider: Spirituality
fore, clinically, the focus would be on mental There is one additional proposed domain of health
health diagnoses as defined by the DSM 5. Symp- that some advocates of the BPS model have
toms associated with these diagnoses could be sought to bring attention to in recent years: spiri-
assessed using mental health screeners or through tual health. Researchers and clinicians argue that
a clinical interview. The psychological domain the role of the spiritual domain needs to be equally
also encompasses assessing for issues related to examined in relation to health. Sulmasy (2002)
mental status functioning including appearance, argued that a truly holistic model focused on the
behavior, attitude, orientation, mood, affect, value of relationships (including the relationships
thought, and speech. These issues are most fre- of each domain of health to the other) should also
quently assessed through a mental status exam. include spirituality – the domain of health
Finally, any testing pertinent to psychological concerned with an individual’s relationship with
functioning also falls within the scope of this the transcendent. The distinction between spiritu-
domain. This level of psychological testing is ality and religiosity is important here. Rather than
often completed by a psychiatrist or psychologist emphasizing prayer or belief in a higher power,
and includes testing for neurodevelopmental dis- the spiritual domain is more concerned with iden-
orders and neurocognitive disorders. tifying an individual’s beliefs and values. These
beliefs and values in turn can then be used to
Social inform how a patient understands, explains, and
While the biological and psychological aspects of makes sense of their health.
the BPS model tend be easily identifiable, the
social domain of health often seems more ambig-
uous. This can be attributed in part to the vast Relevance to Couple and Family Therapy
number of issues that falls under the purview of
the social domain. Clinicians and researchers While the BPS model was initially introduced for
attend to a myriad of issues including family psychiatrists and other medical providers, its popu-
dynamics, availability of social support, access larity continues to grow with couple and family
to resources, employment and financial concerns, therapists, particularly medical family therapists
substance use histories, housing concerns, the (McDaniel et al. 2014). As a vision of health, the
impact of racial and cultural expectations and BPS model helps couple and family therapists
needs, safety issues, and history of incarceration understand a couple’s or family’s functioning from
or oppression (Hodgson et al. 2007). While intake a lens that incorporates biological, psychological,
forms and well-constructed questionnaires or social, and systemic factors. For example, a couple’s
screeners may provide some insight into the social frustrations with infrequent sexual intimacy may be
health of an individual, addressing the implica- partially explained by poorly controlled diabetes.
tions of social health often proves to be more A therapist who does not consider this may struggle
challenging. A difficult reality that researchers to make significant process with improving the cou-
and clinicians frequently face is that the social ple’s intimacy.
aspects of health are oftentimes more difficult to With high rates of comorbidity between physical
act on and change. For example, there may be few health, mental health, and substance use issues, the
options for changing a patient’s insurance status BPS model provides a framework for making sense
or financial concerns. Therefore, while the social of how these issues are interrelated and build treat-
domain can be used to inform how the patient’s ment approaches that systemically address multiple
issues at the same time. As clients’ health is best Findings from a comprehensive assessment
understood and treated at the intersection of the BPS will help the clinician conceptualize the client’s
domains, it is important that the BPS model is presenting issues as the intersection of the BPS
applied throughout all components of therapy domains. This is done by integrating all of the
including during the assessment, conceptualization, information together and understanding how B
and treatment phases. While there are not specific each domain is impacting the client’s function.
guidelines for the application of the BPS model, Once the clinician has conceptualized the case
there are two sets of biopsychosocial-spiritual inter- from a BPS lens, the clinician will want to identify
view guidelines available for clinicians’ use in com- long-term and short-term goals that are aimed at
pleting a comprehensive assessment (Hodgson improving the client’s functioning. At this phase,
et al. 2007, 2016). Examples of questions that may it is important for the clinician to find the balance
be useful in the assessment are featured below. between attending to the client’s pressing con-
cerns and utilizing interventions that target multi-
Biological: ple domains.
• What physical health issues are you and the One of the many benefits of the BPS model is
family most concerned about at this time? that because it is seen as a vision of care, it allows
How do these issues impact the family? for significant flexibility with regard to the setting
• What goals are you working on with your of treatment (e.g., community mental health, pri-
family doctor? mary care, school settings), the treatment time
• What does being healthy mean to you? (e.g., 15 min, 50 min, 90 min), and the client
• How do you keep yourself healthy? composition (e.g., individual, couple, family).
Psychological: The BPS model has been successfully
• Have you had any days recently when you implemented in multiple settings, including pri-
have felt hopeless or unhappy? mary care, community mental health, military set-
• What happens at home when someone in tings, pediatric settings, school-based health
the family is experiencing stress? centers, and independent practice (Hodgson
• Have you had any days recently when you et al. 2014). Therapists have successfully
have felt nervous or spent a lot of worrying? implemented the BPS model in brief sessions
• How do you cope with feeling unhappy, within integrated care practices, as well as in
nervous, or feeling stressed out? traditional 50-min sessions. Without prescribed
• How are your energy levels? interventions or a manualized practice guide, cli-
Social: nicians have the flexibility to apply this approach
• Who among your family and friends is the with any client composition including individ-
most supportive and how do you let them uals, couples, or families.
know when you need support? Clinicians practicing from the BPS model are
• What types of activities do you enjoy doing encouraged to shift away from attending to just
in your free time? psychosocial or relational issues and consider cli-
• How frequently is it difficult for you to get ents’ functioning holistically and systematically.
your medications because of financial For many clinicians, this will require some addi-
issues? tional education about biomedical conditions and
• How do you learn about what you need to their relationship to psychosocial issues. This may
do to keep yourself healthy? feel challenging to some as it means stepping
Spiritual: outside of one’s comfort zone and becoming
• How do your beliefs guide how you make more comfortable talking with clients about topics
sense of your health or some of the issues such as disease progress and medication manage-
you have reported today? ment. Furthermore, to provide the most holistic
• When you are feeling down, do you find care, couple and family therapists are encouraged
prayer or meditation to be helpful? to collaborate with the patients’ medical team.
Collaborating with clients’ medical team will help explaining, but he appears to be getting flustered.
align treatment plans among providers and thus He is visibly anxious. The therapist asks him to
increase adherence to treatment recommenda- pause for a few minutes and try a diaphragmatic
tions. This collaboration will also increase the breathing technique with her. The therapist
clinician’s knowledge and comfort with medical encourages him to take his time explaining that
conditions and medications. she is in no rush and that she wants to hear what he
has to say. He is finally able to slow down a bit
even though he still fumbles with his words occa-
Clinical Example of Application sionally. Tuck explains that he is easily irritated
of Theory in Couples and Families and endorses being disrespectful at times but then
comments that it is because people in the family
Case Vignette 1 intentionally push his buttons.
Beatrice and Tuck have been married for 28 years. Applying the Biopsychosocial Lens. This
They present to the therapist’s office for couple’s case is used to highlight how even in the situation
therapy due to increased frequency of arguments where a couple presents to therapy for a relational
and tension between them. During the intake, they issue, the impact of medical and psychological
report that 6 years ago Tuck was in a devastating car factors still needs to be considered. Even when a
accident and nearly lost his life. The couple reported biological condition is being managed and
that Tuck spent three grueling weeks in a medically attended to thoroughly by a medical treatment
induced coma, had undergone over a dozen surger- team, it can continue to impact the other domains
ies, and received years of medical intervention and of health. In this case, it is evident that even
rehabilitation. They explained that Tuck is now back though Tuck’s TBI is being managed and he con-
home full time with regular visits to his medical and tinues to receive medical care, the side effects of
rehabilitation providers, instead of consistent inpa- having a TBI, such as irritability and decreased
tient treatment. functioning in speech, have negatively impacted
Beatrice tells the therapist that Tuck came out of his relationship with his family. The pressure of
the accident with a traumatic brain injury (TBI). She having to function on the same level as he did
also reports that since the accident there has been a before his life-altering accident is also having a
significant change in Tuck’s attitude. She has deep impact on Tuck and his family. This desire to
noticed that he is moody, irritable, and less patient. have things be the way they were before may also
Beatrice explains that recently Tuck has been rude be connected to Tuck’s increased anxiety and to
toward her and their children including name call- Beatrice’s frustration with the relationship. This
ing, being judgmental, and being openly disrespect- couple would benefit from psychoeducation about
ful of their choices and actions. Beatrice explains the TBI and its impact on the relationship. In
that this is not the same Tuck that she married and addition, the couple would benefit from learning
thinks that the accident is to blame. Tuck sits quietly how to identify when members of the family are
and looks at the ground while Beatrice shares her becoming irritated, as well as developing new
frustrations. She also quietly explains that she does ways of relating to each other.
not know if she can stay married to him if his
behavior does not change. Case Vignette 2
As Tuck begins to talk and explain his side of Forrest is a 63-year-old male. He has been referred
the story, the therapist notices that he often strug- to a well-known, local marriage, and family thera-
gles to find the right words. He appears to be pist by his primary care physician for therapy.
embarrassed when he says the wrong words. Forrest’s physician explains to the therapist that
Later, his face turns red and he looks away when Forrest has diabetes and hypertension. He is also
he lets a curse word slip. He explains that he does on antidepressants, but the physician makes it a
not know why it is so hard for him to explain what point to tell the therapist that Forrest does not like
he is thinking right now. He tries to keep to talk about his depression nor acknowledge his
depression diagnosis. Forrest is also a longtime daunting task for therapists to identify and cre-
smoker and refuses to quit. The physician tells the ate goals for multiple health concerns. This case
therapist that in the referral paper work she will highlights the complexity of health when
document that she is referring Forrest specifically chronic medical illnesses (diabetes and hyper-
for help managing his medical diabetes and behav- tension), a behavioral health risk factor (tobacco B
ioral treatment for smoking cessation, but hopes that use), a mental health diagnosis (depression),
the therapist will address the depression as well. and social factors (recent divorce, limited social
When the therapist meets with Forrest, she learns supports) are comorbid. The spiritual domain in
that 2 years ago he divorced his wife of 35 years. He this case serves as both a strength and challenge
has a tense relationship with his three children, who because while the client can use his faith to cope
took their mother’s side in the divorce and blame with his suicidal ideations, it does impede the
him for breaking apart the family. Forrest states that development of a thorough safety plan. What
he lives alone, but visits his mother in the nursing should be noted is that there is not a singular
home often and spends time with his siblings and best way to approach this case; however,
their families on the weekend. During the week, he starting with behavioral changes for managing
works part time at the post office. Toward the end of the diabetes and hypertension may be a good
the session, Forrest mentions that he recently quit place to start as that is why the client was
taking his depression medication. The therapist referred to therapy. While working on these
inquires about whether he has mentioned this to behavioral changes, this client may also benefit
his physician yet. Forrest tells the therapist that he from psychoeducation about the symptoms of
has not reported this to her and he has no intention to depression, motivational interviewing in efforts
because he does not want to go back on his to increase his collaboration with his medical
medication. provider and adherence to the medical treatment
The therapist completes a brief depression plan, and increasing the client’s engagement
screener and notices that his depression symptoms with social support. It will be incredibly helpful
appear to be quite severe. His depression symptoms to work collaboratively with the medical pro-
include decreased appetite, disrupted sleep cycles, vider and available social supports on the cli-
inability to concentrate, and occasional thoughts of ent’s health management.
being “better off dead.” The therapist inquires more
about the suicidal ideations and about making a
safety plan that includes a support system with Cross-References
whom he can share these feelings. Forrest appears
to become agitated. He tells the therapist that he only ▶ Families with Illness
has thoughts and will not act on them. He refuses the ▶ Health Problems in Couple and Family
safety plan and refuses to tell anyone about the Therapy
thoughts. Forrest tells the therapist that he told ▶ Medical Family Therapy
God and God will help him take care of it. The ▶ Medical Model in Couple and Family Therapy
therapist tells Forrest that she respects his relation-
ship with God and makes a plan for him to talk to
God about his thoughts when they pop up. Forrest References
agrees to continue returning for therapy.
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Internal Medicine, 70(2), 236–259. atric Association recognizes three major forms
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Hodgson, J., Lamson, A. L., & Reese, L. (2007). The do not fulfill diagnostic criteria for mania or
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D. Linville & K. M. Hertlein (Eds.). (2014). The ther-
apist’s notebook for family health care: Homework, defined as an elevated or irritable mood accom-
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families coping with illness, loss, and disability. Loca- three of nine additional symptoms, such as
tion: Routledge. decreased need for sleep, increased goal-
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A biopsychosocial-spiritual assessment in brief or mania and hypomania are differentiated by
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S. T. Fife, & C. M. Peterson (Eds.), Techniques for severity and length. Mania causes functional
the couple therapist: Essential interventions from the impairment, involves psychosis, or requires
experts (pp. 213–217). New York: Routledge. hospitalization; hypomanic episodes do not
McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2014). involve this level of functional impairment.
Medical family therapy and integrated care. Washing-
ton, DC: American Psychological Association. Manic episodes must last one week; hypomanic
Moravec, C. S., & McKee, M. G. (2011). Biofeedback in episodes can be defined on the basis of symp-
the treatment of heart disease. Cleveland Clinic Journal toms lasting at least four days. Many with bipo-
of Medicine, 78, S20–S23. lar disorder experience well periods between
Sulmasy, D. P. (2002). A biopsychosocial-spiritual model
for the care of patients at the end of life. The Gerontol- episodes; others, however, experience mild
ogist, 42(Suppl 3), 24–33. depressive symptoms between episodes. Across
the various forms of bipolar disorder, estimates
of prevalence range between 2% and 4% of the
US population, with lower rates worldwide
Bipolar Disorder in Couple (Merikangas et al. 2007). Most people diag-
and Family Therapy nosed with bipolar disorder experience recur-
rences throughout the life course.
Sheri L. Johnson, Ben Swerdlow, Jennifer Bipolar disorder has been rated as the sixth
Pearlstein and Kaja McMaster leading cause of medical disability worldwide
University of California, Berkeley, Berkeley, (Kleinman et al. 2003). Bipolar disorder has sig-
CA, USA nificant repercussions for relationships, and rela-
tionship satisfaction, in turn, has significant effect
on the outcome of disorder. For more than two
Introduction decades, research has shown that marital and cou-
ples therapy can improve the outcomes for bipolar
Bipolar disorder (BD) is a severe psychological disorder, as well as reduce the effects of bipolar
disorder characterized by symptoms of mania. disorder on family and couples function.
Bipolar Disorder in Couple and Family Therapy 269
Theoretical Context for Concept live with families characterized by high expressed
emotion relapsed compared to 54% of patients
Couple and family therapy in bipolar disorder is returning to live with families characterized by
based on several assumptions. The first assump- low expressed emotion (Miklowitz et al. 1986).
tion is that a stress-diathesis model, integrating Beliefs of controllability, or that the bipolar symp- B
biological and social influences, can be applied toms can be attributed to the patient’s choice or
to understanding bipolar disorder. The second temperament, can intensify tendencies for fami-
assumption is that misinformation and poor lies to engage in expressed emotion. Seventy per-
understanding of bipolar disorder can intensify cent of spouses in one study endorsed beliefs that
relationship conflict. The third assumption is that symptoms were controllable by the patient, and
the symptoms of bipolar disorder can create bur- these attitudes were a strong predictor of marital
den and stress in families. difficulties during manic and depressed phases of
As with other disorders, the stress-diathesis the disorder (Lam et al.2005).
model in bipolar disorder suggests that an under- Data indicate many ways in which the symp-
lying biological vulnerability creates an increased toms of bipolar disorder can present challenges
reactivity to stressors. Heritability estimates, for relationships. When the patient is ill, many
which provide an estimate of the extent to which families experience changes in sexual, social,
the onset of disorder is attributable to genetic socioeconomic, household, parenting, occupa-
influences, are as high as 85% for bipolar disorder tional, and other functional domains that often
(McGuffin et al. 2003). About 5–10% of first put a strain on the people caring for the person
degree relatives of those with bipolar disorder with bipolar disorder. Families tend to endorse
will meet diagnostic criteria for the disorder, a concerns about how well family interactions are
rate that is considerably higher than the general going across a broad range of domains (Young
population (Smoller and Finn 2003). Despite the et al. 2013). The challenges this places on those
strong biological vulnerability to this disorder, it taking care of the person with bipolar disorder
is well documented that familial and social rela- have been referred to as caregiver burden. Care-
tionships can influence the course of bipolar dis- giver burden is consistently found to be elevated
order, as can psychological variables such as among spouses and parents of people with bipo-
tendencies to be highly sensitive to rewards and lar disorder. For example, more than half of a
life events involving goal attainment, sleep dis- sample of spouses reported increasing their
ruption, and impulsivity (Miklowitz and Johnson work hours and childcare responsibilities and
2009). One assumption guiding treatment is that decreasing their social interactions when the
the genetic and biological vulnerability to disor- patient is ill (Lam et al. 2005). Partners of indi-
der may increase vulnerability to negative envi- viduals diagnosed with bipolar disorder
ronments. Given this, one of the goals of couple reported more dissatisfaction with marital and
and family therapy is to reduce the triggers of sexual relationships than did those whose part-
episodes. ner was not diagnosed with bipolar disorder
There is also considerable evidence showing (Lam et al. 2005). This burden carries with it
that the attitudes and behaviors of family, spouses, important consequences, including psychiatric
and other significant others influence the course of or medical illness in the caregivers or separation
bipolar disorder. Critical attitudes in particular are and divorce in couples.
associated with poorer outcomes. Expressed emo- Given the robust evidence that family and cou-
tion, or the degree to which a caregiver expresses ple concerns are common for those with bipolar
critical, hostile, and emotionally over involved disorder and have an important influence on the
attitudes toward the person with bipolar disorder, course of disorder, clinicians and researchers have
is also a strong risk factor for poorer course of frequently emphasized the benefits of involving
illness. For example, over the course of 9 months, family members and significant others in treat-
90% of patients returning from hospitalization to ment as an adjunct to pharmacotherapy.
270 Bipolar Disorder in Couple and Family Therapy
Description education about the symptoms, course, and treat-

ment of bipolar disorder, the importance of long-
Drawing on the above assumptions, most couple term pharmacotherapy, training in communication
and family treatments of bipolar disorder aim to and problem-solving skills to reduce family con-
provide education about the disorder so that fam- flict, and development of a relapse prevention
ily members and partners can better recognize plan. Most of these treatments are offered con-
symptoms and be less blaming, emphasize the jointly to the patient with their family members.
importance of conflict and stress for poor out- Almost all treatments begin with assessment of
comes within bipolar disorders, diminish family the patient and of family concerns. During the
conflict, and address caregiver’s burden and assessment phase, therapists are likely to use
demand. Many treatment approaches also aim to self-report scales and interviews to understand
improve adherence with pharmacotherapy and to how families are faring in different domains
enhance symptom management. The hope is that (e.g., problem-solving, communication, close-
reducing stress in the family environment will ness). In early sessions, family members and
delay, minimize, or prevent recurrences of BD those with bipolar disorder are taught about the
(e.g., Davenport et al. 1977). disorder including the expected course of the dis-
To date, Family Focused Therapy (FFT) has order and the different ways that symptoms of
been the most carefully researched approach (see mania and depression may be expressed. After
the entry in this encyclopedia). Nonetheless, a increasing understanding of the disorder, thera-
number of other approaches have been detailed pists provide more information about available
in the literature, including the Problem Centered pharmacological and psychological treatments to
Systems Therapy of the Family (PCSTF) based on address current symptoms and to prevent relapse.
the McMaster Model of Family Functioning. One of the main goals is to work with the family to
Each of these approaches involve assessment improve medication adherence, as this is an
phase, development of a treatment contract with important facet of relapse prevention. In the next
the family that specifies core treatment goals, phase of therapy, most approaches include a more
treatment involving education, skills and commu- in-depth focus on the problems that the family is
nication training, and then a closure period of facing, ways to problem-solve about those issues,
reviewing gains made and planning for the future. and to consider new solutions that would work
Overall, there is strong evidence that couple well both for the person with bipolar disorder and
and family therapies are helpful for adult and their family members. This work may involve
adolescent patients with bipolar disorder, with a crisis management, communication training, and
two- to threefold reduction in the rate of relapse as a focus on tackling one problem at a time using
compared to control conditions in some studies systematic cognitive and behavioral strategies.
(Miklowitz et al. 2003), although some studies Family members may work together on best strat-
have shown less positive outcomes for adoles- egies for communicating and resolving crises that
cents. Family therapy may be particularly helpful can occur if a patient becomes manic or suicidal.
when families endorse more difficulty and distress Family treatments for BD vary somewhat in
at baseline (Miller et al. 2008). The finding that the foci of treatment and formats. Whereas FFT
family therapies improve treatment and medica- tends to be fairly focused on knowledge of the
tion compliance is particularly robust. illness and ways to reduce family conflict and
over-intrusiveness, the McMaster Model
focuses on six dimensions that have been
Application of Concept in Couple found to be frequently impaired in treatment
and Family Therapy settings: problem-solving, communication,
roles, affective responsiveness, affective
Most family therapy approaches for BD share a involvement, and behavior control. Family
number of core components, including psycho treatment models have been applied with adult
Bipolar Disorder in Couple and Family Therapy 271
and adolescent patients and have been The therapist talked with Nancy individually
implemented with individual families and as for a session to review her personal reasons for
multifamily group therapies (e.g., Fristad considering treatment. Nancy was able to identify
et al. 2009). When multiple families are seen that she felt considerable regret about the fights
together, group members often gain coping that had happened and was deeply traumatized by B
strategies and social support from the group her hospitalization. She was eager to avoid those
interaction. problems again and with encouragement, could
see that medication was one way to gain control
over these difficult problems.
Case Study With Nancy’s commitment to treatment in
place, the therapist met with Nancy and her hus-
The case of Nancy illustrates some of the steps band jointly. Both had a clear sense of what mania
and goals in treatment. Nancy and her family looked like once it was “full-blown” but neither
sought treatment after her third episode of felt like they were sure what the early signs were.
mania. Nancy was typically a very active contrib- This had left Nancy feeling like there was no point
utor to the community and a loving wife and in trying to monitor symptoms; in contrast, her
mother to her two children (ages 2 and 3). None- husband would notice every small shift in her
theless, when her manic symptoms developed, she mood and would get worried if she laughed a little
would find it hard to stay home to take care of the louder, stayed up a little later, or met a new friend.
children – the world enticed her with possibility, Together, they began to learn more about the early
and she would wander the neighborhood for long symptoms of mania and how to consider when
hours, meeting and flirting with strangers, and those might be evolving in a troubling manner.
shopping at a level that challenged the family They began to develop a game plan for managing
budget. Several months ago, during one of her early signs of mania to help prevent the onset of
high periods, her mother confronted her with the another full-blown episode. During this process,
need to stay home to care for the children; major Nancy’s husband often became directive in a way
fights ensued. As her mania progressed, she made that led to conflict. The therapist helped them
biting and harsh comments toward family mem- understand that although his fear was common,
bers and close friends, and she remained haunted Nancy needed a certain amount of autonomy in
by guilt over some of those interactions. Within planning her treatment and care plan. Nancy’s
2 days of those arguments beginning, she began to husband was able to feel reassured when he saw
have terrifying hallucinations, and her husband that Nancy was taking on this responsibility and
called the police for help when she became highly developing skills for checking her own symptoms
agitated and he could not understand her on a daily basis. They were able to talk about the
verbalizations. She was hospitalized for the first challenges to her autonomy that the illness had
time in her life, an event that she found deeply created, and he expressed a deep sense of com-
painful. passion for her experience. At the same time, they
As she left the hospital, though, Nancy both recognized the need to protect the family and
focused on the early “sparkling” phase of the her friendships if relapse were to occur. They
episode, when her symptoms were less severe. worked together to put in place resources to keep
During that phase, she had felt more alluring, the children safe and to help her decide when it
engaged, insightful, and alive than at any other might be good to restrict social interaction and
period of her life. She missed that experience so find a quiet zone until she felt more calm. By
much that she did not want to take medications. working together, they were able to develop
Nancy and her husband, who typically enjoyed Nancy’s plan for self-care and symptom monitor-
a close and supportive relationship, had been ing, a sense of when and how her husband might
experiencing considerable marital conflict over be able to constructively note changes he saw in
whether she should engage in treatment. her mood and energy, a plan for quickly obtaining
272 Birdwhistell, Raymond
medical care in case of relapse, and behavioral treatment interactions. Journal of Clinical Psychiatry,
strategies to implement to avoid damage to rela- 69(5), 732–740. https://doi.org/10.4088/JCP.v69n0506.
Smoller, J. W., & Finn, C. T. (2003). Family, twin, and
tionships if symptoms did unfold. The process of adoption studies of bipolar disorder. American Journal
developing this plan strengthened their relation- of Medical Genetics Part C: Seminars in Medical
ship and allowed them to begin to think about Genetics, 123C(1), 48–58. https://doi.org/10.1002/
spending more time together as a couple. ajmg.c.20013.
Young, M. E., Galvan, T., Reidy, B. L., Pescosolido, M. F.,
Kim, K. L., Seymour, K., & Dickstein, D. P. (2013).
Family functioning deficits in bipolar disorder and
ADHD in youth. Journal of Affective Disorders,
References 150(3), 1096–1102.
American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.). Arling-
ton: American Psychiatric Publishing.
Davenport, Y. B., Ebert, M. H., Adland, M. L., & Birdwhistell, Raymond
Goodwin, F. K. (1977). Couples group therapy as an
adjunct to lithium maintenance of the manic patient.
American Journal of Orthopsychiatry, 47, 495–502. Armine Gevorkyan1 and Ester Yesayan2
1
Fristad, M. A., Verducci, J. S., Walters, K., & Young, M. E. California Department of Corrections and
(2009). Impact of multifamily psychoeducational psy- Rehabilitation (CDCR), Los Angeles, CA, USA
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Kleinman, L., et al. (2003). Costs of bipolar disorder.
PharmacoEconomics, 21, 601–622. Name
Lam, D., Donaldson, C., Brown, Y., & Malliaris, Y. (2005).
Burden and marital and sexual satisfaction in the part-
ners of bipolar patients. Bipolar Disorders, 7, 431–440. Raymond “Ray” L. Birdwhistell, Ph.D.
https://doi.org/10.1111/j.1399-5618.2005.00240.x. (1918–1994)
McGuffin, P., Rijsdijk, F., Andrew, M., Sham, P., Katz, R.,
& Cardno, A. (2003). The heritability of bipolar affec-
tive disorder and the genetic relationship to unipolar
depression. Archives of General Psychiatry, 60(5), Introduction
497–502. https://doi.org/10.1001/archpsyc.60.5.497.
Merikangas, K. R., Akiskal, H. S., Angst, J., Greenberg,
P. E., Hirschfeld, R. M. A., Petukhova, M., & Kessler,
Raymond “Ray” L. Birdwhistell was an American
R. C. (2007). Lifetime and 12-month prevalence of Anthropologist who was well known internation-
bipolar spectrum disorder in the National Comorbidity ally for his significant contributions to the field of
Survey replication. Archives of General Psychiatry, nonverbal communication or body language. He
64(5), 543–552. https://doi.org/10.1001/archpsyc.64.
5.543.
coined the term kinesics, the part of nonverbal
Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, communication that deals with postures of the
T. L., & Suddath, R. L. (2003). A randomized study of body and movements of various parts of the
family-focused psychoeducation and pharmacotherapy body that play a role in communicating. He con-
in the outpatient management of bipolar disorder.
Archives of General Psychiatry, 60, 904–912.
tributed many writings to the field of nonverbal
Miklowitz, D. J., & Johnson, S. L. (2009). Social and communication including, 2 books and about
familial factors in the course of bipolar disorder: 15 papers published in prestigious professional
Basic processes and relevant interventions. Clinical journals such as, Schizophrenia; Group Pro-
Psychology: Science and Practice, 16(2), 281–296.
https://doi.org/10.1111/j.1468-2850.2009.01166.x.
cesses: Transactions of the second conference;
Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., and Lectures on Experimental Psychiatry. He
Snyder, K. S., & Doane, J. A. (1986). EE, affective was also involved in the making of numerous
style, lithium compliance, and relapse in recent onset films, such as Microcultural Incidents in Ten
mania. Psychopharmacology Bulletin, 22, 628–632.
Miller, I. W., Keitner, G. I., Ryan, C. E., Uebelacker, L. A.,
Zoos; TDR-009; and the Lecture on Kinesics by
Johnson, S. L., & Solomon, D. A. (2008). Family treat- Ray L. Birdwhistell at the Second Linguistic-
ment for bipolar disorder: Family impairment by Kinesic Conference Nov. 4–7, 1964.
Birdwhistell, Raymond 273
Career these family members and among those with

schizophrenia.
Raymond “Ray” Birdwhistell received a bache- Being an anthropologist, he was interested in
lor’s degree in 1940 from Miami University in the study of communication more broadly than
Oxford, Ohio, followed by his Master’s degree just kinesics, including linguistics and anthropol- B
in 1941 from Ohio State University. He then ogy and sometimes film and the arts. Raymond
completed his doctoral training and received Birdwhistell collaborated with Margaret Mead,
his Ph.D. in Anthropology in 1951 from the Gregory Bateson, Erving Goffman, and Dell
University of Chicago. It was during the time Hymes, among many others. Additionally, he
he spent conducting his dissertation fieldwork was influenced by linguist-anthropologists
among the Kutenai Indians of British Columbia George L. Trager and Henry Lee Smith Jr.
(1944–1946) where his interest in nonverbal Raymond Birdwhistell introduced a system of
behavior began. During the time he was com- annotation meant to assist in the recording, anal-
pleting his dissertation, Raymond Birdwhistell ysis, and interpretation of cross-cultural body
began teaching at the University of Toronto motion. In his research he observed that that
(Ontario). He then went on to teach for there were differences in how people expressed
10 years at the University of Louisville, Ken- themselves through gestures and body movement
tucky, and helped in racial integration of the patterns based on their different cultures, which
University. He also taught at the State Univer- led him to understand that gestures and body
sity of New York at Buffalo from 1956 to 1959 motion patterns are socially learned. Conse-
and at Temple University. In 1959, he was quently, he concluded that nonverbal communi-
appointed as senior research scientist at the cation cannot be analyzed in one universal way
Eastern Pennsylvania Psychiatric Institute in across all cultures. Instead, he insisted that body
Philadelphia. He continued to conduct research movement patterns be analyzed and viewed
and analysis in kinesics for five decades, includ- within the context of the specific culture in
ing studying videos of interactions among fam- which they are learned. He highlighted that
ily members of individuals who had when observing a bilingual speaker as she/he
schizophrenia. He held the position of professor changes languages, the speaker also tends to
at The Annenberg School of Communication at change patterns of body movement.
the University of Pennsylvania from 1969 until Raymond Birdwhistell used cameras and slow-
he retired in 1988. Throughout his career he motion projectors to compare and analyze
taught many influential individuals in the field, detailed behavioral motion patterns with what
including Erving Goffman and Alan Lomax. individuals were verbally communicating as they
spoke. He also used these films to analyze patterns
of body motion and interaction and to study how
Contributions to Profession such nonverbal communication is learned. Addi-
tionally, Raymond Birdwhistell created films with
Raymond “Ray” Birdwhistell, Ph.D. coined the the filmmaker Jacques van Vlack, for the purpose
term “kinesics,” which is the nonverbal commu- of providing technical training on kinesics: Micro-
nication through gestures and body movements cultural Incidents in Ten Zoos; TDR-009; and the
or patterns. He studied and wrote extensively Lecture on Kinesics by Ray L. Birdwhistell at the
about body motion patterns, gestures, and non- Second Linguistic-Kinesic Conference Nov. 4–7,
verbal aspects of communication within various 1964.
countries and cultures. Raymond Birdwhistell
studied videos of interactions among family
members who had someone with schizophrenia Cross-References
in their family to see if there was a different
pattern of body motion communication between ▶ Social Learning Theory
274 Bisexual Couples
References systems (McLean 2007; Scherrer et al. 2015;

Todd et al. 2016). Third, given the unique experi-
Birdwhistell, R. L. (1952). Introduction to kinesics: An ences associated with being bisexual, it is critical
annotation system for analysis of body motion and
that therapeutic practitioners are knowledgeable
gesture. Washington, DC: Department of State, Foreign
Service Institute. about bisexual people and their unique experi-
Birdwhistell, R. L. (1955). Background to kinesics. ETC: ences in intimate relationships and in families.
A Review of General Semantics, 13(1), 10–18. Biphobia is also pervasive within the therapeutic
Birdwhistell, R. L. (1959). Contribution of
relationship (Dworkin 2001; Page 2007; Scherrer
linguistic–kinesic studies to the understanding of
schizophrenia. In A. Auerback (Ed.), Schizophrenia: 2013), a bias that can be mitigated with practi-
An integrated approach (pp. 99–123). New York: tioners’ conscientious intervention. This encyclo-
Ronald Press. pedia entry provides an overview of how bisexual
Birdwhistell, R. L. (1963). The kinesic level in the inves-
identities are relevant in intimate relationships and
tigation of the emotions. In P. H. Knapp (Ed.), Expres-
sion of the emotions in man (pp. 123–139). New York: family systems.
International University Press.
Birdwhistell, R. L. (1970). In E. Goffman, D. Hymes,
G. Samkoff, & H. Glassie (Eds.), Kinesics and context:
Essays on body motion communication. Philadelphia:
Relevant Research
University of Pennsylvania Press.
This section provides an overview of scholarship
relevant to bisexual people’s intimate and familial
relationships. Specifically, this section reviews
definitions of bisexuality, conceptualizations of
Bisexual Couples biphobia, research on bisexuality in therapeutic
practice, research on bisexual people in relation-
Kristin S. Scherrer ships, and scholarship on bisexuality in family
Department of Social Work, Metropolitan State relationships. The concept of bisexuality is mer-
University of Denver, Denver, CO, USA curial, and there is no universally agreed upon
definition of what it means to be bisexual
(Esterberg 2006; Halperin 2009). Some concep-
Introduction tualize bisexuality as a psychological quality,
focusing on same- and different-sex attractions.
Bisexuality is an often invisible topic even within Others conceptualize bisexuality as primarily
scholarship on sexual orientation. Yet, for several behavioral, examining previous and current sex-
reasons, bisexuality remains an important topic ual and romantic relationships. Other scholarship
within the field of couple and family therapy to examines those who adopt bisexuality as an iden-
examine in and of itself. First, bisexual people tity. Self-identification represents a particularly
make up the demographic majority of gay, les- salient classification for therapeutic practitioners
bian, and bisexual populations (Egan et al. 2007; as a person’s bisexual identification conveys
Herbenick et al. 2010; Mosher et al. 2005), mak- meaning about the self, internally as well as within
ing bisexuality an important dimension of sexual a social and cultural context. Practitioners work-
diversity that practitioners should be knowledge- ing with clients who indicate bisexual attractions,
able about. Second, bisexual people face unique behaviors, or identities must be careful in making
challenges because of their bisexuality – an expe- assumptions about other dimensions of clients’
rience that can be understood as biphobia. experiences. For instance, a person may identify
Biphobia is pervasive and can negatively affect as bisexual, but may or may not have had behav-
bisexual people’s relationships to both heterosex- ioral experiences with members of a particular
ual and gay/lesbian people. Biphobia also has gender category. Similarly, a client may describe
profound effects on interpersonal relationships, same- and different-sex attractions or behaviors,
such as in intimate relationships or within family but not identify as bisexual. In other words,
Bisexual Couples 275
practitioners should seek to adopt client-focused Hughes 2004; Mohr et al. 2001, 2009; Page
understandings of their sexual orientation, as the 2007). Practitioners have more negative beliefs
meaning and salience of their identities vary. about bisexual people than about lesbian/gay peo-
Despite the variation in definitions of bisexuality, ple (Eliason and Hughes 2004). Further, these
a more general definition of bisexuality can indi- biphobic beliefs shape practitioners’ work with B
cate attraction to people of one’s own gender and bisexual clients in problematic ways (Bowers
people of other genders. and Bieschke 2005; Mohr et al. 2009, 2001;
A discussion of therapeutic practice with Murphy et al. 2002). Research with bisexual cli-
bisexual people would be neglect without exam- ents indicates that practitioner bias negatively
ining the concept of biphobia. Biphobia describes affects their experiences of psychotherapy. For
the stereotypes and negative attitudes that people instance, one of the issues most commonly faced
hold about bisexuality (Israel and Mohr 2004; by bisexual people is having their bisexuality
Ochs 1996; Rodríguez-Rust 2002). One common invalidated by their therapist (Page 2007). Bisex-
stereotype about bisexuality is that bisexual peo- ual people also report that their practitioners lack
ple are in transition toward an “authentic” hetero- knowledge about bisexuality and bisexual issues
sexual or gay/lesbian identity. Bisexual people or that their practitioners believe that bisexuality
may be viewed as duplicitous, as they are assumed is unhealthy (Page 2007). Additional education
to be seeking to avoid the stigma of identifying as and critical self-reflection are a critical need for
gay/lesbian, or alternatively seen as at an early practitioner competency in working with bisexual
stage in their identity development and naïve to clients (Mohr et al. 2001; Murphy et al. 2002).
their true sexual orientation (Ochs 1996; Issues of biphobia also carry into bisexual peo-
Rodríguez-Rust 2002). These beliefs stem from ple’s intimate relationships. In this section, the
the expectation that individuals should only be term intimate relationships is utilized in recogni-
romantically attracted to people of one gender tion of the fact that although the majority of the
(Bradford 2004; Rodríguez-Rust 2002) and con- research on bisexual people’s intimate relation-
vey disbelief that bisexuality is a “real” sexual ships focuses on dyadic relationships, some bisex-
orientation. Another stereotype about bisexuality ual people pursue polyamorous or
centers on strong, deviant sexual drives, which are nonmonogamous relationships. The term non-
seen as even more hedonistic than lesbian or gay monogamous is an umbrella concept for relation-
individuals (Israel and Mohr 2004). People who ship statuses that are intentionally not
hold this stereotype often express disbelief that a monogamous. Polyamory is a more specific term
bisexual person could ever be satisfied in a that describes “having multiple emotionally inti-
monogamous relationship. Bisexual people are mate relationships simultaneously. Often, though
seen as sexually indiscriminate and libel to have not always, these relationships are sexual in
sex with “anything that moves” (Ochs 1996). nature; the emphasis in polyamory is generally
Related to this stereotype is the assumption that on the presence of multiple romantic partners”
bisexual people are carriers of sexually transmit- (Fierman and Poulsen 2011, p. 17). Not all bisex-
ted infections (Eliason 2001; Mohr et al. 2009). ual people (or gay, lesbian, heterosexual people)
As a result of this stereotype, bisexual people are desirous of monogamous dyadic relationships
often deal with other people’s assumptions about (Kleese 2005; Rodríguez-Rust 2002; Rust 2003).
their issues with commitment, fidelity, and trust- Scholarship indicates that bisexual people may be
worthiness (Eliason 2001; Spalding and Peplau more likely (than heterosexual or gay/lesbian indi-
1997). viduals) to seek out nonmonogamous relation-
Scholarship about therapeutic practice with ships and less likely to regard monogamy as an
bisexual people indicates that practitioners are idealized relationship form (Rodríguez-Rust
not exempt from unconsciously adopting 2002; Rust 2003). Forming and maintaining non-
biphobic attitudes. Practitioners’ beliefs generally monogamous relationships in a cultural context
mirror other biphobic stereotypes (Eliason and that privileges monogamy is a likely source of
stress for bisexual people who engage in non- lesbian people. However, a burgeoning body of
monogamous relationships. literature examines bisexual people experiences in
Misconceptions about bisexuality affect het- families of origin (McLean 2007; Scherrer et al.
erosexual, gay, and lesbian people’s interests in 2015; Todd et al. 2016; Watson 2014). This
forming intimate relationships with bisexual peo- research finds that bisexual people may be less
ple (Armstrong and Reissing 2014; Eliason 1997; likely to disclose their sexual orientation to family
McLean 2007; Rodríguez-Rust 2002; Spalding members (McLean 2007). Furthermore, bisexual
and Peplau 1997). Spalding and Peplau (1997) people’s disclosure decisions are mediated by
found that heterosexual individuals believe bisex- their relationships’ status (Costello 1997; Scherrer
ual individuals to be nonmonogamous, unfaithful, et al. 2015). For example, bisexual people in inti-
sexually risky, and more likely to spread sexually mate relationship are more likely to disclose their
transmitted infections. Similarly, heterosexual identity (Scherrer et al. 2015). Further, the gender
undergraduate students were reluctant to engage of their significant other also medicates disclosure
in a relationship with a hypothetical bisexual per- decisions (Costello 1997; Scherrer et al. 2015).
son to whom they were attracted (Eliason 1997). Biphobia also shapes bisexual people’s dis-
Other research has found that participants who closure experiences with their families of origin,
were asked to pair up profiles of single people for instance, as it influences how a bisexual
were more likely to match a bisexual profile to person may choose to come out to their families
bisexual profile and less likely to match a bisexual (Scherrer et al. 2015; Watson 2014). Bisexual
profile to either a lesbian or gay profile or a het- people often utilize a disclosure strategy that
erosexual profile (Breno and Galupo 2008), indi- they see as maximizing desirable outcomes in
cating the idea that bisexual people are seen as less their family relationships (Scherrer et al. 2015),
desirable intimate partners. Taken together, this although the desirable outcomes vary from per-
research indicates that bisexual people experience son to person. Scherrer et al. (2015) found that
challenges in intimate relationships because of many bisexual people “simplified” their identity
their bisexuality. when coming out by describing themselves as
Furthermore, once in a relationship, biphobic gay or lesbian, hoping to avoid family members’
stereotypes also affect bisexual people’s experiences negative conceptions about bisexuality. When
in intimate relationships (McLean 2007; Rodríguez- bisexual people do come out as bisexual to
Rust 2002). For example, these stereotypes may members of their family of origin, they fre-
manifest as bisexual people may not feel comfort- quently anticipated negative responses based
able disclosing their identity to a partner, fearing on biphobic stereotypes (Scherrer et al. 2015;
stigma or rejection (McLean 2007). The stereotype Watson 2014). Stereotypes about bisexuality
that bisexual people are sexually promiscuous, sex- also shape how family members respond to
ually insatiable, or nonmonogamous may also man- learning about a bisexual family member’s sex-
ifest in an intimate partner’s concerns that a bisexual ual identity (Scherrer et al. 2015; Todd et al.
person may not be able to adhere to monogamous 2016). Family members were (surprisingly)
expectations. Stereotypes that bisexual people are knowledgeable about stereotypes about bisexu-
confused or unsettled about their sexual orientation ality, often as they described bisexuality as a
may manifest in intimate relationships as the inti- temporary identity on the way to a stable
mate partner may fear that the bisexual person may gay/lesbian/heterosexual identity (e.g., “I
decide that they are no longer attracted to the roman- thought it was a phase”) (Scherrer et al. 2015)
tic partner’s gender identity category. or as associated with sexual irresponsibility
Relatively little literature focuses on the family (Todd et al. 2016). Family members engaged
relationships of bisexual persons. More fre- with these stereotypes, both explicitly and
quently, scholarly research subsumes bisexual implicitly, to try to understand their bisexual
people’s family relationships alongside gay and family member (Scherrer et al. 2015; Todd
Bisexual Couples 277
et al. 2016). Taken together research indicates to assist couples in explicitly discussing
that the social construction of bisexuality is biphobic stereotypes and in examining how
important for understanding bisexual people’s these stereotypes shape their interactions with
experiences in families. and expectations of one another. Bisexual indi-
viduals who engage in nonmonogamous or B
polyamorous relationships may also benefit
Special Considerations for Couple and from an in-depth discussion of the challenges
Family Therapy and strengths associated with these identities, in
consideration of the challenges associated with
This section provides an overview of scholarship being embedded in a cultural context that
relevant to therapeutic practice with bisexual peo- devalues these relationships (Rust 2003).
ple in regard to their intimate and familial relation- Third, bisexual people in intimate relationships
ships. Scholarly research provides a number of may also experience challenges from their broader
insights for therapeutic practitioners. First and family systems. As detailed in the scholarly research
foremost, practitioners must pursue ongoing on bisexual people’s family relationships, bisexual
opportunities to improve their knowledge about people often navigate familial disclosure once they
bisexuality and assess their own unconscious are in intimate relationships. Bisexual clients strug-
biases about bisexuality. Ongoing clinical super- gling with their relationships with families of origin
vision and continuing education on issues of may benefit from exploring how stereotypes about
bisexuality will be critical to achieving this goal. bisexuality shape their familial relationships. This
Practitioner must also keep in mind that while may provide space for bisexual clients to describe
being knowledgeable about bisexuality is neces- experiences of familial support as well as marginal-
sary to effectively practice with this population, ization and ultimately provide the practitioner with a
practitioners must also be careful to avoid overly better understanding of the client’s familial context.
focusing on the client’s sexuality if it is not rele- Practitioners should affirm that there is no “wrong”
vant to the presenting issue. or “right” way to come out to one’s family members,
Second, in working with bisexual people in nor is there an imperative to disclose one’s identity
regard to their intimate relationships, practi- to one’s family. Rather, clients can examine some of
tioners should anticipate that stereotypes about the positive and negative potential outcomes of
bisexuality may negatively shape relationship different disclosure strategies. One strong theme in
quality, for instance, as a bisexual person may research on the family relationships of bisexual
not even feel comfortable disclosing their iden- people concerns the challenge that many bisexual
tity to their significant other. Practitioners are people feel in regard to how to be authentic with
advised to talk openly about biphobic social their families (Firestein 2007; Scherrer et al. 2015).
attitudes and then to examine how these stereo- For those bisexual clients who are interested, prac-
types may shape partners’ expectations of one titioners may seek to encourage conversations
another. If the client is interested, the practi- within the family so that a bisexual person can
tioner may work with the bisexual about poten- fully explain their identity and their relationships to
tially disclosing their identity to their partner. their families.
Practitioners may also potentially work with the In consideration of the fact that intimate relation-
partner on their stereotypical beliefs about ships are always situated within the broader context
bisexuality. “Because trust and intimacy are of family systems, practitioners should also be pre-
usually needed to sustain intimate relationships, pared to work with families on issues relevant to
these relationships may be particularly difficult bisexuality. Practitioners working with the families
for bisexual people partnering with individuals of bisexual people will potentially benefit from
who do not believe in a ‘real’ bisexual identity” examining stereotypes about bisexuality with their
(Scherrer 2013, p. 244). Practitioners may wish clients. Conceptualizations of bisexual people as
promiscuous, nonmonogamous, or untrustworthy Professional Psychology: Research and Practice,

contradict social expectations of “good” family 36, 97–103.
Bradford, M. (2004). The bisexual experience: Living in a
members. This may strain bisexual people’s abilities dichotomous culture. Journal of Bisexuality, 4(1–2),
to maintain positive family relationships. At the 7–23.
same time, stereotypes about bisexual people as Breno, A. L., & Galupo, M. P. (2008). Bias toward bisexual
nascent in their sexual identity development or that women and men in a marriage-matching task. Journal
of Bisexuality, 7(3–4), 217–235.
bisexual people will eventually realize their hetero- Costello, C. Y. (1997). Conceiving identity: Bisexual, les-
sexuality may lead to more affirming responses bian and gay parents consider their children’s sexual
from family members. Addressing these stereotypes orientations. Journal of Sociology and Social Welfare,
directly will enable families to better understand 24(3), 63–89.
Dworkin, S. H. (2001). Treating the bisexual client. Jour-
how cultural constructions of bisexuality may prob- nal of Clinical Psychology, 57(5), 671–680.
lematically shape their understandings of their Egan, P. J., Edelman, M. S., & Sherrill, K. (2007). Find-
bisexual family member. These expectations will ings from the Hunter College poll of lesbians, gays,
shape familial experiences above and beyond the and bisexuals: New discoveries about identity, polit-
ical attitudes, and civic engagement. New York:
disclosure moment, including interactions with a Hunter College, CUNY. Retrieved July 6, 2012,
partner, decisions around parenting, entering into a from http://as.nyu.edu/docs/IO/4819/hunter_col
marriage relationship, or other familial events. lege_poll.pdf.
When working with families on issues of Eliason, M. (1997). The prevalence and nature of biphobia
in heterosexual undergraduate students. Archives of
bisexuality, family systems approaches have Sexual Behavior, 26(3), 317–326.
been identified as a potentially fruitful approach Eliason, M. (2001). Bi-negativity: The stigma facing bisex-
(Scherrer et al. 2015), as well as more generally ual men. Journal of Bisexuality, 19(2–3), 137–154.
with LGB families (Baptist and Allen 2008; Eliason, M. J., & Hughes, T. (2004). Treatment counselor’s
attitudes about lesbian, gay, bisexual, and transgen-
Heatherington and Lavner 2008; Scherrer dered clients: Urban vs. rural settings. Substance Use
2016). Coming out in families may be best & Misuse, 39, 625–644.
understood as an ongoing process, whereby Esterberg, K. (2006). The bisexual menace revisited; or
family members disclose their identities, pro- shaking up social categories is hard to do. In
S. Seidman, N. Fisher, & C. Meeks (Eds.), Handbook
vide support and education for one another, of the new sexuality studies: Original essays and inter-
and influence one another’s thoughts and beliefs views (pp. 169–176). New York: Routledge Press.
about having an LGB family member (Baptist Fierman, D. M., & Poulsen, S. S. (2011). Open relation-
and Allen 2008; Heatherington and Lavner ships: A culturally and clinically sensitive approach.
American Family Therapy Academy Monograph
2008; Scherrer 2016; Scherrer et al. 2015). Series, 7, 16–24.
Using a family systems approach in a therapeu- Firestein, B. A. (Ed.) (2007). Becoming visible: Counsel-
tic context provides an understanding of coming ing bisexuals across the lifespan. New York, NY:
out as a complex, interdependent process with Columbia University Press.
Halperin, D. (2009). Thirteen ways of looking at a bisex-
implications that unfold over time. ual. Journal of Bisexuality, 9(3–4), 451–455.
Heatherington, L., & Lavner, J. A. (2008). Coming to
terms with coming out: Review and recommendations
for family systems-focused research. Journal of Family
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Armstrong, H. L., & Reissing, E. D. (2014). Attitudes Dodge, B., & Fortenberry, J. D. (2010). Sexual
toward causal sex, dating, and committed relationships behavior in the United States: Results from a national
with bisexual partners. Journal of Bisexuality, 14(4), probability sample of men and women aged 14-94.
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Baptist, J. A., & Allen, K. R. (2008). A family’s coming out Israel, T., & Mohr, J. J. (2004). Attitudes toward bisexual
process: Systemic change and multiple realities. Con- women and men: Current research, future directions.
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Bowers, A. M., & Bieschke, K. J. (2005). Psychologists’ Kleese, C. (2005). Bisexual women, non-monogamy and
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selors’ clinical responses: An analogue study of a Samuel Major1 and Adam R. Fisher1,2 B
female bisexual client. Journal of Counseling Psychol- 1
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Mohr, J., Weiner, J. L., Chopp, R. M., & Wong, S. J. Evanston, IL, USA
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(2009). Effects of client bisexuality on clinical judg- Brigham Young University, Provo, UT, USA
ment: When is bias most likely to occur? Journal of
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behavior and selected health measures: Men and Name of Concept
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National Center for Health Statistics.
Murphy, J. A., Rawlings, E. I., & Howe, S. R. (2002).
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Ochs, R. (1996). Biphobia: It goes more than two ways. In
B. A. Firestein (Ed.), Bisexuality: The psychology and more contextual models of therapy in the 1940s
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sand Oaks: Sage. was adapted as an expression of the systemic
Page, E. (2007). Bisexual women’s and men’s experi- perspective predominant in marriage and family
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ing visible: Counseling bisexuals across the lifespan therapy (Nichols and Davis 2012). The black box
(pp. 52–71). New York: Columbia University Press. is the simplest way of approaching the individual
Rodríguez-Rust, P. (2002). Bisexuality: The state of the mind within a family system, basing it solely
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41(3), 238–248.
ence, engineering, and biology. A black box
Scherrer, K. S. (2016). Gay, lesbian, bisexual and queer
grandchildren’s disclosure process with grandparents. represents something whose internal system is
Journal of Family Issues, 37(6), 739–764. unknown; studying the object involves looking
Scherrer, K. S., Kazyak, E. A., & Schmitz, R. (2015). Getting at what goes in or comes out rather than trying to
‘bi’ in the family: Bisexual people’s disclosure strategies
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680–696. fundamental concepts are key for understanding
Spalding, L. R., & Peplau, L. (1997). The unfaithful lover: the black box concept in family systems theory.
Heterosexuals’ stereotypes of bisexuals and their (1) General systems theory describes living sys-
relationships. Psychology of Women Quarterly, 21(4),
tems as holistic entities whose properties arise
611–625.
Todd, M., Oravecz, L., & Vejar, C. (2016). Biphobia in the from the relationship of individual parts; living
family context: Experiences and perceptions of systems are then maintained through inputs and
bisexual individuals. Journal of Bisexuality, 16(2), outputs from the environment (Nichols
144–162.
and Schwartz 2001). What this means is that
Watson, J. B. (2014). Bisexuality and family: Narratives of
silence, solace, and strength. Journal of GLBT Family families in family therapy are viewed as living
Studies, 10, 101–123. systems – individual members are parts of the
280 Black Box Concept in Family Systems Theory
system whose interactions give rise to defining In other words, the mind can be most simply
the function of the whole family system. understood as a black box whose thoughts, feelings,
(2) Cybernetics is the study or analysis of the emotions, and intentions may be inaccessible and
flow of information between feedback mecha- are ultimately extraneous to the overall analysis and
nisms in a self-regulating system (Nichols and improvement of the presenting problem in therapy.
Schwartz 2001). Cybernetics relates to a Rather than working on unraveling intrapsychic
family’s patterns of communication and behav- conflict, emotions, or thoughts in therapy, the ther-
ior and how those patterns either maintain or apeutic focus is on changing the communication and
change the functioning of the family unit. Inter- behavior in the client system.
vention would then work best through manipu-
lation of patterns in the family system. When
general systems theory and cybernetics were Application of Concept in Couple and
introduced, family therapists began to look Family Therapy
primarily – if not exclusively – at the interac-
tions between members of a family system Application of the black box concept gives thera-
rather than at the intrapsychic processes of pists a clinical advantage in terms of simplifying
each individual. their hypotheses about the presenting problem(s).
“No ultimately unverifiable intrapsychic hypotheses
need to be invoked” (Watzlawick et al. 1967, p. 25);
the therapist can focus solely on communication
Description between spouses or family members. Couple and
family therapists can focus initial efforts on the
With the introduction of general systems theory and simplest and least invasive methods and only
cybernetics as a theoretical backdrop for framing move on to more complex theories when needed
problems in therapy, the black box concept marks to lift constraints in the couple or family system
a radical expression of the systems perspective. The (Pinsof et al. 2017). For example, integrative sys-
metaphor of the black box – as applied to the mind – temic therapy (IST; Pinsof et al. 2017) posits three
states that the inner workings of human beings (e.g., “levels of the mind” (M1–M2–M3). The M1 level
thoughts and emotions) are impossible to truly of mind consists of emotion and meaning drawn
observe, let alone work with in therapy. Therefore, from approaches such as CBT or narrative therapy;
the best way to analyze how human systems work is M2 includes simple structural models of the mind
through the observable input-output relations of such as object relations or internal family systems;
communication and behavior. As Watzlawick et al. M3 is based on self-psychology, applied when cli-
(1967) stated, ents are proven to be “too fragile to modify their
The impossibility of seeing the mind “at work” internal processes” (Pinsof et al., p. 121). Breunlin –
has in recent years led to the adoption of the one of the IST developers – places the black box
Black Box concept from the field of telecommu- concept at an additional level of the mind (“M0”;
nication. Applied originally to certain types of
captured enemy equipment that could not be
personal communication, 2017); the black box con-
opened for study because of the possibility of cept is positioned as an initial level of the mind
destruction charges inside, the concept is more before M1. The couple and family therapist may
generally applied to the fact that electronic hard- thus opt to initially work at the M0 level of mind
ware is by now so complex that it is sometimes
more expedient to disregard the internal structure
before moving on to deeper levels as needed.
of a device and concentrate on the study of its
specific input-output relations. While it is true
that these relations may permit inferences into Clinical Example
what “really” goes on inside the box, this knowl-
edge is not essential for the study of the function of
the device in the greater system of which it is a Morgan and Lamar presented in couple therapy
part. (pp. 43–44) with complaints about frequent fights that
Black Men in Couples and Families 281
always seemed to escalate to the point of one with individuals, couples, and families. Washington,
leaving the house or threats of ending the mar- DC: American Psychological Association.
Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967).
riage even though they would typically begin Pragmatics of human connection: A study of interac-
with ostensibly benign issues. Lamar tional patterns, pathologies, and paradoxes.
would often forget to clean up the living room New York: Norton. B
before Morgan returned home from work; Mor-
gan would often spend too much money on
exercise classes. The therapist – utilizing the
black box concept – initially applied the sim- Black Men in Couples
plest approach in tracking each partner’s behav- and Families
iors and overt communications throughout the
couple’s problem sequence. Once each partner Adia Gooden1 and Anthony L. Chambers2
1
was engaged in the process of therapy, the ther- The University of Chicago, Chicago, IL, USA
2
apist implemented behavioral suggestions for The Family Institute at Northwestern University,
the couple to implement at key points in the Center for Applied Psychological and Family
sequence with the goal of preventing the same Studies, Northwestern University, Evanston,
escalation – thus making the same negative IL, USA
outcomes less likely – such as one of the part-
ners slowing down the sequence as it was occur-
ring by noting they were both getting caught in Synonyms
their typical negative cycle.
African American men
Cross-References
Introduction
▶ Breunlin, Douglas C.
▶ First Order Cybernetics Black men in the United States are a unique pop-
▶ Integrative Systemic Therapy ulation, and it is important to understand their
▶ Jackson, Donald social, ecological, and historical experiences in
▶ Second-Order Cybernetics in Family Systems order to effectively support them in therapy.
Theory Here, the term Black reflects having some African
▶ Sequences in Couple and Family Therapy heritage, and the primary focus of this entry will
▶ Strategic Family Therapy be on African American men. African American
▶ Structural Family Therapy men primarily have ancestors who were brought
▶ Watzlawick, Paul to the United States to be slaves. While many
immigrants from African countries, Europe, and
the Caribbean who have African ancestry do not
References identify as African American, the second and third
generations of these immigrants often identify as
Lebow, J. (2014). Couple and family therapy: An integra- African American and integrate into the larger
tive map of the territory. Washington, DC: American Black American community. Therefore, for the
sake of inclusivity, the term Black is used in this
Nichols, M. P., & Davis, S. D. (2012). Family therapy:
Concepts and methods (11th ed.). Hoboken: Pearson entry. When assessing Black clients, it is impor-
Education. tant to ask specifically how they identify. Some
Nichols, M. P., & Schwartz, R. C. (2001). The essentials of prefer the term Black, while others prefer African
family therapy. Boston: Allyn and Bacon.
American, and as mentioned some will disclose
Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L.,
Rampage, C., & Chambers, A. L. (2017). Integrative their immigrant heritage, which is critical back-
systemic therapy: Metaframeworks for problem solving ground information for case conceptualization.
282 Black Men in Couples and Families
Finally, as with all other populations, there is more significant portion of Black upper- and middle-
heterogeneity within the Black population than class families. Coming from a middle- and upper-
between Blacks and other racial groups. The class background will influence Black men’s
points highlighted in this entry are generalizations experience of their race and the world. Black
and should be used as guides for further men have a pervasive consciousness of how they
assessment. are perceived in the world and are very aware of
how they present themselves physically and
engage with others. Black men raised in America
Description may have received the consistent message that the
expectation for Black men in this country is that
Black men have a long legacy of struggle in the they will not succeed. They may feel pressure to
United States dating back to slavery. Black men avoid being incarcerated or dying early.
are often misrepresented and misunderstood. Experiencing discrimination and the history of
Research has demonstrated that the behavior of Black people being mistreated by institutions
Black males is more likely to be interpreted as may cause Black men to be wary of sharing things
aggressive than the same behavior by White about themselves in the context of these institu-
males. Further, Black men are frequently stereo- tions and with people who they do not trust.
typed as thugs or people who are lazy and unwill- Black masculinity is also an important factor to
ing to work. These stereotypes are inaccurate and consider. Often, there is a dynamic of hyper-
contribute to the discrimination that Black men masculinity among Black men. Black men, par-
experience in housing, employment, and the legal ticularly those reared in impoverished communi-
system. The legacy of unequal education for ties, are socialized to be tough and independent as
Black people in the United States has often limited a means of survival. Therefore, Black men are
Black men to low-skill, low-wage jobs. With the often taught as children not to express emotions
closing of many manufacturing plants, numerous other than anger. This impacts Black men’s ability
Black men found themselves out of work with few and willingness to process difficult experiences
alternatives. Additionally, the war on drugs, and to enter into spaces such as therapy or roman-
which began in the late 1970s, started mass incar- tic relationships where they are asked to be vul-
ceration in the United States, which has resulted in nerable. Black men may be navigating the tension
large proportions of Black men being incarcerated between expectations for their behavior based on
for minor, nonviolent drug crimes (Alexander the norms for men in mainstream society and the
2012). Being charged with a felony makes it norms for Black men. Specifically, Black men
even more difficult for many Black men to find must navigate the tension between competing in
work. Having difficulty finding work and being an individualistic way as proscribed by main-
able to provide for their families has taken a toll on stream American society and supporting members
many Black men emotionally. of their family or community as they succeed,
Even with this legacy of discrimination, many which is encouraged by Black cultural values.
Black men have achieved at high levels of educa- Research has demonstrated that Black men expe-
tion, business, medicine, politics, and the legal rience psychological distress when navigating
field. Black men have strengths that are often their male gender roles particularly if they have
underappreciated by the general public. Black internalized racist stereotypes (Wester et al. 2006).
men typically display high levels of resilience
and resourcefulness. Black men are faced with
constant negative assumptions about who they Relevant Research About Family Life
are, and yet time and again, they persist in jobs,
as fathers and as partners. Black Men in Romantic Relationships
Further, it is important to note that not all Black The racism and oppression that Black men expe-
men come from low-income families; there is a rience in their daily lives may contribute to
Black Men in Couples and Families 283
feelings that they must assert more power and authoritarian style of parenting, in order to help
control in their romantic relationships in order to prepare their children for the difficult realities of
make up for emasculating experiences. Black being a Black person in America. Black fathers
male partners may take their frustrations and dis- are also involved in racial socialization, which
appointments related to experiencing racism out involves helping Black children to feel positively B
on their partners. This can contribute to more about themselves and the Black community and
arguments and tension in romantic relationships. helping them navigate the challenging experi-
Additionally, research has demonstrated that ences of Black people in America and to buffer
Black men feel they should be the primary finan- them against negative racial stereotypes
cial providers for their family even though many (Livingston and McAdoo 2007).
expect their partners to be gainfully employed A combination of systemic racism and fewer
(Haynes 2000). Black men may feel threatened job opportunities makes it challenging for Black
by their female partner’s success and simulta- men to obtain consistent, gainful employment and
neously insecure about their own accomplish- therefore causes challenges for Black men as they
ments (Chambers 2008). They may have work to be providers for their children. Further,
experienced stymied careers or fewer opportuni- when Black men are employed, they do not earn
ties due to the discrimination against Black men. as much as White men with the same levels of
Black men may have difficulty expressing education. Having difficulty providing financially
emotions in their romantic relationships. Addi- for children can be accompanied by shame for
tionally, they may feel like it is not okay to show Black men and may contribute to an emotional
vulnerability to their partners, which can create distancing from children.
distance in romantic relationships. However, Black fathers who live in neighborhoods char-
research has demonstrated that Black, middle- acterized by community violence are concerned
class, heterosexual couples tend to be egalitarian about the safety of their children. Starting when
and partners tend to work together to navigate the they have preschool-aged children, Black fathers
challenges that they face (Cowdery et al. 2009). It play important roles in helping to keep their chil-
is important to note that Black couples are less dren safe through supervising their children’s
likely to get married than couples from other racial behavior and monitoring what they are doing
groups. Chambers and Kravitz (2011) have and being exposed to. Black fathers also teach
asserted that the lower marriage rates are in part their children safety strategies to use in and out-
due to the financial, discrimination, and family side of their homes (Letiecq and Koblinsky 2004).
stressors that many Black couples face.
Black Fathers Special Considerations for Couple

The prevailing stereotypes of uninvolved and dis- and Family Therapy
interested Black fathers are largely inaccurate.
Even when Black fathers do not have primary Alliance Building with Black Male Clients
custody of their children they still commonly Black men are often apprehensive about engaging
play an important role in supporting and caring in individual, couple, and family therapy, and
for their children. Black fathers are involved in therapists should account for this and take steps
caring for, nurturing, and socializing their chil- to ensure that their Black male clients feel wel-
dren, and research has demonstrated that they comed and accepted. Therapists should keep in
display comparable levels of involvement to mind that it may take longer to build trust in the
White fathers (Smith et al. 2005). Additionally, therapeutic relationship; being patient with this
Black fathers share parenting decisions with their process will help Black male clients to feel more
partners and the parenting relationships with the comfortable opening up in therapy over time.
mothers of their children tend to be egalitarian. Black people including Black men are often
Black men are more likely to engage in an socialized to keep personal matters private (e.g.,
284 Black Men in Couples and Families
“don’t air your dirty laundry”) and may be hesitant relationship is exactly the thing that can destroy
to share personal information with a therapist who is it. Thus, clinicians need to assess a couple’s capacity
initially a stranger. To build rapport, it is essential for to be vulnerable as well as help the couple, espe-
therapists to show respect for Black male clients. cially the Black male partner, to understand the
Black men often experience disrespect in their function and importance of expressing vulnerability
everyday lives when their manhood and personhood in a marital relationship (Chambers 2008).
are ignored. Therapists should begin by addressing The issue of gender disparities among Black
their Black male clients using formal titles. Less Americans is a sociological one with interpersonal
formality can be adopted if suggested by a client implications (Chambers & Kravitz 2011). With a
or if the therapist receives approval from the client to disproportionate number of Black men
use their first name. Additionally, Black men are underperforming with regard to employment and
often blamed unfairly in a variety of contexts. It is income, issues of gender identity and leadership
important that therapists are careful not to place can constrain one’s ability to appropriately
inappropriate blame on Black male clients and express vulnerability. Hence, it is important to
work sensitively to support them in understanding understand each person’s conceptualization of
their role in conflicts. gender roles in the context of a romantic relation-
Black people tend to engage in what is referred ship and especially how the man has held onto his
to as high-context communication; this means that ideas of masculinity when his female partner is the
nonverbal cues (e.g., tone, volume, hand gestures) primary financial provider.
play a large role in communication. Additionally, Finally, if Black fathers do not initiate therapy
high-context communication may rely on shared for their family or children, it is important for the
references including slang. Therapists should be therapist to actively engage Black fathers in the
aware of potential differences in communication therapeutic process given the important role that
styles with their clients and leave room for their they play in their children’s lives.
clients to communicate in a way that is most
comfortable for them. Therapists are encouraged
to ask for clarification if they do not understand Cross-References
what a client is intending to express.
It is important for therapists to take into consid- ▶ African Americans in Couple and Family
eration the intersectionality of Black male client’s Therapy
race, gender, and sexual orientation. As mentioned ▶ Black Women in Couples and Families
above, Black men experience their gender in unique ▶ Cultural Competency in Couple and Family
ways. Further, Black men who identify as gay, Therapy
bisexual, queer, or transgender may be navigating ▶ Cultural Values in Couples and Families
challenging gender norms and may experience dis- ▶ Culture in Couple and Family Therapy
crimination within the Black community.
Pertinent Clinical Issues References

In light of the literature delineated above, a critical
construct that has significant clinical implications Alexander, M. (2012). The new Jim Crow: Mass incarcer-
for working with couples and families is vulnerabil- ation in the age of colorblindness. New York: The New
Press.
ity. In fact, there is a glaring paradox when it comes Chambers, A. L. (2008). Premarital counseling with mid-
to vulnerability. As previously stated, Black men are dle class African Americans: The forgotten group. In
frequently given the message to not show vulnera- M. Rastogi & V. Thomas (Eds.), Multicultural couple
bility if you want to be successful in the world. therapy. Thousand Oaks: Sage.
Chambers, A. L., & Kravitz, A. (2011). Understanding the
Although minimizing vulnerabilities in certain con- disproportionately low marriage rate among African
texts can be helpful, the paradox is that trying to Americans: An amalgam of sociological and psycho-
manage and hide vulnerabilities in an intimate logical constraints. Family Relations, 60(5), 648–660.
Black Women in Couples and Families 285
Cowdery, R. S., Scarborough, N., Knudson-Martin, C., African American women. African American
Seshadri, G., Lewis, M. E., & Mahoney, A. R. (2009). women are women whose ancestors were brought
Gendered power in cultural contexts: Part II. Middle
class African American heterosexual couples with to the United States to be slaves. Many immi-
young children. Family Process, 48(1), 25–39. grants from Africa, Europe, and the Caribbean
Haynes, F. E. (2000). Gender and family ideals an explor- who have African ancestry do not identify as B
atory study of black middle-class Americans. Journal African American. However, the second and
of Family Issues, 21(7), 811–837.
Letiecq, B. L., & Koblinsky, S. A. (2004). Parenting in third generations of these immigrant families
violent neighborhoods African American fathers share often identify as African American and integrate
strategies for keeping children safe. Journal of Family into the larger Black American community.
Issues, 25(6), 715–734. Therefore, for the sake of inclusivity, the term
Livingston, J. N., & McAdoo, H. P. (2007). The roles of
African American fathers in the socialization of their Black is used in this entry. When assessing
children. In McAdoo (Ed.), Black families (4th ed.). Black clients, it is important to ask specifically
Thousand Oaks: Sage. how they identify in terms of race and ethnicity.
Smith, C. A., Krohn, M. D., Chu, R., & Best, O. (2005). Some prefer the term Black, while others prefer
African American fathers myths and realities about
their involvement with their firstborn children. Journal African American, and some will disclose their
of Family Issues, 26(7), 975–1001. immigrant heritage, which is critical background
Wester, S. R., Vogel, D. L., Wei, M., & McLain, R. (2006). information for your case conceptualization.
African American men, gender role conflict, and psy- Finally, as with all other populations, it is impor-
chological distress: The role of racial identity. Journal
of Counseling & Development, 84(4), 419–429. tant to remember that there is more variation
within the Black population than between Black
people as a whole and other racial groups. The
points highlighted in this entry are generalizations
and should be used as guides for further
Black Women in Couples assessment.
and Families
Adia Gooden Description

The University of Chicago, Chicago, IL, USA
Black women have a large number of strengths,
which are often overlooked and are important to
Synonyms highlight. Black women are often extremely resil-
ient. Black women attend college and graduate
African American Women school at high rates and often serve as matriarchs
for their families. Black women have a legacy of
figuring out how to feed, clothe, and keep their
Name of Family Form families together and healthy with limited
resources. While many Black women are faced
Black Women in Couples and Families with challenges related to racism, sexism, and
receiving lower pay and higher unemployment
than White women, they continue to work to
Introduction protect and provide for their families. Further,
Black women often take pride in their appearance
Black women in the United States are a unique and the appearance of their children. They may
population, and it is important to understand their have rituals of regularly going to get their hair
social, ecological, and historical experiences in styled and nails manicured; they may spend a lot
order to effectively support them in therapy. of time and energy making sure that their children
Here, the term Black reflects having some African look presentable. This is related in part to the
heritage; the primary focus of this entry will be on belief that if you present yourself well and you
286 Black Women in Couples and Families
look respectable, people will treat you better. This concerns are exacerbated by the fact that Black
comes from a legacy of being judged, discrimi- women often feel like they must take care of
nated against, and disregarded in the United States everyone else during difficult times and fre-
because of race and poverty. Black women tend to quently fail to care for themselves. Additionally,
step up and take responsibility when their families many Black women have experienced trauma in
are in need. In addition to caring for their own their lives. Black women’s symptoms related to
children, Black women often help to care for anxiety and depression may present differently
grandchildren, nieces, and nephews. Most Black and often go undetected. Specifically, Black
people have a communalism orientation, which women are more likely to have somatic
involves feeling responsible for loved ones and (physical) symptoms, engage in overeating, and
people in your community. spend too much time and money on physical
It is important to note that not all Black people appearance when experiencing depression and
are poor or come from low socioeconomic back- anxiety, which may be overlooked by mental
grounds. While rates of poverty are higher in health-care professionals (Jones and Shorter-
Black communities than in White communities, Gooden 2003). Further, Black women may con-
there are significant portions of Black people who tinue to function at high levels even when
were born into or have achieved upper- and experiencing significant symptoms of depression.
middle-class status. Therapists should assess and Overall, Black women are less likely to receive
consider socioeconomic status (SES) in their mental health treatment than White women. There
work with Black female clients. The intersections are a number of reasons for these disparities,
of race, gender, and SES influence Black women’s including lower access to affordable health care,
personal, professional, and family experiences. financial limitations, and a historically grounded
Black women are often religious – the majority mistrust of health-care professionals. There is a
are Christian – and many draw strength from their legacy in the United States of mistreating Black
religious and spiritual beliefs and their involve- people within the medical system, which has
ment in a church community. Churches often made it less likely for people from these commu-
serve as surrogate families for Black people. nities to seek help when they need it. Further,
Black women commonly engage in prayer as a research has demonstrated that when Black peo-
form of religious coping during times of chal- ple reach out to mental health professionals for
lenge. Additionally, when Black women and help, they are less likely to receive return phone
their families experience success, this will often calls or engage in therapy than their White,
be attributed to the grace of God and will be met middle-class counterparts (Kugelmass 2016).
with high levels of gratitude. While religion and
spirituality can serve as an important strength for
Black women, some conservative Christian tradi- Relevant Research About Family Life
tions may discourage mental health treatment and
assert that mental illness can be prayed away. This Black Women in Couples
can be a hindrance to Black women interested in Black women are less likely to be married than
seeking psychotherapy. White women. It is important to note that eventu-
As with any population, Black women also ally the majority of Black women do get married,
face challenges. Black women experience both but they tend to marry later in life than White
racism and sexism. These stressors, along with women (e.g., marriage in mid-to-late 30s
experiencing financial strain and limited access vs. mid-to-late 20s). Lower marriage rates
to health care, contribute to a host of medical among Black women are due to a number of
and psychological concerns that many Black factors. First, a combination of mass incarcera-
women have to navigate. Black women have tion, differences in gender birth rates, and high
higher rates of heart disease, cancer mortality, death rates for young Black men means there are
and HIV than White women. These health fewer Black men available for women to date and
Black Women in Couples and Families 287
marry. Additionally, financial insecurity may keep independent to being interdependent and vulner-
Black couples from getting married (Karney and able within a romantic relationship when a partner
Bradbury 2005). Heterosexual Black women are is available. Black women are socialized to be
often frustrated by their limited options for Black strong and encouraged to hold the paradoxical
male partners. Additionally, many Black women space of strength and sensitivity (Jones and B
want to have a Black family, not a mixed-race Shorter-Gooden 2003). Black women may
family, and therefore may be unwilling to date receive complaints from Black male partners
men from other races or ethnicities. Further, about being too outspoken and independent.
research has demonstrated that Black women are Black heterosexual couples tend to be egali-
often found to be least desirable and not tarian (Marks et al. 2008). This is due in part to
approached by men of other races or ethnicities the fact that in order to take care of financial and
for romantic relationships. This combination of family needs, it is important for both partners in
factors, along with the loyalty that many Black Black couples to be employed and to work
women feel to Black men, likely contributes to together inside of the home. Research has dem-
Black women being more likely to marry Black onstrated that partners in egalitarian relation-
men who are less educated and earn less money ships report higher levels of contentment; this
than them. Some Black women may experience is a strength for Black couples (Marks
feelings of anger, resentment, and disappointment et al. 2008). Despite this strength, the divorce
related to their relationships with Black men or the rate for Black marriages is higher than the
limited eligible Black men. Other Black women divorce rate for White marriages. Black couples
may stay in relationships with Black male partners contend with stressors related to racism, unem-
longer than is healthy or tolerate disrespectful or ployment, and finances. Additionally, while
insensitive behavior in part due to concerns about Black romantic relationships tend to be more
the “shortage” of eligible Black men to date. egalitarian, Black women may frequently put
Additionally, Black women who are partnered the needs of their partner and their children
may feel pulled to downplay their strengths and ahead of their own, at times neglecting their
successes to make Black male partners feel more own health and well-being. Black women may
comfortable. Overall, research has demonstrated overcompensate to support or fill in the gaps that
that difficulties in relationships with Black men their Black male partners will not or cannot fill
are one of the top concerns for Black women due to difficulties finding employment and
(Jones and Shorter-Gooden 2003). stress related to racial discrimination. Black
It is important to recognize that the legacy of women may over-function and be less likely to
disrupting Black families in slavery continued express their concerns to Black male partners
into the twentieth century through public housing because they empathize with the discrimination
policies that discouraged two-parent households their Black male partners experience outside of
and is ongoing with mass incarceration. These the home and do not want to add to that stress
factors have left many Black women as the (Jones and Shorter-Gooden 2003).
heads of their households and matriarchs. This It is important to note that some Black
necessarily influences romantic heterosexual rela- women are in same-sex relationships. The
tionships between Black men and women. Many dynamics in Black lesbian couples are similar
Black women have been raised to be self- in some respects to heterosexual relationships.
sufficient; the need to independently care for Black women in same-sex relationships may be
themselves and their families has been modeled more likely to value economic independence
by Black mothers and grandmothers. Addition- than Black women in heterosexual relation-
ally, a significant number of Black women have ships. Black women in same-sex couples are
children out of wedlock and experience periods of also likely to endorse egalitarian values related
single parenting. These factors can make it chal- to the division of household responsibilities
lenging for Black women to transition from being (Moore 2008).
288 Black Women in Couples and Families
Black Mothers strong, self-sufficient, and unbothered, which can

Being a mother is a significant and honorable role make it hard for them to express their concerns
for Black women. Black mothers often take on the (Watson and Hunter 2015). Therapists should be
role of primary caregiver for their children while patient with this process and gently help Black
working full time. Many Black grandmothers help female clients to feel more comfortable sharing
to raise their grandchildren or serve as primary more in therapy over time. Black people, includ-
caregivers when parents are unable to care for ing Black women, are often socialized to keep
their children. In addition to the common respon- personal matters private (e.g., “don’t air your
sibilities that mothers take on related to ensuring dirty laundry”) and may be hesitant to share per-
that their children are healthy and safe, Black sonal information with a therapist who is initially
mothers take on additional tasks to help prepare a stranger. As a show of respect, therapists should
their children to function successfully in a world begin by addressing their middle-aged and older
where Black people are often discriminated Black female clients using formal titles. Less for-
against. One key task of Black mothers is racial mality can be adopted if suggested by a client or if
socialization, which involves helping Black chil- the therapist receives approval from the client to
dren to feel positively about themselves and the use their first name.
Black community and helping them navigate the Black people tend to engage in what is
racism and discrimination Black people experi- referred to as high-context communication,
ence. Black mothers attempt to do this while also which means that nonverbal cues (e.g., tone,
preventing their children from having overly neg- volume, hand gestures) play a large role in com-
ative views of White people or mainstream soci- munication. Additionally, high-context commu-
ety (Nobles 2007). It is a difficult task that nication may rely on shared references
requires a delicate balance. Black mothers are including slang. Therapists should be aware of
intentional and thoughtful about how they social- potential differences in communication styles
ize their children in these ways. with their clients and leave room for their clients
Additionally, Black mothers may have a strict to communicate in a way that is most comfort-
parenting style (Black parents are more likely to able for them. Therapists are encouraged to ask
use the authoritarian style of parenting) and low for clarification if they do not understand what a
tolerance for talking back or resistance by their client is intending to express.
children. Teaching children that they cannot talk Black women tend to be very connected to
back and that they must contain their emotions their families and spend a lot of time and energy
and always follow the instructions of people in working to care for families, and therapists
authority is a way to help Black children protect should be thoughtful about engaging family
themselves when they are out in the world. Black members in therapy with Black women; this
mothers work to prepare their Black children for may include looking beyond the nuclear family
encounters with police who may be racist and to include extended family members. Addition-
violent. Black mothers often have understandable ally, when family members are not available to
anxieties about the safety and well-being of their participate in the therapy, therapists should con-
children. sider how familial relationships affect Black
women and address these interpersonal con-
cerns in individual therapy. Kelly and Boyd-
Special Considerations for Couple Franklin (2005) suggest therapists should use a
and Family Therapy systems therapy approach that involves doing
family therapy with one person if the entire
Black women may be apprehensive about engag- family is not willing or able to engage in
ing in therapy and often take a while to feel therapy.
comfortable and open up. This may be due in Therapists should also keep in mind that Black
part to Black women being socialized to appear women may not show symptoms of depression in
Blamer Stance in Couples and Families 289
expected ways. Therapists should do thorough Nobles, W. W. (2007). African American family life: An
evaluations and explore symptoms that might instrument of culture. In H. P. McAdoo (Ed.), Black
families (4th ed., pp. 69–79). Thousand Oaks: Sage.
not seem to be obvious manifestations of depres- Watson, N. N., & Hunter, C. D. (2015). Anxiety and
sion, such as somatic symptoms (Watson and depression among African American women: The
Hunter 2015). It is important for therapists to costs of strength and negative attitudes towards psy- B
acknowledge and take into account the external chological help-seeking. Cultural Diversity and Ethnic
Minority Psychology, 21(4), 604–612.
and potentially internalized negative stereotypes
that Black women face. Additionally, it is neces-
sary for therapists to make room for Black female
clients to process their experiences related to
microaggressions, racism, and sexism.
Blamer Stance in Couples and
Families
Forogh Rahim, Dara Winley, Elizabeth Adedokun

Cross-References and Jessica Chou
Therapy
▶ Black Men in Couples and Families Introduction
Therapy Blaming is not uncommon among clients and
▶ Cultural Values in Couples and Families therapists in the therapeutic setting (Paivinen
▶ Culture in Couple and Family Therapy et al. 2016).

References
Jones, C., & Shorter-Gooden, K. (2003). Shifting: The

The blamer stance has captured the attention of
double lives of Black women in America. New York: theoreticians and practitioners over the years and
Harper Collins. refers to the shifting of responsibility for conflict
Karney, B. R., & Bradbury, T. N. (2005). Contextual influ- that occurs in couple and family relationships.
ences on marriage implications for policy and interven-
From a communication perspective, blame can be
tion. Current Directions in Psychological Science,
14(4), 171–174. conveyed implicitly or explicitly; but regardless,
Kelly, S., & Boyd-Franklin, N. (2005). African American blame ascribes moral judgment from one person to
women in client, therapist, and supervisory relation- another (Paivinen et al. 2016).
ships: The parallel processes of race, culture, and fam-
ily. Voices of color: First-person accounts of ethnic
minority therapists. In M. Rastogi & E. Wieling Description
(Eds.), Voices of color: First-person accounts of ethnic
minority therapists (pp. 67–89). Thousand Oaks: Sage.
Kugelmass, H. (2016). “Sorry, I’m not accepting new
The blamer stance is seen as someone who behaves
patients” An audit study of access to mental health in a way that implies superiority while deflecting
care. Journal of Health and Social Behavior, 57(2), any faults or guilt onto another person (Carlson et al.
168–183. 2017). Someone taking the blamer stance may indi-
Marks, L. D., Hopkins, K., Chaney, C., Monroe, P. A.,
cate disapproval in attempts to influence or at least
Nesteruk, O., & Sasser, D. D. (2008). “Together, we are
strong”: A qualitative study of happy, enduring African to protect themselves from others (Bowen et al.
American marriages. Family Relations, 57(2), 2005). Those who are blamed might become defen-
172–185. sive and or lose motivation in therapy, while those
Moore, M. R. (2008). Gendered power relations among
who are not blamed may believe they are not
women: A study of household decision making in
Black, lesbian stepfamilies. American Sociological responsible for working toward conflict resolution
Review, 73(2), 335–356. (Sprenkle et al. 2009).
290 Blamer Stance in Couples and Families
Application of Concept in Couple and rooted in family of origin relationships. How-

Family Therapy ever, what gets communicated to Nina is his
anger and frustration rather than how Charles
Therapists play an active role in unpacking truly feels. Additionally, Charles and Nina’s
unmet needs to promote healthy communication experiences of the world may be different
(Goldenberg and Goldenberg 2012) that can based on their differences in various cultural
result in changing the blamer stance. It is impor- factors, such as race and gender. Nina lives
tant for the therapist to identify the blamer with identities that are marginal and may feel
stance and verbalize an understanding of the alone and misunderstood by Charles in this
underlying unmet needs of the person issuing regard. The therapist can work toward helping
blame in order to create a safe environment for this couple better understand their conflict as a
change. The blamer may feel “endangered and result of differing worldviews based on experi-
[react] by attacking in order to cover up feeling ences out in the real world. By attending to the
empty, unloved and unworthy” (Goldenberg underlying judgments, each individual may be
and Goldenberg 2012, p. 225). It then becomes more open to taking accountability for their part
the therapist’s goal to help the blamer take the in the conflict and also practice being more
risk of being congruent between what they are vulnerable with each other.
truly feeling and communicating. Furthermore,
blaming communication may have different
meanings across cultures. Therapists must prac-
tice from a culturally sensitive lens and model Cross-References
culturally appropriate communication in order
to reduce blame (Bermudez 2008). ▶ Fair Fighting in Couple Therapy
Clinical Example References
Charles and Nina are seeking couple therapy Bermudez, D. (2008). Adapting Virginia Satir techniques
related to increased arguments after moving to to Hispanic families. The Family Journal, 16(1),
51–57.
Philadelphia. Charles, a 23-year-old Caucasian Bowen, C., Stratton, P., & Madill, A. (2005). Psychological
male, and college graduate, is currently looking functioning in families that blame: from blaming events
for employment. Nina, a 22-year-old African to theory integration. Journal of Family Therapy, 27(4),
American female, also a recent graduate, is 309–329.
Carlson, M. W., Oed, M. M., & Bermudez, J. M. (2017).
now in graduate school. During session, Nina Satir’s communication stances and pursue–withdraw
begins by discussing the stress of starting school cycles: An enhanced emotionally focused therapy
and not having close friends and family nearby framework of couple interaction. Journal of Couple &
for support. Relationship Therapy, 16(3), 253–270.
Goldenberg, H., & Goldenberg, I. (2012). Family therapy:
Charles believes most of the fighting stems An overview. New York: Cengage Learning.
from Nina being more invested in her graduate Paivinen, H., Holma, J., Karvonen, A., Kykyri, V. P.,
program than the relationship. Charles describes Tsatsishvili, V., Kaartinen, J., Penttonen, M., &
that while he tries to make a concerted effort to Seikkula, J. (2016). Affective arousal during
blaming in couple therapy combining analyses of
prioritize their relationship, he feels that he is the verbal discourse and physiological responses in
only one working at it. two case studies. Contemporary Family Therapy,
The therapist may promote a systemic view 38, 373–384. https://doi.org/10.1007/s10591-016-
of the problem by bringing the couple’s atten- 9393-7.
tion to their relational and communication pat- Common factors in couple and family therapy: The
terns. Charles may be feeling abandoned by overlooked foundation for effective practice.
Nina, and this sense of abandonment may be New York: Guilford Press.
Blended Family 291
Stepfamilies take many forms: only one adult

Blended Family may bring children (“simple” stepfamily). Both
adults may bring children (“complex” stepfam-
Patricia L. Papernow ily). Adult stepcouples may be married or
Institute for Stepfamily Education, Hudson, (increasingly) unmarried cohabiting. Previous B
MA, USA parenting relationships may have ended with
divorce, death, or, in the case of unmarried
cohabiting partners, neither. Divorce rates have
Name of Family Form fallen in the USA, except over age 50 where the
rate doubled between 1990 and 2010 (Brown and
“Blended Family” Lin 2012). Thus, increasing numbers of new
stepcouples are over age 50, with adult children
and even grandchildren. All of these stepfamily
Synonyms forms face five major challenges to intimate rela-
tionships (Papernow 2013):
Stepfamily; “Remarried family”
1. Insider/outsider positions are intense and
stuck. Strong bonds of attachment, shared his-
Introduction tory, and shared values lie in parent-child rela-
tionships, not in step relationships. This
“Blended family” is a commonly used term for structure makes stepparents “stuck outsiders”
stepfamily. Although the phrase captures the to already-established powerful parent-child
human longing for closeness and oneness, it is (and ex-spouse) relationships. Parents become
misleading. Becoming a stepfamily proves to be “stuck insiders,” torn between their children’s
less like blending a smoothie and more like asking needs and their partners. Struggling
a group of Japanese and a group of Italians to live stepcouples can easily become increasingly
intimately together. “Remarried family” is often divided and disconnected. Clinicians must
used interchangeably with “stepfamily.” How- often help hold the intense affect this challenge
ever, many stepcouple marriages are a first mar- creates. Stepcouples often need help building
riage for one or both adults. Forty-two percent of empathy and understanding across their
Americans have a close step relationship (Pew insider/outsider divide.
Research Center 2011), making it critically impor- 2. Children struggle with losses, loyalty binds, and
tant that all clinicians develop a solid understand- change. Adults often describe stepchildren as
ing of stepfamily dynamics, the challenges they “manipulative,” “resistant,” or “splitting.” In
create, and evidence-based, evidence-informed fact, while a new relationship is a wonderful
strategies for meeting those challenges. gift for adults, children (even adult children)
often experience their stepfamily as yet another
set of losses (Cartwright 2008). Stepparents can
Description also engender loyalty binds: “if I care about my
stepmother/stepfather, I am disloyal to my
Stepfamilies differ fundamentally from first-time mom/dad.” Adults often want to move forward
families. In first-time families, children are born quickly. But, for many children, adjustment to a
into an already-established adult couple relation- new stepfamily is more difficult and takes longer
ship. They generally arrive hardwired for attach- than divorce. Stepfamily adjustment is easier for
ment to both of their parents, and vice versa. In a boys and children under eight and seems to be
stepfamily, at least one parent-child relationship harder for girls, especially preadolescent girls
precedes the adult couple relationship. Parent- (van Eeden-Moorefield and Pasley 2012). Clini-
child attachment excludes stepparents. cians often need to help stepcouples to prioritize
292 Blended Family
both parent-child relationships and the Relevant Research

stepcouple relationship, and to proceed much
more slowly. The unique challenges of stepfamilies first
3. Parenting tasks divide parents and steppar- received attention from clinicians (Papernow
ents. Research establishes that children do 1993; Visher and Visher 1979, 1996). No major
best in all family forms with “authoritative” clinical work appeared again until Browning and
parenting that is both loving (warm, respon- Artfelt (2012) and Papernow (2013). Despite the
sive) and moderately firm (setting develop- prevalence of this family form, and the need for
mentally appropriate expectations and evidence-informed clinical help, these remain the
monitoring behavior) (Bray 1992). When this only two clinical books available. Meanwhile the
challenge goes badly, stepparents move too research has exploded. (For excellent reviews of
quickly into a disciplinary role. Frustrated the research see: Ganong and Coleman 2017;
stepparents become increasingly harsh and Stewart 2007; van Eeden-Moorefield and Pasley
authoritarian; parents become increasingly 2012.)
protective and permissive. Neither serves chil- Family scholars agree: becoming a stepfamily
dren. Stepparents can often help parents to takes time, with estimates ranging from 3 to
“firm up,” and parents can help stepparents to 6 years for successful stabilization, and much
“soften up.” The research provides clear guide- longer in struggling stepfamilies. (For a summary
lines for meeting this challenge: parents need of these findings, see Papernow 2013,
to retain the disciplinary role until and unless pp. 162–166, 206–207.) Again, stepfamily adjust-
stepparents have formed caring trusting rela- ment is more difficult for children under 8, seems
tionships with stepchildren. Meanwhile, step- to be harder for girls, and is especially hard for
parents have input, and parents have final say preadolescent girls (van Eeden-Moorefield and
about their own children. Across many cul- Pasley 2012).
tures, authoritarian (harsh and cold) steppar- Parents need to retain the disciplinary role until
enting is toxic. (For citations and research or unless stepparents form caring and trusting
overview see: Ganong and Coleman 2017; relationships with their stepchildren (Bray 1999;
Papernow 2013, pp. 65–84, 200–201.) Ganong and Coleman 2017; Hetherington et al.
4. A new family culture must be forged in the 1998). Stepparents must begin by forging rela-
presence of already-established cultures. tionships with stepchildren, i.e., with “connection
Shared understandings about noise, mess, hol- not correction” (Papernow 2013). Authoritarian
iday rituals, money, etc., lie in parent-child (harsh and firm, not loving) parenting by steppar-
relationships, not step relationships. Differ- ents is particularly damaging to stepparent-
ences, large and small, often saturate daily stepchild relationships (Bray 1999; Ganong et al.
life. Struggling stepfamilies argue over right 2011; Hetherington et al. 1998), including, it
and wrong. Successful stepfamilies slowly appears, in cultures that accept authoritarian par-
build a new family culture while simulta- enting (e.g., Nozawa 2015).
neously respecting and honoring established The field has suffered from what Ganong and
family traditions, values, and habits. Coleman call a “deficit comparison” model that
5. Ex-spouses (other parents) are part of the fam- posits never-divorced families as “normal” and
ily. Children have another parent, dead or alive, stepfamilies as “deviant.” In the last few decades,
nourishing or abusive, outside the nuclear fam- the field has become more sophisticated. For
ily. Child well-being is highest with low paren- instance, early research found that children in step-
tal conflict, collaborative co-parenting, and families have slightly lower well-being scores.
when children feel securely connected to all However, although these findings are significant,
the adults in their lives (Ganong and Coleman effect sizes are small (Ganong and Coleman 2017).
2017; Grych and Fincham 2001; Papernow A meta-analytic review of the literature found a
2013, pp. 102–125, 202–204). great majority of stepchildren scoring in the normal
Blended Family 293
range of development (Jeynes 2007). Another (I) psychoeducational (information about what
meta-analytic review found 43 % of children in is normal, what works to meet stepfamily chal-
stepfamilies scoring higher than those in never lenges, and what does not), (II) interpersonal
divorced families (Amato 1994). Over the years, (building compassion and forging connection
as stepfamily scholarship has matured, it has in the face of divisive challenges), and (III) B
become clearer that differences in well-being are intrapsychic family-of-origin work (healing
due more to process variables, particularly parent- family-of-origin wounds that are intensifying
ing, conflict, and numbers of transitions, than to reactivity to stepfamily challenges).
family structure (Dunn 2002; Ganong and
Coleman 2017; Jeynes 2007).
Cross-References
Special Considerations for Couple and ▶ Bray, James

▶ Browning, Scott
Family Therapy
▶ Papernow, Patricia
It is vital for clinicians to understand that stepfam- ▶ Remarriage in Couple and Family Therapy
▶ Visher, Emily
ily structure places subsystems in competition
▶ Visher, John
with each other for secure connection. When par-
ents turn to their children, stepparents are left out.
When stepparents have the full attention of their
partners, children feel excluded. When the whole
References
family is together, parent-child subsystems easily
Amato, P. R. (1994). The implication of research findings
dominate, eclipsing stepparent-stepchild relation- on children in stepfamilies. In A. Booth & J. Dunn
ships. Stepfamilies do need time together to create (Eds.), Stepfamilies: Who benefits? Who does not?
a new family culture. However, stepfamilies also (pp. 81–88). Hillside: Lawrence Erlbaum.
Bray, J. (1992). Family relationships and children’s adjust-
need to meet their competing attachment needs by
ment in clinical and nonclinical stepfather families.
establishing regular reliable alone time for each Journal of Family Psychology, 6, 60–68.
subsystem: adult stepcouple, parent-child, and Bray, J. (1999). From marriage to remarriage and beyond:
stepparent-stepchild. Findings from the developmental issues in stepfamilies
research project. In E. M. Hetherington (Ed.), Coping
Likewise, these competing needs make “fam-
with divorce, single parenting, and remarriage. A risk
ily therapy” with a whole stepfamily inadvisable. and resiliency perspective (pp. 263–273). New York:
Clinicians must think systemically, but proceed in Lawrence Erlbaum.
subsystems (adult couple, parent-child relation- Brown, S. L., & Lin, I. (2012). The gray divorce revolu-
tion: Rising divorce among middle-aged and older
ship, sibling relationships, ex-spouse relation-
adults, 1990–2010. Journals of Gerontology: Series
ship), or with individual therapy firmly grounded B. Psychological Sciences and Social Sciences, 67,
in a systemic understanding of stepfamily dynam- 731–741.
ics. Stepparent-stepchild and whole-family thera- Browning, S. C., & Artfelt, E. (2012). Stepfamily therapy:
A 10-step clinical approach. Washington, DC: Ameri-
pies come after attachment needs are met in other
can Psychological Association.
subsystems (Browning and Artfelt 2012; Cartwright, C. (2008). Resident parent-child relationships
Papernow 2013). Parents do often ask for family in stepfamilies. In J. Pryor (Ed.), International hand-
or child therapy to “help children adjust.” How- book of stepfamilies (pp. 208–230). Hoboken: Wiley.
Dunn, J. (2002). The adjustment of children in stepfam-
ever, children are often helped most by helping the ilies: Lessons from community studies. Child and Ado-
adults to develop more realistic expectations, pro- lescent Mental Health, 7(4), 154–161.
viding psychoeducation about effective strategies Ganong, L., & Coleman, M. (2017). Stepfamily relation-
for meeting stepfamily challenges, and increasing ships: Development, dynamics, and interventions
(2nd ed.). New York: Springer.
parent-child attunement and alone time.
Ganong, L., Coleman, M., & Jamison, T. (2011). Patterns
It is helpful to conceptualize clinical work of stepparent – stepchild relationship development.
on three different levels (Papernow 2013): Journal of Marriage and Family, 73, 396–413.
294 Bloch, Donald
Grych, J. H., & Fincham, F. D. (Eds.). (2001). the Family where he served as Director, and his
Interparental conflict and child development: Theory, editorship of family therapy’s flagship journal,
research, and application. New York: Cambridge Uni-
versity Press. Family Process and Family Systems Medicine
Hetherington, E. M., Bridges, M., & Insabella, G. M. (Weiner 1996). Always tempered and collabora-
(1998). What matters, what does not? Five perspectives tive, Dr. Bloch is credited with creating a “big
on the association between marital transitions and chil- tent” under which constructive dialogue took
dren’s adjustment. American Psychologist, 53,
167–184. place among the many disparate voices of the
Jeynes, W. H. (2007). The impact of parental remarriage on pioneers of family therapy. The field of family
children: A meta-analysis. Marriage & Family Review, therapy that ultimately emerged from this dia-
40(4), 75–98. logue owes him a debt of gratitude. Dr. Bloch
Nozawa, S. (2015). Remarriage and stepfamilies. In S. R.
Quah (Ed.), The Routledge handbook of families in was born and raised in New York City in a
Asia (pp. 345–358). London: Routledge. second-generation Jewish immigrant family. He
Papernow, P. L. (1993). Becoming a stepfamily: Stages of was described by colleagues as being a very
development in remarried families. New York: Taylor funny, creative, and authentic human being; one
& Francis.
Papernow, P. L. (2013). Surviving and thriving in stepfam- of the original family therapists who saw the
ily relationships: What works and what doesn’t. importance of applying systemic approaches to
New York: Routledge. healthcare. He was trained as a psychoanalyst at
Pew Research Center. (2011). A portrait of stepfamilies. the Chestnut Lodge under the supervision of two
Washington, DC: Pew Research Center Social and
Demographic Trends. highly influential psychiatrists, Frieda Fromm-
Stewart, S. D. (2007). Brave new stepfamilies. Thousand Reichman and Harry Stack Sullivan. It was the
Oaks: Sage. Lodge’s understanding of psychosis in interper-
van Eeden-Moorefield, B., & Pasley, K. (2012). sonal terms that further swayed Bloch to a more
Remarriage and stepfamily life. In G. Petersen &
K. Bush (Eds.), Handbook of marriage and the family systemic approach to psychotherapy. According
(3rd ed., pp. 517–548). New York: Springer. to Dr. Bloch, aspects of the Lodge’s approach to
Visher, E. B., & Visher, J. (1979). Stepfamilies: A guide to treatment captured family healthcare in motion. In
working with stepparents and stepchildren. New York: the 1950s he abandoned psychoanalysis in favor
Taylor & Francis.
Visher, E. B., & Visher, J. (1996). Therapy with stepfam- of systems theory and eventually a family
ilies. New York: Brunner Mazel. approach to psychotherapy. Dr. Bloch died in
2014 at the age of 91 (Sluzki 2014; Seaburn
2015).
Bloch, Donald
Career
Diana J. Semmelhack
Midwestern University, Downers Grove, IL, USA In 1972 Donald Bloch became the Ackerman
Institute’s second director. He served in this role
until 1990. The world famous Ackerman Institute
Introduction for the Family was founded in 1960 by Dr. Nathan
W. Ackerman (Weiner 1996). Dr. Ackerman also
Donald Bloch was a psychiatrist who influenced trained as a psychoanalyst and abandoned this
the development of the field of family therapy approach after WWII and began treating families
primarily through his influential leadership posi- and groups. A group of families under his care
tions (Doherty 2015). This leadership touched started what was originally a very small not-for-
family therapy organizations such as the Ameri- profit institute that mushroomed into the
can Family Therapy Academy (AFTA) where he Ackerman Institute for the Family. Under Bloch’s
served as president, The Ackerman Institute for leadership, the institute inaugurated and expanded
Blow, Adrian John 295
its clinical training program, developed a large References

family therapy clinic housed in the Institute and
developed a series of research projects designed to Doherty, W. J. (2015). Don Bloch’s vision: A commentary.
Family Systems & Health, 2, 99.
study special populations, among them the
Peek, C. J. (2015). Don Bloch’s vision for collaborative
women’s project that included Peggy Papp, Olga family health care: Progress and next steps. Family B
Silverstein, Betty Carter, and Mariane Walters. Systems & Health, 2, 86–98.
Dr. Bloch’s interest in special populations is Seaburn, D. (2015). Donald A. Bloch, MD:
A remembrance. Family Systems, & Health, 1, 3–4.
highlighted by his first paper, “The Delinquent
Sluzki, C. (2014). In memoriam. www.iftafamilytherapy.
Integration,” which defined delinquency as an org/docs/DonBloch.pd
interpersonal pattern rather than an intrinsic Weiner, E. L. (1996). An interview with Donald A.
characteristic. Today, the Institute’s focus on devel- Block, MD. Families, Systems, & Health, 14, 95–14.
oping clinical projects to study difficult populations
continues to distinguish the Ackerman Institute
from others of its kind. During his tenure,
Dr. Bloch was instrumental in attracting many Blow, Adrian John
prominent family therapists to the Ackerman.
Dr. Bloch’s distinguished career is also marked Tim Welch
by editorship of Family Process (Peek 2015). He Human Development and Family Studies,
founded the journal, Family Systems Medicine, and Michigan State University, East Lansing,
had a critical role in the development of the Collab- MI, USA
orative Family Healthcare Association. The Associ-
ation focuses on advocacy of the fair distribution of
resources and listening to diverse voices in need of Name
mental healthcare. Dr. Bloch steadfastly drew his
systems expertise to help bridge the mind-body gap Adrian John Blow Ph.D. (b. 1965)
and pursue a more humane, egalitarian, and inter-
disciplinary view of healthcare.
Introduction
Contributions to the Profession Adrian Blow, Ph.D., has made significant contri-
butions to the field of Couple and Family Therapy
Dr. Bloch is a noted pioneer of the field of family (CFT) and is known for his work on common
therapy. He was not a prolific writer or the creator factors across CFT theories, resiliency processes
of one of the models of family therapy. Rather, he in military families, and infidelity in committed
was a wise man who brought thoughtfulness and relationships.
respect to a field still in its adolescence. He was
liked and admired and often sought to navigate
challenging situations. He was the recipient of Career
many awards commensurate with his contribu-
tions to the field of family therapy. Adrian Blow received his Ph.D. in Marriage and
Family Therapy from Purdue University in 1999.
He spent 6 years (1999–2005) as a faculty member
Cross-References at Saint Louis University in the department
of Counseling and Family Therapy, where he also
▶ Ackerman Institute for the Family served as department chair. In 2005, he joined
▶ Family Process (Journal) the faculty at Michigan State University in
296 Blow, Adrian John
the Human Development and Family Studies of the system (e.g., school teachers or medical
department where he is currently a full professor. professionals). The expanded therapeutic alliance
He has served as the program director for the Cou- consists of the alliance between the therapist and
ple and Family Therapy program since 2011 and the individual members of the family as well as
was associate chair of the department from 2015 to the alliance between various sub-systems in the
2018. He has been involved in several large feder- family. Finally, the interruption of sequences
ally funded grants related to military deployment occurs when family therapists interrupt negative
for over a decade. Blow’s research includes post- cycles in families and allow them to adopt more
deployment adjustment of National Guard couples, adaptive ways of relating to each other.
studies of interventions to boost resiliency, and Blow is also known for recognizing the vital
other family-based interventions. He has also role a therapist plays in treatment outcomes. In
published on the intersection of spirituality in writing about the relationship between common
women coping with breast cancer. In 2017, he factors, therapy models, and therapists, Blow
received the American Association for Marriage writes that therapy models are the vehicle through
and Family Therapy (AAMFT) training award. which common factors operate. In turn, a therapy
model works through a therapist. Thus, it is a
therapist who activates important change mecha-
Contributions to Profession nisms that affect therapy success. Blow contends
more research should examine how a therapist
Blow is well known for his contribution to effects treatment outcomes and what differentiates
research on common factors across theories of effective and ineffective therapists.
Couples and Family Therapy. In particular, Blow Blow is also well-regarded for his contribu-
(together with Doug Sprenkle) is well known for tions to infidelity in committed relationships. He
articulating a “moderate” common factors stance has written several journal articles and book chap-
in CFT theories. This approach contends there are ters on the topic and has presented at state and
few overall differences in treatment outcomes national conferences. Blow is also a nationally
among effective therapies. The approach leaves recognized expert on military families and has
room that in some circumstance, for some clients, numerous publications and presentations on resil-
one therapy model may be more well-suited than iency processes in military families as well as
another. His work argues that common change issues related to access and mental health treat-
elements found in diverse models of therapy and ment for military personnel.
the process of therapy itself accounts for a large
portion of why CFT works. Additionally, Blow
and colleagues have articulated four common fac- Cross-References
tors found in CFT models that are unique to
CFT: (a) relational conceptualization of the prob- ▶ Common Factors in Couple and Family
lem; (b) the expanded direct treatment system; Therapy
(c) the expanded therapeutic alliance; and ▶ Infidelity in Couples
(d) interruption of interactions. Relational concep- ▶ Military Families
tualization of problems sees human difficulties
through a relational lens: it contextualizes prob-
lems as occurring within a social network and References
keeps the whole system in mind even when
interacting with a part of the system. The Blow, A. J., & Hartnett, K. (2005a). Infidelity in committed
expanded direct treatment system refers to the relationships II: A substantive review. Journal of Mar-
ital and Family Therapy, 31, 217–234.
work of CFTs when they expand the focus of Blow, A. J., & Hartnett, K. (2005b). Infidelity in committed
treatment from the identified patient to other rele- relationships I: A methodological review. Journal of
vant members of the system, and to those outside Marital and Family Therapy, 31, 183–216.
Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy 297
Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who developed within these approaches, the authors
delivers the treatment more important than the treat- maintain that it is a useful tool for any therapist
ment itself? The role of the therapist in common factors.
Journal of Marital and Family Therapy, 33, 298–317. seeking to be mindful and planful with the process
Gorman, L., Blow, A. J., Ames, B., & Reed, P. (2011). of therapy.
National Guard families after combat: Mental health, B
use of mental health services, and perceived treatment
barriers. Psychiatric Services, 62, 28–34.
Sprenkle, D., & Blow, A. J. (2004). Common factors and Theoretical Framework
our sacred models. Journal of Marital and Family
Therapy, 30, 113–129. The blueprint for therapy is an essential compo-
nent of Integrative Systemic Therapy (hereafter
IST) and reflects its tenets. IST is a comprehensive
therapeutic perspective applicable to individual,
Blueprint for Therapy in couple, and family therapy and useful with most
Metaframeworks: any presenting problem. Although IST has gen-
Transcending the Models of eral utility in the field of psychotherapy, it is
Family Therapy currently most widely utilized by couple and fam-
ily therapists and family psychologists. IST is also
Nancy Burgoyne a basis for teaching systemic, integrative, and
The Family Institute at Northwestern University, empirically informed practice as well as a frame-
Evanston, IL, USA work for the lifelong learning and growth of psy-
chotherapists (Pinsof et al. 2017). IST is based on
two premises. The first is integration. The authors
Name of Strategy/Intervention believe that “the field of psychotherapy has to
move beyond specific models (empirically
Blueprint for Therapy supported or not) to a comprehensive and integra-
tive framework that simultaneously incorporates
and transcends those models” (Pinsof et al. 2017,
Introduction p. ix). This belief is linked to the quest for a
common factor approach (Sprenkle et al. 2009).
The blueprint for therapy is a schema that differ- The authors observe that “the movement toward a
entiates the moment-to-moment events that take comprehensive and integrative approach heralds
place in a psychotherapy encounter into a recur- the emergence of psychotherapy as a mature clin-
sive sequence of four elements: hypothesizing, ical science” (Pinsof et al. 2017, p. ix). The second
planning, conversing, and reading feedback. premise is based on systems theory. IST is
These elements define the essential decision- grounded within “the systemic beliefs and prac-
making and decision-evaluating process that tices that drove the creation and growth of the field
unfolds in a therapeutic exchange and serves as of family therapy” (Pinsof et al. 2017, p. ix). IST
an organizing tool for managing within and posits that all psychotherapy takes places within
between session planning (Breunlin et al. 2011). the biopsychosocial context that includes the indi-
The blueprint for therapy was first introduced vidual’s biology and experience of themselves,
by Breunlin, Schwartz, and Mac Kune-Karrer in multiple relationships, community(ies), and the
Metaframeworks: Transcending the Models of larger society. To consider an individual and
Family Therapy (1992). It was later woven into their problems apart from these layers of context,
Integrative Problem Centered Metaframeworks while appealing in its simplicity, leads a therapist
(Russell et al. 2016; Breunlin et al. 2011; Pinsof to incomplete and potentially pathologizing
et al. 2011). It has been most recently and fully hypotheses. The systemic, integrative approach
elaborated in Integrative Systemic Therapy of IST, within which the blueprint for therapy is
(Pinsof et al. 2017). Although the blueprint was nested, provides a framework for simultaneously
298 Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy
embracing the individual and their context (Pinsof integrating intervention strategies from a variety
et al. 2017; Russell et al. 2016). of models and the basis for the incorporation of
The blueprint is an expression of several of feedback, including empirical feedback, into the
IST’s theoretical pillars and therapy guidelines. work” (Pinsof et al., p. 82).
First, IST’s position that humans can progres-
sively know reality, but can never fully know it,
supports the idea of hypothesizing (vs. knowing) Description of Strategy or Intervention
and testing hypotheses in the blueprint. Second,
IST’s emphasis on collaboration and the therapeu- The blueprint, including its four recursive ele-
tic alliance establishes the importance of client ments (hypothesizing, planning, conversing, and
feedback as a primary factor in hypothesizing. feedback), is most effectively and usefully
Third, the blueprint is IST’s schema for integrat- portrayed graphically as in Fig. 1. The arrows of
ing concepts and interventions and helping the the diagram depict both the directionality and the
therapist and clients determine what to do when recursiveness of the process.
what they are doing is not working (Pinsof This visual allows the therapist to see the recur-
et al. 2017). sive pattern that drives the therapeutic encounter
and the opportunities the therapist has for focus-
ing on any one component in order to make deci-
Rationale for Strategy or Intervention sions about their own behavior and/or assess the
impact of the current therapeutic strategy. Impor-
The blueprint for therapy guides a therapist’s tantly, the blueprint components also function to
decision-making, facilitates evaluation of the contain and organize the knowledge and skills a
effects of treatment, and provides the basis for therapist needs to conduct the aspects of therapy
the clinical–scientific method of integrative psy- associated with that component. The bodies of
chotherapy (Breunlin et al. 2011; Pinsof et al. knowledge associated with each component of
2011). The tool breaks down what a therapist the blueprint are beyond the scope of this entry
does (or is well advised to do) into clearly identi- but can be found in Pinsof et al. (2017).
fiable steps. This heuristic ensures that therapists Hypothesizing is a feedback-informed process
are intentional and collaborative about what they of understanding the client(s) dilemma(s) and
are thinking and doing at each juncture. In the reflects all or part of the therapist’s current formu-
context of training and professional development, lation of the case. The therapist and client(s) seek
the blueprint provides a means to evaluate thera- explanations for both the presenting problem and
pists’ skills and choices, as well as the progress of various events and processes that occur within the
a given course of treatment. therapy (Breunlin et al. 2011). The blueprint
The blueprint is a process for deciding how to guides the therapist to select a working hypothesis
accomplish any and all of the problem-solving from a vast field of potential explanations (in IST
and relational tasks of therapy. In addition to
providing a map for decision-making, the blue-
(Hypothesizing) H C (Conversing)
print is a tool for treatment planning, as well as a
vital resource for reflection and course correction.
“It has utility on a moment-to-moment basis
within sessions (micro level of therapy) and
between sessions as a means of planning therapy
(macro level of therapy). In a sense, each therapy
is a single case study in which the blueprint is (Planning) P F (Feedback)
continuously used to intervene and correct the
Blueprint for Therapy in Metaframeworks: Trans-
course until the presenting problems are solved. cending the Models of Family Therapy,
Significantly, the blueprint logic is the tool for Fig. 1 Blueprint for therapy
Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy 299
these are called “hypothesizing metaframe- Case Example

works”) that focuses exclusively on one or more
constraints that block the client from accessing The following example illustrates the blueprint in
their strengths and resources in order to resolve motion.
the presenting problem. When clients have diffi- A single father and his three children ages 8, 7, B
culty in the therapy, this feedback prompts further and 5 attend a third session. The father is seeking
collaborative hypothesizing progressively reveal- help “getting my kids to behave.” For the third
ing the factors that prevent change (Breunlin et al. week in a row, the children are poorly organized
2011; Pinsof et al. 2017). and fight with one another, and the therapist is
Planning happens both within and between unable to engage the family in a useful way. The
sessions and reflects the therapist’s intentional therapist observes (reads the feedback) that the
decision-making about where and how to focus father is agitated and seemingly preoccupied, the
the treatment. Planning is driven by the hypothe- children alternate between bidding for the father’s
sis at play. A therapist must choose strategies to attention and acting out, and the therapist feels
employ to influence the change process (e.g., helpless and is over-functioning in the session.
action-based strategies, meaning- or emotion- The therapist discusses the case with her supervi-
based, biobehavioral, or intrapsychic strategies). sion team. The team observes that there is a lack of
In IST, these strategies are organized into plan- effective leadership in the family and that the
ning metaframeworks. Planning is intended to therapist is undermining the father by stepping
move the change process forward and to create into that void (hypothesizing). The group wonders
and maintain a therapeutic alliance (Pinsof et al. (expanding the hypothesis) what keeps the father
2011, 2017). from being a leader to his children. The orgy of
Conversing refers to the conversations through ideas that is typical of hypothesizing extends deep
which plans are developed and explored. Conver- into the father’s history and wide into the commu-
sation is a collaborative process where the thera- nity within which the family resides. The team
pist and client exchange information, develop an decides the most useful hypothesis to pursue first
understanding of the client(s)’ concerns, manage is the one that seems most directly related to the
and advance the therapeutic alliance, and formu- reason the family is seeking help – reorganize the
late a course of action (Pinsof et al. 2017). Con- system to support the father in the hierarchy.
versation is the vehicle through which Given the age of the children, the team decides
interventions are typically delivered in therapy. the therapist should use play (planning). The
Lastly, feedback involves careful attending to therapist reconvenes the family and creates an
clients’ verbal and nonverbal communication and enactment that utilizes a part of the presenting
the therapist’s intrapsychic experience. “The ther- problem (the children’s behavior on the school
apist tracks the content and themes of conversa- bus) as raw material. The therapist invites the
tion, observable behavior and interaction, reports family to “play school bus” (conversing) and
of actions and interactions, empirical data regard- assigned the father the role of the driver. The
ing progress in therapy, and her or his internal therapist enters and exits the scene (reads feed-
(emotional) reactions” (Pinsof et al. 2017, p. 81). back, hypothesizes, recommits to the plan) and
Feedback informs the therapist on every level, playfully encourages the father (conversing) to
including the strength of the alliance, the clients’ “run the bus the way he thinks it should be run.”
responsiveness to the treatment plan, the reso- The family enjoys the activity and both the
nance of the hypotheses being pursued, the suc- father and therapist appear buoyed (feedback).
cess of specific interventions, and the therapist’s Based on the feedback, the therapist maintains
use of self. Feedback provides the therapist with the treatment strategy (plan) over a series of
data to confirm or revise hypotheses and modify sessions and varies the in-session and between-
plans or specific conversational elements as session work to allow the father and children to
needed. settle into their new structure.
300 Bonds in Couple and Family Therapy
Several months into the therapy, the therapist Cross-References

observes (feedback) that the family lacks energy
and the father appears withdrawn. The therapist ▶ Breunlin, Douglas C.
scans her knowledge of the family (hypothesizing) ▶ Chambers, Anthony
for a possible explanation for the current distress. ▶ Integrative Problem-Centered Metaframeworks
The therapist has a hypothesis about loss (based on ▶ Integrative Systemic Therapy
the prior hypothesizing session with her supervision ▶ Lebow, Jay L.
team) but does not have a clear understanding of the ▶ Pinsof, William M.
affect in the room, though she feels sadness ▶ Rampage, Cheryl
(intrapsychic feedback) and so decides (planning) ▶ Russell, William P.
to ask the family about it by describing the behaviors ▶ Web of Human Experience in Couple and
that she sees: “I notice that no one is smiling today Family Therapy
and that Dad is looking at his hands. What do you
see?” With this question, the therapist invites the
family to share (conversing) their current experi- References
ence. The therapist observes (feedback) that the
father struggles to communicate and that the middle Breunlin, D. C., Pinsof, W. M., Russell, W. P., & Lebow,
J. L. (2011). Integrative problem centered
and youngest children begin to fight. The therapist
Metaframeworks (IPCM) therapy I: Core
thinks (hypothesizing) that the children are concepts and hypothesizing. Family Process, 50(3),
attempting to distract the father from his distress 293–313.
and determines (planning) that the children need Pinsof, W. M., Breunlin, D. C., Russell, W. P., & Lebow,
J. L. (2011). Integrative problem centered meta-
an outlet for their discomfort that does not under-
frameworks (IPCM) therapy II: Planning,
mine the father’s leadership. The therapist asks the conversing and reading feedback. Family Process,
father (conversing) to give his children the paper 50(3), 314–336.
and crayons on an adjacent table to draw a picture of Pinsof, W., Breunlin, D. C., Russell, W. P., Lebow, J.,
Rampage, C., & Chambers, A. (2017). Integrative sys-
the family. The children draw pictures, one that
temic therapy. Washington, DC: APA Books, American
includes the absent mother and one that does not Psychological Association.
(feedback). This leads the therapist to develop a Russell, W. P., Pinsof, W., Breunlin, D. C., & Lebow,
hypothesis regarding the family’s loss and chooses J. (2016). Integrative problem centered meta-
frameworks (IPCM) therapy. In T. L. Sexton &
to support the family (plan) to discuss their grief
J. Lebow (Eds.), Handbook of family
(conversing) over the missing mother and wife. therapy (4th ed., pp. 530–544). New York:
This ongoing and continually evolving thera- Routledge.
peutic process invites client participation and wel- Sprenkle, D., Davis, S., & Lebow, J. L. (2009). Common
factors in couple and family therapy: The overlooked
comes expansion and/or course correction as
foundation for effective practice. New York: Guilford
therapist and clients collaboratively address the Press.
layers of constraint that maintain the presenting
problem (Pinsof et al. 2017). In this example, the
family was constrained in at least two ways, by the
father’s difficulty in providing leadership to his Bonds in Couple and Family
children and by the family’s shared grief over the Therapy
loss of the absent mother and wife. The undeni-
able interaction between these variables was most Andrew S. Brimhall and David M. Haralson
effectively addressed by the strategy of pursuing East Carolina University, Greenville, NC, USA
one hypothesis at a time through the blueprint up
until the juncture at which additional constraints
were revealed. The blueprint for therapy provided Name of Concept
the structure necessary to both understand and
guide the process. Bond
Bonds in Couple and Family Therapy 301
Synonyms Description
Alliance; Attachment; Link; Tie As individuals age, attachment bonds are transferred
from primary caregivers to pair bonds; romantic
partners who replace the asymmetrical bonds devel- B
Introduction oped between parents and children with symmetri-
cal bonds that are mutual. Several methods have
Bond is an emotional attachment between one or been developed to help determine the quality of
more individuals. To be considered an attachment these bonds, both parent child and romantic partners
bond, the relationship must have four defining (Farnfield and Holmes 2014). The original measure-
characteristics: proximity maintenance, separa- ment of mother-child attachment was coined the
tion distress, safe haven, and secure base. Rela- strange situation which observed the reactions of
tionships may have some of these characteristics young children when their mothers left the room
(referred to as affiliative bonds) but to be classified and returned and when the children confronted
as an attachment bond, all four must be present. someone unknown. Responses to these events help
determine how they deal with the four major dimen-
sions (i.e., proximity maintenance, separation dis-
Theoretical Context for Concept tress, safe haven, and secure base). The most
extensive assessment for adults is the adult attach-
Psychologist John Bowlby (1958) was one of the ment interview (AAI).
first to formally study the concept of an attach-
ment bond. According to Bowlby, children
instinctively form emotional attachments to Application of Concept in Couple and
their caregivers in order to obtain a sense of Family Therapy
safety. Other theorists have built upon Bowlby’s
original ideas by distinguishing between differ- The term “emotional bond” is a hallmark of emo-
ent attachment styles and by applying attachment tionally focused therapy where emphasis is placed
bonds to adult and professional relationships on healing emotional wounds and on restoring the
(i.e., romantic relationships and therapist-client attachment bond between one or more family mem-
alliance) (Cassidy and Shaver 2008; Davis et al. bers (Johnson 2004). When working with parents
2012). According to these theorists, both chil- and children, therapists work to help parents main-
dren and adults form one of four attachment tain an active presence where they consistently rein-
styles: secure, anxious, avoidant, and disorga- force that the child is lovable and that the world is
nized attachment (Bartholomew and Horowitz safe. When working with romantic partners, Susan
1991). Individuals with an anxious or preoccu- Johnson developed the A.R.E model to help part-
pied attachment become demanding of their partners become more accessible, responsive, and
ner or caregiver’s time and attention, while engaged three hallmarks of secure attachment.
individuals with an avoidant attachment seek Other therapy models also work with emotional
distance. Those with a disorganized attachment injuries, and couples and families try to restore
style often feel paralyzed, wanting to be close, trust when these bonds have been damaged.
and yet fearing rejection. According to Bowlby, In cases where attachments have been dam-
as children navigate the world around them, they aged, therapists can often serve as temporary
begin forming internal working models – a cog- attachment figures; people who help reestablish
nitive map which associates certain people or safety and reinforce the message the client are
scenarios as either being safe or dangerous. valuable. Perhaps for this reason, common factor
These internal working models form the basis literature emphasizes the importance of the thera-
of how individuals interact in future relationships peutic alliance and list it as the most instrumental
(Hazan and Shaver 1987). in creating change.
302 Borcsa, Maria
Clinical Example Cross-References
Charles and JoAnn came into therapy because of ▶ Adult Attachment Interview
“communication problems.” JoAnn complained ▶ Attachment-Based Family Therapy
that Charles often “shut down” and refused to ▶ Attachment Disorders in Couple and Family
talk about difficult subjects. JoAnn explained Therapy
that it felt painful for her when he refused to ▶ Attachment Theory
speak, reporting that the silence reminded her of ▶ Circle of Security: “Understanding Attachment
her father who never showed her enough affec- in Couples and Families”
tion. She recalled that she often tried to get her
father’s attention, but that he seemed “too busy”
with work or other obligations. Charles
References
explained that growing up, he often felt like he
was never “good enough,” that he was often Bartholomew, K., & Horowitz, L. M. (1991). Attachment
criticized in front of others, and that he never styles among young adults: A test of a four category
felt safe enough to express his true feelings. model. Journal of Personality and Social Psychology,
Charles explained that he coped with this rejec- 61, 226–244.
Bowlby, J. (1958). The nature of the child’s tie to his
tion by emotionally distancing himself from mother. International Journal of Psychoanalysis, 39,
others and “shutting down.” 350–373.
In this scenario, JoAnn began forming an Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of
internal working model that others were attachment theory: Theory, research, and clinical
applications. New York: Guilford Press.
unavailable and unsafe, a model originally Davis, S. D., Lebow, J. L., & Sprenkle, D. H. (2012).
developed through her experiences with her Common factors of change in couple therapy. Behavior
father. Charles, on the other hand, began Therapy, 43(1), 36–48. https://doi.org/10.1016/j.
forming an internal working model that told beth.2011.01.009.
Farnfield, S., & Holmes, P. (2014). The routledge hand-
him it was not safe to express emotions or to book of attachment: Assessment. London: Routledge.
look weak, especially in front of others. His way Hazan, C., & Shaver, P. (1987). Romantic love conceptu-
of dealing with these messages was to internal- alized as an attachment process. Journal of
ize his feelings and distance himself. Because of Personality and Social Psychology, 52(3), 511–524.
Johnson, S. M. (2004). The practice of emotionally focused
these internal working models, both of these couple therapy: Creating connection (2nd ed.).
individuals have formed insecure attachment New York: Brunner-Routledge.
styles – Charles leaning toward avoidance and
JoAnn toward anxious. Both of these models
interfere with their ability to form a secure
attachment bond. A therapist working from an
emotionally focused stance may serve as a tem- Borcsa, Maria
porary attachment figure and help model avail-
ability and safety, thus strengthening the Valeria Pomini
therapist-client bond (Davis et al. 2012). This First Department of Psychiatry, National and
modeling helps provide each client the strength Kapodistrian University of Athens, Athens,
necessary to take that risk with their partner. Greece
Specifically, work with Charles would focus on
helping him become vulnerable and vocalizing
his need for JoAnn while also working with Name
JoAnn to understand that she is loved by
Charles and his attempts to shut down are not a Maria Borcsa, PhD, Dipl.-Psych., Professor of
reflection of his love for her but rather a way to Clinical Psychology (b. 1967), University of
protect himself. Applied Sciences Nordhausen, Germany
Borcsa, Maria 303
Introduction During the 1990s, she completed her training

in CBT (University of Freiburg) and in Systemic
Maria Borcsa is a brilliant representative of the Individual and Family Therapy with a special
“fourth generation” of systemic couple and family focus on multicultural systems as well as a further
psychotherapists in Europe. By promoting a truly training in Systemic Supervision and Counselling B
European, trans-national perspective, bridging the for Institutions (IF Weinheim). She holds a Ger-
Eastern and Western European cultures, the man state license as Psychological Psychothera-
Southern and the Northern, she shows a unique pist and a certificate of the European Association
capacity in creating synergies among international of Psychotherapy (EAP).
organizations and their members. She excelled as Maria Borcsa’s clinical experience developed
President of the European Family Therapy Asso- mainly at the Outpatient Department for Clinical
ciation (EFTA) from 2013 to 2016. During this and Rehabilitation Psychology at Freiburg
time, she increased among other things, the scien- University. She has been acting as psychotherapist
tific production of the association by founding the in private practice (both CBT and systemic ther-
Springer EFTA Book Series, of which she is apy) and as supervisor in different clinical and
co-editor. Her personal academic activities focus training institutions. As a trainer, she is renowned
on qualitative research in the field of systemic internationally.
couple and family therapy, with a special interest
in multicultural and transnational couples/families
as well as the change in relational life through the Contributions to Profession
usage of digital technologies.
Professor Borcsa’s work focuses on transcultural
aspects in the life of individuals, couples, families,
Career and larger systems, with her special interest in this
topic enriched by her personal history and expe-
Maria Borcsa was born in Romania into a Hungar- rience. “Globalized families” are transnational
ian family and grew up in Germany; she speaks families maintaining family ties across different
German, English, French, and Hungarian. She stud- countries and languages, the strengthening of their
ied Psychology, Philosophy, and Sociology at the bonds often facilitated by the use of Information
Universities of Mainz, Freiburg i. Br. (Germany) Communication Technologies (ICTs) (Borcsa and
and Strasbourg (France). In Freiburg, she con- Hille 2016). She is particularly interested in the
cluded her PhD (2001) in a research project on influence of ICTs on family relationships as well
identities/alterities with a dissertation on blind-born as their utilization in couple and family therapy,
persons belonging to three different generations. training, and supervision, touching upon ethical
Subsequently, she continued her academic career and deontological issues.
at the University of Wales, Bangor, UK. In 2004, Professor Borcsa has contributed to the appli-
she joined Nordhausen University of Applied Sci- cation of qualitative methods to couple and family
ences, Health Care and Social Studies program, therapy, bringing research closer to the complex-
Department of Business and Social Sciences, ity of clinical practice (Borcsa and Rober 2016;
where she is Professor of Clinical Psychology, act- Ochs et al. 2019, in prep). More specifically, she
ing as Dean of the Department (2008–2013). She is introduced Objective Hermeneutics as an investi-
a co-founder and board member of the Institute for gating method aiming at identifying – through the
Social Medicine, Rehabilitation Sciences and microanalysis of therapy transcripts – “latent
Healthcare Research, and founder of the interdisci- meaning structures” that people are not aware of
plinary course Systemic Counseling (Master of in their communication. This method serves to
Arts), a cooperation between Nordhausen Univer- reconstruct the specificity of a single clinical
sity and a long-established private institute case, while dialectically revealing general social
(IF Weinheim) – the first of its kind in Germany. configurations. Through this process, the
304 Borderline Personality Disorder in Couple and Family Therapy
researcher/clinician may help the family/couple References

towards a second-order change, by altering the
rules of their structures in addition to their inter- Borcsa, M., & Hille, J. (2016). Virtual relations and
globalized families – The Genogram 4.0 Interview.
actional patterns.
In M. Borcsa & P. Stratton (Eds.), Origins and origi-
The societal domain of human interactions nality in family therapy and systemic practice
remains one of Maria Borcsa’s main concerns: (pp. 215–234). Cham: Springer.
how couple and family therapists can act system- Borcsa, M., & Nikendei, C. (Eds.). (2017). Psychotherapie
nach Flucht und Vertreibung. Eine praxisorientierte
ically at different levels, as therapists-citizens,
und interprofessionelle Perspektive auf die Hilfe für
facing difficult issues like conflicts, migration, Flüchtlinge. Stuttgart: Thieme.
and poverty prevalent in our post-modern socie- Borcsa, M., & Rober, P. (Eds.). (2016). Research perspec-
ties, becoming facilitators of change, and promot- tives in couple therapy. Discursive qualitative methods.
Cham: Springer.
ing the Aristotelian logos, ethos, and techne
Borcsa, M., & Stratton, P. (Eds.). (2016). Origins and
within the globalized polis. originality in family therapy and systemic practice
Professor Borcsa has been an organizer of sci- (EFTA book series, Vol. 1). Cham: Springer.
entific conferences (e.g., EFTA, Athens 2016; Ochs, M., Borcsa, M., & Schweitzer, J. (Eds.). (2019, in
prep.). Linking systemic research and practice – inno-
QRMH7 – Qualitative Research in Mental Health,
vations in paradigms, strategies and methods (EFTA
Berlin 2018) and developed an extensive editorial book series, Vol. 4). Cham: Springer.
activity that includes being founder and co-editor
of the EFTA Book Series (Springer International),
associate editor of the Encyclopedia of Couple
and Family Therapy (Springer International),
co-editor of Psychotherapie im Dialog (Thieme Borderline Personality
Germany), and co-editor of the Austrian-German Disorder in Couple and Family
Journal Systeme. She serves on the Editorial Therapy
Boards of Testing, Psychometrics, Methodology
in Applied Psychology, Contemporary Family Alan E. Fruzzetti1 and Alexandra King2
1
Therapy, and Family Process. Department of Psychiatry, McLean Hospital/
Her intense professional participation at both Harvard Medical School, Belmont, MA, USA
national and European levels includes being a
2
University of Nevada – Reno, Reno, NV, USA
board member (2005–2011) of Systemische
Gesellschaft (German Association for Systemic
Research, Therapy, Supervision, and Counsel- Introduction
ling) and a board member of EFTA
(2007–2016), as well as Chair of the Chamber of Borderline personality disorder (BPD) is a perni-
National Family Therapy Organizations (NFTO) cious disorder in which the vast majority of people
of EFTA (2010–2013) and President of EFTA struggle with painful emotions and a consequent
(2013–2016). She is Honorary Member of the lack of self-control related to trying to escape
Hellenic Systemic Thinking & Family Therapy from, or alleviate, those emotions, resulting in
Association (HESTAFTA). nearly 10% lifetime suicide rate and a self-harm
rate upward of 80–90%. BPD is characterized
by pervasive instability across multiple domains:
Cross-References affect/emotion, social and interpersonal function-
ing, identity/self-image, cognition/problem solv-
▶ Conversation and Discourse Analysis in ing, and overt behavior control (Gunderson et al.
Couple and Family Therapy 2018). However, although pervasive emotion
▶ Couple and Family Therapy in the Digital Era dysregulation is at the core of BPD, transactions
▶ European Family Therapy Association within the individual’s social and family context
▶ Systeme (Journal) are essential for the development, maintenance,
Borderline Personality Disorder in Couple and Family Therapy 305
and remediation of problems related to severe have a variety of temperamental vulnerabilities

and chronic emotion dysregulation. Emotion that affect their emotions, including emotion sen-
dysregulation occurs when a person is unable to sitivity (they discriminate or pick up on emotional
accept or change different components of the cues that others frequently miss) and emotion
emotion process and thus experiences enough reactivity (they have strong reactions when their B
distress, due to high negative emotional arousal, emotions are triggered), and once emotionally
that it interferes with effective self-management activated, that person may take a long time to
and the person’s ability to organize behavior to return to emotional baseline (cf. Linehan 1993).
support long-term goals (Fruzzetti et al. 2008). Additional vulnerabilities may be transient, but
This includes lacking the skills needed, or using important, such as not having enough sleep,
maladaptive strategies, to regulate emotional being hungry, or having physical pain, as well as
responses and/or manage painful emotions the person’s current baseline emotional arousal.
(Kring and Sloan 2010; Neacsiu et al. 2013), and Then, when an event occurs, high vulnerabilities
most often occurs in a social or family context increase the frequency, intensity, and duration of
(Fruzzetti and Iverson 2006). It is easy for parents, emotional reactions. In addition, the person may
partners, and other family members to misunder- become judgmental (about the event, another per-
stand the experiences that people with BPD have, son, or him/herself), which also increases emotion
frequently invalidating their family member and intensity. When emotional arousal becomes suffi-
often exacerbating his or her emotional distress. In ciently high, it may change into a secondary emo-
addition, about 10% of all outpatients meet full tion, either through conditioning or judgmental
criteria for BPD (many more have significant thought processes. For example, if one partner
BPD features), and parents and partners of people (Aldus) is late coming home, the other partner
with BPD and related problems frequently strug- (Emelia) might understandably be worried
gle with their loved ones’ suicidality and self- (perhaps something bad happened) and disap-
harm, as well as their intense emotions. pointed (she was looking forward to seeing
Consequently, both people with BPD and their Aldus). However, if she becomes judgmental in
parents, partners, and family members need help, her thinking (e.g., “he’s an insensitive jerk”), her
and couple and family therapy specialized for emotion can quickly morph into something very
their needs can be very effective. different (in this case, anger, as a secondary emo-
tion). Once secondary emotions arise, people have
difficulty modulating them and begin to express
Theoretical Framework their emotion inaccurately (e.g., blaming, judg-
ing), making it difficult for others to understand.
Severe and pervasive emotion dysregulation is External process: Accurate expression is easy
commonly understood to develop in a transaction to understand. It is descriptive, expresses under-
between an individual’s vulnerabilities and an standable primary emotions, connects the relevant
invalidating family and social environment event to the person’s primary emotion, and puts
(Fruzzetti et al. 2005; Grove and Crowell 2017; relatively fewer demands on the other person.
Linehan 1993). These ongoing transactions have However, when people express secondary emo-
both an internal process and an interpersonal com- tions, others cannot immediately understand them
ponent (see Fig. 1). because secondary emotions are not integrally
Internal process: Every emotional reaction connected to whatever happened. Consequently,
begins with an event of some kind (internal, others are likely to invalidate the person’s experi-
such as a memory or thought, or external, such ence. Of course, in some families invalidating
as the behavior of another person), and this initial responses are common even when a child or part-
emotional reaction is a primary emotion, which ner expresses himself/herself accurately. Evi-
is both universal and adaptive (Greenberg and dence is clear that being validated actually
Safron 1989). Those who develop BPD may soothes emotional arousal and facilitates
Borderline Personality
Emotion Vulnerabilities Pervasive History of
Disorder in Couple and
Family Therapy, Invalidating Responses
Fig. 1 Transactional
Event
model for emotion
dysregulation
Judgments
Heightened Emotional Arousal

(leading to emotion dysregulation)
Dysregulated
Inaccurate Expression
Actions
Invalidating Responses
(From Others & Yourself)
cooperation, while, conversely, being invalidated responsible for the development and maintenance
results in sustained or exacerbated negative emo- of BPD, these kinds of transactions are also
tional arousal and less cooperation (cf. Edlund extremely common in more ordinary distressed
et al. 2015; Shenk and Fruzzetti 2011). Thus, a couples and families. In fact, most of the problems
pervasively invalidating family and/or social in communication in conflictual or chaotic fami-
environment makes a very significant contribu- lies can be understood easily within this frame-
tion to chronic emotion dysregulation, the core work. Because of this transactional pattern, along
of BPD. with high emotional reactivity, not only can there
Although psychotherapy can be effective at be colossal misunderstanding and conflict in these
helping people with BPD learn to modulate and families, but in-session behavior can sometimes
regulate their emotions, couple and family therapy be difficult to manage. We will break these inter-
and family skills have been shown to be an effec- ventions down into two separate sets: (1) the skills
tive adjunctive component for BPD, addressing that parents and partners need to learn and (2) spe-
the two key steps highlighted above: accurate cific intervention strategies used in couple or fam-
expression and validating responses to replace ily therapy with BPD. For couples, more details
inaccurate expression and invalidating responses may be found in Fruzzetti (2006) or Fruzzetti and
(Fruzzetti and Worrall 2010; Fruzzetti 2006, Payne (2015), and for parents and families, more
2018). details are provided in Fruzzetti (2018). In all
cases, the intermediate goals are to increase both
accurate expression and validating responses.
Description Strategies and Interventions Family Skills: There are many skills needed to
reduce emotion reactivity, improve communica-
Although ongoing transactions between emotion- tion and problem solving, and bring partners and
ally vulnerable individuals and their invalidating family members together. Skills include (a) emo-
social and family environments may be tion self-management, largely drawn from
Borderline Personality Disorder in Couple and Family Therapy 307
Linehan’s DBT skills (2014), mindfulness and successful work: (a) blocking dysfunctional reac-
relationship mindfulness skills, to help family tions early, even prior to their emergence in the
members slow their reactivity and be able to session; (b) liking the patient/family members and
focus descriptively on the other person and stay communicating this via irreverence, staying non-
connected to their long-term relationship goals judgmental, playfulness, etc.; (c) coaching more B
(loving each other, wanting a better relationship, skillful behavior whenever possible; (d) balance
etc.); (b) accurate expression; (c) validation, to therapist communication (include both warmth,
communicate the legitimacy of the other’s expe- genuineness and irreverence, humor); and
rience; (d) relationship reactivation, to help (e) use the “revolving door strategy” to send out
reintroduce both nonnegative and pleasant activi- one family member while working to help the
ties, decrease reactivity, and build shared positive individual still in the room, allowing a bigger
experiences; and (e) radical acceptance, to let go push for change (which might be humiliating in
of residual and reactive negative emotion related front of the other family members) or bigger val-
to the past and/or to things that can’t be changed, idation about the situation (which might be
and either parenting skills or closeness skills, embarrassing for the others).
depending on the relationship.
Treatment Targets: Because there are fre-
quently high levels of distress and self-harm, and Clinical Example
suicidality in this population, it is important that
family interventions augment individual treat- Sam worked late, didn’t feel well, and was
ment when one member of the family is actively grumpy when he got home. Typically, this
suicidal or self-harming. That individual will need would be his time to take over some of the
more help to become safe and stable than family child care for his and Terri’s 6-month-old, who
sessions alone can provide. Thus, safety is always Terri had been caring for all day. Anticipating
the priority target, and even when the suicidal or that, Sam felt exhausted, overwhelmed, and
self-harming individual has an individual treat- guilty as he came into the house, didn’t make
ment provider, the family sessions will start with eye contact with Terri, and immediately
a focus on safety whenever these risks are present. complained that the kitchen was a mess. Terri
For example, sessions can explore the role that was tired, also, and really looked forward to
parents or partners might play vis-à-vis a recent Sam coming home, both to get some relief
self-harming or suicidal episode (including from childcare and because she felt warm and
increased urges) and/or may seek ways that par- loving feelings toward Sam. She was really dis-
ents and partners can help the individual stay safe appointed when he greeted her with a complaint,
without compromising developmental tasks, gen- but quickly spun into self-judgments (“I should
erational boundaries, or roles (cf. Fruzzetti 2018 have cleaned up the kitchen”) and shame, and
for more details). then judgments about Sam (“what an
Other targets include emotion self- asshole. . .I’ve been taking care of everything
management and reducing invalidating around here, made a nice dinner, and he doesn’t
responses, relationship reactivation, improved even appreciate it!) and anger. She quickly
communication (accurate expression and vali- yelled at him, told him he was a “selfish jerk”
dating responses) and problem management, and burst into tears. Sam yelled back for her to
and enhanced closeness (for couples) or leave him alone, and “what is wrong with you?”
improved relationships overall. Imagine that instead of complaining about
Treatment Strategies: Treating very distressed the kitchen, saying “leave me alone” and criti-
and emotionally dysregulated families can be cizing her, Sam had said (accurate expression)
challenging. These strategies can help reduce “Terri, I’m exhausted and getting sick, and
in-session escalation and create opportunities for I know you must be exhausted, too. . .but
would you mind taking care of the baby the rest psychopathology. In D. K. Snyder, J. Simpson, &
of the night so that I can go to sleep early?” She J. Hughes (Eds.), Emotion regulation in couples
and families: Pathways to dysfunction and health
would have known what Sam was feeling and (pp. 249–267). Washington, DC: American Psycholog-
wanting and could have told him to go get ical Association.
some rest. Fruzzetti, A. E., & Payne, L. G. (2015). Couple therapy and
This argument was typical for this couple. Treat- the treatment of borderline personality and related dis-
orders. In A. Gurman, D. Snyder, & J. Lebow (Eds.),
ment included slowing down and hearing each step Clinical handbook of couple therapy (5th ed.,
of the transaction for each of them, in the form of a pp. 606–634). New York: Guilford Press.
step-by-step (or chain) analysis. When one or the Fruzzetti, A. E., & Payne, L. (in press). Assessment of
other became highly reactive in the session, the couples, parents and families in dialectical behavior
therapy. Cognitive and Behavioral Practice.
therapist was typically able to block one from Fruzzetti, A. E., & Worrall, J. M. (2010). Accurate expres-
attacking the other. On a couple of occasions, the sion and validation: A transactional model for under-
therapist asked one of them to step out to the standing individual and relationship distress. In
waiting area for a few minutes, both to validate K. Sullivan & J. Davila (Eds.), Support processes in
intimate relationships (pp. 121–150). New York:
and coach the one left in the session in the skills Oxford University Press.
noted above, to help that partner practice managing Fruzzetti, A. E., Shenk, C., & Hoffman, P. D. (2005).
his/her emotions and communication. Then the Family interaction and the development of borderline
therapist did the same with the other partner, and personality disorder: A transactional model. Develop-
ment and Psychopathology, 17, 1007–1030.
then brought them back together to redo the argu- Fruzzetti, A. E., Crook, W., Erikson, K., Lee, J., &
ment (now a conversation) in real time. Worrall, J. M. (2008). Emotion regulation. In W. T.
New skills take a lot of practice to use effec- O’Donohue & J. E. Fisher (Eds.), Cognitive behavior
tively, particularly for clients who have been in therapy: Applying empirically supported techniques in
your practice (2nd ed., pp. 174–186). New York:
dysfunctional patterns of interpersonal interac- Wiley.
tions for long periods of time and are highly Fruzzetti, A. E., Gunderson, J. G., & Hoffman, P. D.
reactive. But, as family members become more (2014). Psychoeducation. In J. M. Oldham,
comfortable expressing themselves accurately A. Skodal, & D. Bender (Eds.), Textbook of personality
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these skills in more and more situations. Family Fruzzetti, A. E., Payne, L., Hoffman, P. D. (in press). Dialec-
and other relationships can be as challenging as tical behavior therapy with families. In L. A. Dimeff,
they are necessary for people with BPD and their K. Koerner, & S. Rizvi (Eds.), Dialectical behavior ther-
apy in clinical practice: Applications across disorders
loved ones, but effective and respectful solutions and settings (2nd ed.). New York.
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easier as well as enjoyable, with meaningful psychotherapy. American Psychologist, 44, 19–29.
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Gunderson, J. G., Fruzzetti, A. E., Anruh, B., & Choi-
References Cain, L. (2018). Competing theories of borderline
personality disorder. Journal of Personality Disor-
Edlund, S. M., Carlsson, M. L., Linton, S. J., ders, 32, 148–167. https://doi.org/10.1521/
Fruzzetti, A. E., & Tillfors, M. (2015). I see you’re in pedi.2018.32.2.148.
pain: The effects of partner validation on emotions in Linehan, M. M. (1993). Cognitive-behavioral treatment of
patients with chronic pain. Scandinavian Journal of borderline personality disorder. New York: Guilford
Pain. https://doi.org/10.1016/j.sjpain.2014.07.003. Press.
Fruzzetti, A. E. (2018). DBT with parents, couples and Linehan, M. M. (2014). DBT skills training manual.
families to augment stage 1 outcomes. In M. Swales New York: The Guilford Press.
(Ed.), Oxford handbook of dialectical behaviour Shenk, C., & Fruzzetti, A. E. (2011). The impact of vali-
therapy. London: Oxford University Press. dating and invalidating responses on emotional reac-
Fruzzetti, A. E., & Iverson, K. M. (2006). Intervening with tivity. Journal of Social and Clinical Psychology, 30,
couples and families to treat emotion dysregulation and 163–183.
Boss, Pauline 309
Midwest in 1997, the ethnic cleansings of Kosovo

Boss, Pauline in the late 1990s, the September 11th attacks on
New York City in 2001, the Malaysian Airlines
Tai Mendenhall flight 370 disappearance in 2014, and most recently
University of Minnesota, St. Paul, MN, USA in Fukushima, Japan, and Tbilisi, Georgia. These B
efforts have informed and evolved (and continue to
evolve) in synchrony with other scholars and prac-
Name titioners worldwide who are aligning what they do
in therapy, community engagement, and research
Pauline Boss, Ph.D., LMFT with what Boss set into motion.
Biography Scholarship and Contributions
Pauline Boss is an internationally recognized In its most general sense, “loss” is an experience that
scholar, educator, and family therapist. She earned all humans endure from time to time (e.g., launching
her Ph.D. in Child Development and Family Studies adult children from the home, mourning a loved-
from the University of Wisconsin-Madison in 1975, one’s memory after death, going through a painful
where she then began her academic career as an break-up). According to Boss, ambiguous loss rep-
assistant professor. After achieving tenure 1981, resents a unique type of loss that is arguably more
Boss transitioned to the University of Minnesota’s stressful and difficult to cope with. Situated within
(UMN) Department of Family Social Science. She the context(s) of human relationships, it carries no
is a Fellow in the American Psychological Associa- verification of death and/or certainty that the person
tion (APA) and American Association for Marriage we are losing will ever return (physically or
and Family Therapy (AAMFT), former president of psychologically).
the National Council on Family Relations (NCFR), This ambiguity manifests itself in two primary
and a clinician in private practice. Since retiring ways: Type 1 ambiguous loss occurs when there is
from the UMN in 2005, Boss has continued to physical absence and psychological presence of a
actively contribute to the field – as Professor loved one. Losses like this can range from rela-
Emeritus – through writing, speaking, and training tively common experiences like those involving
efforts across both national and international forums. absent parents following a divorce or lost contact
Boss’s principal expertise and professional con- between family members during immigration, to
tributions as a scientist practitioner are centered catastrophic experiences like kidnapping and miss-
within the theory of ambiguous loss. This work ing persons in the contexts of war, terrorist attacks,
is based on decades of scholarship and clinical or natural disasters like tsunamis or earthquakes.
practice with individuals and families who have Type 2 ambiguous loss occurs when there is phys-
been traumatized by chronic illnesses and disabil- ical presence and psychological absence. This loss
ities (e.g., alcoholism, head injuries), human- occurs when loved ones become cognitively or
caused atrocities and suffering (e.g., war, terror- emotionally missing, as they do with injuries
ism), and national disasters (e.g., tsunamis, earth- resulting in head-trauma and/or illnesses like
quakes). It began with Boss’s early work with Alzheimer’s disease, alcoholism, and depression.
wives of missing-in-action (MIA) pilots who One of the hallmarks that makes ambiguous
served in Vietnam and Southeast Asia in the loss so difficult to endure is that does not fit well
1970s and continued with her engagement with into culturally prescribed scripts for coping and
providers, community leaders, and survivors dur- grieving. It defies “resolution” and creates long-
ing the aftermaths of the Armenia earthquake in term confusion about who is “in” (or not in) a
1989, the Red River Valley floods in the upper family. For example, how does a family decide
310 Boszormenyi-Nagy, Ivan
that a loved one has died when they do not have Boss, P. (2002). Ambiguous loss: Working with families of
proof that she/he has really passed away? How do the missing. Family Process, 41, 14–17.
Boss, P. (2004a). Ambiguous loss research, theory, and
they memorialize a loved one’s death when they do practice: Reflections after 9/11. Journal of Marriage
not have a body to conduct a funeral over, cremate, & Family, 66(3), 551–566.
or bury? How does a family say “goodbye” to a Boss, P. (2004b). Ambiguous loss. In F. Walsh &
person who is still physically alive and present, but M. McGoldrick (Eds.), Living beyond loss: Death in
the family (2nd ed., pp. 237–246). New York: Norton.
not psychologically “there” anymore as a parent, Boss, P. (2006). Loss, trauma, and resilience: Therapeutic
spouse, or child? work with ambiguous loss. New York: Norton.
Informed by decades of research and clinical Boss, P. (2007). Ambiguous loss theory: Challenges for
work, Boss has begun to answer these scholars and practitioners [Special Issue.]. Family
Relations, 56(2), 105–111.
questions. She and colleagues have done this by Boss, P. (2010). The trauma and complicated grief of
challenging the notion of “closure,” Instead, clinical ambiguous loss. Pastoral Psychology, 59(2), 137–145.
approaches – best advanced within family- and - Boss, P. (2011). Loving someone who has dementia: How
community-formats (not individual therapy) – walk to find hope while coping with stress and grief. San
Francisco: Jossey-Bass.
alongside people in finding meaning in their expe- Boss, P. (2015). Coping with the suffering of ambiguous
riences and pain. These approaches endeavor to loss. In R. E. Anderson (Ed.), World suffering and the
temper (or adjust, as culturally- and situationally- quality of life (pp. 125–134). New York: Springer.
appropriate) mastery, reconstruct identity, and nor- Boss, P. (2016a). Ambiguous loss. Retrieved from http://
www.ambiguousloss.com/
malize ambivalence (versus trying to resolve or Boss, P. (2016b). The context and process of theory devel-
“fix” it). In healing and growth, they act to revise opment: The story of ambiguous loss. Journal of Fam-
interpersonal attachments and discover – and ily Theory & Review, 8, 269–286.
indeed, embrace – new hope. Boss, P., & Carnes, D. (2012). The myth of closure. Family
Process, 51(4), 456–460.
Boss has published her work extensively across Boss, P., Doherty, W., LaRossa, R., Schumm, W., & Stein-
both professional (e.g., peer-reviewed journals, metz, S. (Eds.). (1993/2009). Sourcebook of family
clinician-oriented book-chapters and books) and theories and methods: A contextual approach.
lay (e.g., books for general audiences, fact-sheets, New York: Plenum.
Boss, P., Beaulieu, L., Wieling, E., Turner, W., & LaCruz,
and web-resources) arenas. Several of these are S. (2003). Healing loss, ambiguity, and trauma:
listed below. A community-based intervention with families of
As of this writing, Boss’s energies in union workers missing after the 9/11 attack in
informing, inspiring, and facilitating new genera- New York City. Journal of Marital & Family Therapy,
29(4), 455–467.
tions of scholars to continue advancing the theory Boss, P., Bryant, C. M., & Mancini, J. (2016). Family stress
of ambiguous loss – and its application(s) – across management: A contextual approach (3rd ed.). Thou-
different loss-types, cultures, and disciplines is sand Oaks: Sage.
nothing short of inspiring. Her legacy, already
strongly felt, will continue to grow as our field(s)
endeavor to better understand, ease suffering, and
foster resilience vis-à-vis some of the most stress-
ful kinds of losses that humans can bear. Boszormenyi-Nagy, Ivan
Grace E. Hazeltine and Molly F. Gasbarrini

California School of Professional Psychology,
References and Suggested Readings
Alliant International University, Los Angeles,
Boss, P. (1975). Psychological father absence and pres- CA, USA
ence: A theoretical formulation for an investigation
into family systems pathology (Doctoral dissertation).
Madison: University of Wisconsin-Madison.
Name of the Person
Boss, P. (1999/2000). Ambiguous loss: Learning to live
with unresolved grief. Cambridge, MA: Harvard Uni-
versity Press. Ivan Boszormenyi-Nagy
Boszormenyi-Nagy, Ivan 311
Short Introduction Boszormenyi-Nagy also became a founding

member of two important organizations devoted
Ivan Boszormenyi-Nagy, born in 1920, was a Hun- to the practice of family therapy, the Family Insti-
garian American psychiatrist and family therapist tute of Philadelphia, one of the earliest private
who made significant contributions to the field of training facilities for family therapy in the United B
marriage and family therapy, most notably by States and the American Family Therapy Associ-
pioneering the development and practice of contex- ation, currently known as the American Family
tual therapy (also known as contextual family ther- Therapy Academy.
apy) in the 1970s. Through an extensive career as Throughout his career he won numerous
both a scholar and educator, Boszormenyi-Nagy awards including the Hungarian Republic Gold
directly and indirectly influenced marriage and fam- Medal and an honorary doctoral degree in medi-
ily therapists until his death in 2007, and his cine from the University of Bern, Switzerland. He
approach continues to inspire new generations of served as a psychiatric research director, educator,
therapists in the United States and internationally. and clinical supervisor to developing marriage
and family therapists in the United States and
internationally; and published 4 books and over
Career 80 papers, some of them translated into many
languages.
Boszormenyi-Nagy was born in Budapest, Hun-
gary, where he began his career as a psychiatrist
after graduating medical school from the Contributions to the Profession
Budapest’s Peter Pazmany University in 1944.
During his psychiatric training, Boszormenyi- Upon migrating to the United States as a psychi-
Nagy also studied biochemistry and physics. atrist, Boszormenyi-Nagy began a career in Chi-
He left Hungary in 1948 and, while a political cago in 1950 as a biochemical researcher with the
refugee in Austria, he worked as a physician for the goal of identifying biological markers of schizo-
International Refugee Organization. Following phrenia, which he considered a first step in finding
this, he migrated to the United States, arriving in a cure for this disorder. He later left this field to
Chicago in 1950. After 6 years conducting bio- focus on trying to define what constitutes effective
chemical research, he returned to clinical work therapy and very soon he and his team started to
and obtained a U.S. Board Certification in Psychi- include family members in the treatment for cli-
atry in 1956. In 1957, he accepted a position as the ents suffering from schizophrenia who were hos-
director of a research unit on schizophrenia at the pitalized on his research unit at EPPI. During this
Eastern Pennsylvania Psychiatric Institute (EPPI) period, Boszormenyi-Nagy became one of the
in Philadelphia where he worked until the closing pioneers of family therapy, organizing some of
of the Institute in 1980. While working at EPPI, the earliest family therapy conferences, and later
Boszormenyi-Nagy taught at several universities developing contextual therapy. He later renamed
throughout the Philadelphia area, including a pri- his research unit the Department of Family Psy-
mary appointment at Hahnemann University, now chiatry. His department offered training in family
Drexel University, where he founded a Master of therapy to many professionals in the Philadelphia
Family Therapy Program in 1978 and from which area and also inspired many early European fam-
he retired as Emeritus Professor of Psychiatry in ily therapists.
1999. Also in 1978, he founded The Institute for Key among his contributions to the practice
Contextual Growth, which has served as a private and understanding of clinical psychologist is the
training program for many local and international identified importance of fairness and loyalty in
family therapists. During all his professional life, close relationships. His book Invisible Loyalties,
he simultaneously maintained a private practice of coauthored with Geraldine Spark, has influenced
couple and family therapy. generation of therapists throughout the world.
312 Boundaries in Structural Family Therapy
Cross-References “to protect the differentiation of the system.

Every family subsystem has specific functions
▶ Contextual Family Therapy and makes specific demands on its members, and
▶ Framo, James the development of interpersonal skills achieved
▶ Intergenerational Couple and Family Therapy in these subsystems is predicated on the subsys-
▶ Invisible Loyalties in Families tems freedom from interferences by other subsys-
▶ Ledgers in Couple and Family Therapy tems” (Ibid., pp. 53–54). Boundary permeability
will therefore affect family functioning.
References
Description
Boszormenyi-Nagy, I. (2014). Foundations of contextual ther-
apy: Collected papers of Ivan Boszormenyi-Nagy, M. D.
First described boundaries in the family as
New York: Routledge. (Original work published 1987).
Boszormenyi-Nagy, I., & Framo, J. L. (1985). Intensive enmeshed or disengaged. Later (1974) he applied
family therapy: Theoretical and practical aspects. these terms to two extremes of boundary function-
New York: Brunner/Mazel. (Original work published ing and stated that “all families can be conceived
1965).
of as falling somewhere along a continuum whose
Boszormenyi-Nagy, I., & Krasner, B. R. (2014). Between
give and take: A clinical guide to contextual therapy. poles are two extremes of diffuse and rigid bound-
New York: Routledge. (Original work published 1986). aries (Ibid., p. 54). Diffuse boundaries between
Boszormenyi-Nagy, I., & Spark, G. M. (2013). Invisible subsystems leads to a heightened “sense of
loyalties: Reciprocity in intergenerational family therapy.
belonging,” (Ibid., p. 55) and family members
New York: Routledge. (Original work published 1984).
will respond immediately to any departure from
expectations. On the other hand, rigid boundaries
and disengagement between subsystems results in
Boundaries in Structural a lack of a sense of cohesion and a “tolerance for a
Family Therapy wide range of variation in its members” (Ibid.,
p. 55).
Richard Holm
Minuchin Center for the Family, Woodbury,
NJ, USA Application of Concept in Couple and
Family Therapy
Introduction Boundary assessment is critically important for

understanding the interaction between the fam-
“Boundary Definition” according to Davidson ily system and larger systems, the interaction
(1983) was one of the most important concepts among subsystems within the family system,
of General Systems Theory. It provided an inclu- including the couple system, and finally, in the
sive contextual view that was expansive enough understanding of the therapist as part of the
to include the significant factors relevant for system. Diffuse external boundaries of the fam-
understanding a particular organism or entity ily can invite or allow enmeshed entanglements
(p. 33). Minuchin (1974) viewed the family and with outside helping systems resulting in a dilu-
its subsystems as circumscribed by boundaries. tion of internal decision-making and boundary
definition processes (Minuchin 1984;
Colapinto 1995; Minuchin et al. 2007). On the
Theoretical Context for Concept other hand, families may view the outside
world as a threat and develop rigid external
Boundaries are the “rules defining who partici- boundaries as protection against external
pates and how.” (Ibid., p. 53). Their function is intrusion.
Boundaries in Structural Family Therapy 313
Diffuse boundaries between subsystems Mother: When you went to Jean’s party, her mother
within the family may be evidenced by over told me what you ate. She told me you ate a
fruit cup.
involvement between a parent(s) and a child or Daughter: What did you do, check up on me?
children resulting in an inappropriate intrusion Father: Yes. (ibid., p. 65)
into one another’s world (Minuchin et al. 1967, B
1978, 2007; Minuchin 1974; Minuchin and
Fishman 1981; Minuchin 1984). A rigid bound- In summary, the rules within the system that
ary contributing to disengagement between the govern who belongs and how is significant for
clinical work as Minchin states, “A therapist
parental subsystem and the child subsystem
occasions a neglect of the needs of the children often functions as a boundary marker, clarifying
in terms of guidance and nurturance (Colapinto diffuse boundaries and opening inappropriate
rigid boundaries. His assessment of family sub-
1995).
More recently boundary assessment has been systems and boundary functioning provides a
applied to work with couples, utilizing the con- rapid diagnostic picture of the family which ori-
ents his therapeutic intervention” (Minuchin
cepts of Structural Family Therapy that, in the past
focused on the couple as a member of the parental 1974, p. 56).
subsystem, Simon (2015) directed attention to the
couple system itself and the permeability and
flexibility of its external and internal boundaries References
for proper functioning.
Directing attention to the therapist as a part of Colapinto, J. (1995). Dilution of family process in social
services: Implications for treatment of neglectful
the system, (Minuchin et al. 1996; 1998, 2014) families. Family Process, 34, 59–74.
notes that the nature of the boundary between the Davidson, M. (1983). Uncommon sense: The life and
therapist and the family needs to remain perme- thought of Ludwig von Bertalannffy (1901–1972),
able in order for the therapist to effectively posi- father of general systems theory. Los Angeles:
J. P. Tarcher, Inc.
tion him/herself from a close, median/middle, or Minuchin, S. (1974). Families and family therapy.
disengaged/distant position depending on the Cambridge, MA: Harvard University Press.
intervention need. Minuchin, S., & Fishman, H. C. (1981). Family therapy
techniques. Cambridge, MA: Harvard University Press.
Minuchin, S. (1984). Family kaleidoscope. Cambridge,
MA: Harvard University Press.
Clinical Example Minuchin, S., Montalvo, B., Guerney, B. L., &
Schumer, F. (1967). Families of the slums. New York:
A brief clinical example of diffuse boundaries, Basic.
characterized by hyper-vigilance, is exhibited in Minuchin, S., Rosman, B. L., & Baker, L. (1978).
Psychosomatic families: Anorexia nervosa in context.
the following dialog between parents and their Cambridge, MA: Harvard University Press.
adolescent daughter: Minuchin, S., Simon, G. M., & Lee, W. Y. (1996; 2006,
2nd ed.). Mastering family therapy: Journeys of
Mother: I am not home to watch you! Growth and Transformation. New York: Wiley.
Daughter: Well, that’s what it feels like. Minuchin, P., Colapinto, J., & Minuchin, S. (1998; 2007,
Father: You must have a guilty conscience or 2nd ed.). Working with families of the poor. New York:
something. Guildford.
Daughter: No! You do watch me. Your room is Minuchin, S., Nichols, M. P., & Lee, W. Y. (2007).
right across from mine. I can’t go up, I can’t go Assessing families and couples: From symptom to
down, I can’t go anyplace. system. Boston: Allyn and Bacon.
Mother: You have to realize you’re only fifteen. Minuchin, S., Reiter, M., & Borda, C. (2014). The craft of
You can’t have everything your own way. You family therapy: Challenging certainties. New York:
have to be guided and supervised by your Routledge.
parents. Simon, G. M. (2015). Structural couple therapy.
Daughter: I have nothing my own way! Minuchin In A. S. Gurman (Ed.), Clinical handbook of couple
(1978, pp. 65). When the child is apart from the therapy (5th ed., pp. 358–384). New York:
family, this occurs: Guilford Press.
314 Boundary Making in Couple and Family Therapy
such cases, a therapeutic reconstruction of

Boundary Making in Couple boundaries may be necessary (Minuchin 1985;
and Family Therapy Minuchin et al. 2014).
Lisa Scott, Alexander Julian and Chunyue Tu

Brigham Young University, Provo, UT, USA Rationale for the Strategy or
Intervention
Name of the Strategy or Intervention Within systems theory, family systems cannot
function well if there are not clear boundaries
Boundary Making in Couple and Family Therapy (Minuhcin 1974). Furthermore, in order for
boundaries to be effective, they should be
adequately permeable. If boundaries are too per-
Introduction meable, the individuals within the system might
accept dangerous environmental influences, but if
Boundaries are an inherent part of all families and the boundaries are too impermeable, individuals
couples. Boundaries determine which roles individ- may shut out potentially beneficial influences
uals and family subsystems (e.g., children or par- (Wetchler and Hecker 2015). For example,
ents) play, expectations of each party, and Minuchin (1974) highlighted the importance of a
responsibilities of family members. Boundaries clear but permeable boundary between the marital
can be classified as diffuse, clear, or rigid. For prac- and child subsystems. He explained that the
titioners adhering to a systems theory approach, the boundary between parents and children should
goal in therapy is to help clients form clear bound- be permeable enough that a child feels supported,
aries that are not too diffuse or too rigid. The more a but clear enough that the child does not take on
family or a couple strays from having clear bound- parental roles (p. 57).
aries, the more likely they are to experience dys-
function (Wetchler and Hecker 2015).
Description of the Strategy or
Intervention
The therapist facilitates boundary making by
According to Minuchin (1974), boundary mak- aiding the family in clarifying which interac-
ing is the “basic principle” in systems theory tions are open to certain family members but
and therefore crucial in the formation of healthy closed to others. Through this process,
family systems. Within a family system, each detouring mechanisms and avoidance patterns
subsystem (e.g., the marital subsystem or the are corrected and the development of communi-
child subsystem) has set boundaries that create cation skills is encouraged (Colapinto 1991).
separation from other subsystems (Minuchin During family and individual therapy, family
1985). The rules and patterns of interaction members can be encouraged to find a balance
within and between subsystems are created and between rigid and diffuse boundaries in order to
maintained by all members of the family create clear and healthy boundaries (Wetchler
(Minuchin and Fishman 1981). It is believed and Hecker 2015). Diffuse boundaries describe
that the family members’ roles are expected to cases where two individuals or subsystems do
evolve across time for developmental and envi- not have clearly established roles. For example,
ronmental reasons. Some families have issues a situation in which one of the children has taken
with boundary maintenance and change, and in on parental responsibilities (or who has become
Boundary Making in Couple and Family Therapy 315
parentified) is likely to occur in a family system Cross-References

that has diffuse boundaries between parental
and child subsystems. Conversely, a family or ▶ Attachment Disorders in Couple and Family
couple with rigid boundaries is one in which Therapy
subsystems or individuals are considered to be ▶ Attachment Theory B
too confined, where roles are strictly adhered to, ▶ Attachment-Based Family Therapy
and in which not much interaction or collabora- ▶ Autonomy in Families
tion is allowed. An example of this could be ▶ Bonds in Couple and Family Therapy
found in a family where the parents rarely ▶ Boundaries in Structural Family Therapy
speak with the children and hold the belief that ▶ Closed Systems in Family Systems Theory
“Children are to be seen and not heard” ▶ Deepening Emotional Experience and
(Wetchler and Hecker 2015). Restructuring the Bond in Emotionally
▶ Differentiation of Self in Bowen Family Sys-
Case Example tems Theory
▶ Enmeshment in Couples and Families
Our case example will cover part of a session ▶ Fusion in Family Systems Theory
conducted with a three-person family consisting ▶ Individuation in Family
of a mother (Usha), father (Robert), and adoles- ▶ “I-Thou” in Couple and Family Therapy
cent child (Megan). Megan has been exhibiting ▶ Marital Fusion in Couples
excessively aggressive behavior and the family ▶ Minuchin, Salvador
has sought therapy as a result. ▶ Open Systems in Family Systems Theory
▶ Parent-Child Interaction Family Therapy
Therapist: And do each of you take the time to ▶ Parentified Child in Family Systems
do what you want? ▶ Restructuring the Bond in Emotion-Focused
Usha: Ha! I can’t remember the last time Therapy
I did anything for myself, perhaps ▶ Roles in Couples and Families
last year when I went out to lunch ▶ Separation-Individuation in Families
with my sister. ▶ System in Family Systems Theory
Therapist: Why don’t you have time to spend ▶ Systems Theory
on yourself? Surely Megan is old ▶ Undifferentiated Family Ego Mass in Bowen
enough that she doesn’t need Therapy
constant supervision.
Robert: You would think so, but Usha spends
so much time either trying to prevent
Megan from getting into trouble or References
arguing with her that she really
doesn’t have time for herself to ever Colapinto, J. (1991). Structural family therapy.
just unwind. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of
family therapy (Vol. 2, pp. 417–443). New York:
Therapist: Robert, this may be an opportunity Routledge.
for you to support Usha in creating Minuchin, S. (1974). Families & family therapy. Oxford:
her own “space” for herself within Harvard University Press.
your family’s dynamic. Maybe you Minuchin, P. (1985). Families and individual development:
Provocations from the field of family therapy. Child
can offer to work with Megan at Development, 56(2), 289–302.
times when Usha is feeling that she Minuchin, S., & Fishman, H. C. (1981). Family therapy
needs some personal time? techniques. Cambridge, MA: Harvard University Press.
316 Bowen Center for the Study of the Family, The
Minuchin, S., Reiter, M. D., & Borda, C. (2014). The craft Murray Bowen added new faculty and
of family therapy: Challenging certainties. New York: expanded training opportunities. Interest in the
Routledge.
Wetchler, J. L., & Hecker, L. L. (Eds.). (2015). An intro- training programs by mental health professionals,
duction to marriage and family therapy (2nd ed.). clergy, organizational, and financial professionals,
New York: Routledge. and other disciplines grew. As out of town trainees
returned home, they established a network of cen-
ters across the country that sponsored conferences
and their own educational programs. Interns and
Bowen Center for the Study of clinical fellows in family therapy and biofeedback
the Family, The staffed the sliding fee scale clinic at the Bowen
Center. Research seminars were added for those
Robert J. Noone who had participated for several years in the post-
Center for Family Consultation, Evanston, graduate programs.
IL, USA Central to Bowen’s research and the develop-
ment of his theory was a belief that it was possible
one day for a science of human behavior to be
Introduction developed. The observation that the family func-
tioned as a unit provided a foundation to move in
The Georgetown University Family Center was that direction. It provided a step toward a less
founded in 1975 by Murray Bowen, MD, who, at subjective view of human behavior. Given the
the time, was a clinical professor in psychiatry and prominence of subjectivity in the effort to study
director of Family Programs at the Georgetown human behavior and the strong tendency for a
University School of Medicine in Washington, theory to become a belief system, as occurred
DC. Dr. Bowen had moved to Georgetown fol- with Freud’s psychoanalytic theory, Bowen
lowing his landmark 5-year study of the family at thought it vital that the theory be in contact with
NIMH (1954–1959). Based on this research and the natural sciences. Toward that end, he decided
further studies, he developed a formal systems to invite natural scientists to be the principal guest
theory of the family, which was published in speakers at the annual Georgetown Family Sym-
1966 (Bowen 1978). Initially, he taught psychiat- posium beginning in 1975. Prior to that year, he
ric residents and medical students. A group of had invited prominent individuals in the field of
graduating residents who participated began the family therapy to be the principal guest speakers.
Symposium on Family Theory and Family Psy- A Theory Meeting that Dr. Bowen began in
chotherapy in 1965, which has continued to the 1963 at Georgetown continues to provide an
present day. opportunity for individuals experienced in
When a growing number of mental health pro- Bowen Theory to present their work and research
fessionals showed interest in learning more about on a twice-a-month basis. Another continuing
his theory of family systems, he began a postgradu- program is the monthly Clinical Conference.
ate training program in 1969. When Dr. Bowen was The Clinical Conferences began at the Medical
awarded a grant from NIMH for fellowships in College of Virginia, where Bowen conducted a
family psychiatry, he founded the Georgetown Uni- series of videotaped clinical interviews with fam-
versity Family Center in 1975, which then moved ilies to demonstrate the application of his theory
off campus. He remained the director of the Family in a clinical setting. The meetings were moved to
Center until his death in 1990. An additional post- the Georgetown University Medical Center in
graduate program was initiated in 1975 for mental 1978 and became a formal monthly teaching
health professionals who lived at a distance from conference by Dr. Bowen and later by other
Washington. In this program, the trainees met for faculty. These sessions were observed by a pro-
three days, four times a year. A sliding fee scale fessional audience and then discussed with the
family clinic was also added in 1975. families present. The videotaped sessions
Bowen Center for the Study of the Family, The 317
represent the world’s largest collection of Sciences, a peer-reviewed journal of articles

recorded family therapy sessions and are cur- related to Bowen Theory and the natural sci-
rently housed at the National Library of Medi- ences, was published and continues to the pre-
cine in Washington, DC. sent. In 2013, Dr. John Butler edited The
The monthly Clinical Conferences have con- Origins of Family Psychotherapy, a compilation B
tinued to the present. Each month, a different of Dr. Bowen’s papers written during the NIMH
faculty member is responsible for the program study, many of which had not been previously
and selects a topic of his or her own professional published. And in 2015, The Family Emotional
interest. The format of the day includes a lecture System: An Integrative Concept for Theory, Sci-
on a particular theme followed by videotaped ence, and Practice, which highlighted the ongo-
clinical sessions that illustrate the topic. The ing interchange occurring between natural
long, continuous history and the format of video- scientists and Bowen theorists, was edited by
taping families who are invited to the clinical day Robert Noone and Daniel Papero. Roberta Gil-
make this conference unique in the world of bert has written several books on Bowen The-
family theory and family psychotherapy. ory, and Peter Titelman has edited several books
The Bowen Center also hosts Annual Spring (e.g., Titelman 2014) on a variety of topics
Conferences. These conferences each focus on a related to the theory and its application.
single concept related to Bowen Theory. Guest In 1990, The Georgetown Family Center left
scientists, researchers, and leaders in the study Georgetown University and became incorporated
of family systems offer presentations related to as a nonprofit organization in the District of
the central focus of this two-day conference. Columbia, receiving a 501(c)(3) tax-exempt sta-
Each year at the conference, the Caskie tus. When Dr. Bowen died that year, Michael
Research Award is given to support an impor- Kerr, MD, became the next director. Later the
tant research effort in Bowen Theory. All pro- Center purchased a condominium suite at 4400
grams have continued to the present day (go to MacArthur Boulevard in Washington, giving the
www.thebowencenter.org for more details on Family Center a permanent address for the
the Center’s programs). first time.
The Bowen Center also offers a clinical intern- Dr. Kerr added new faculty who took on
ship for professionals with graduate degrees in responsibilities such as hosting the clinical con-
mental health disciplines and at least 1 year in ferences, supervising, training, organizing confer-
the Postgraduate Training Program at the Bowen ences, and speaking at network centers around the
Center. The intern receives referrals from the country. A videotaped series of interviews, Family
clinic, ongoing supervision from a faculty mem- Matters, with Bowen Center faculty and others
ber, and continued Bowen Center Postgraduate discussing Bowen Theory, was begun and pro-
Program training. duced by the University of the District of Colum-
Dr. Bowen wrote extensively about the bia. An advisory board was appointed and assisted
development of his ideas. Family Therapy in the Center in launching its website and
Clinical Practice, a compilation of his papers, recommending the name change to the Bowen
was published in 1978, permitting a wider expo- Center for the Study of the Family to recognize
sure and more in depth understanding of the Dr. Bowen as its founder. In 2011, Dr. Kerr retired
theory. In 1988, Family Evaluation by and Dr. Anne McKnight was selected to be the
Dr. Michael Kerr, with an Epilogue by Bowen, next director of the Bowen Center.
was published, and segments were featured in The mission of the Center is to lead the contin-
The Atlantic Monthly. Dr. Daniel Papero, faculty ued development of Bowen Family Systems The-
at the Georgetown Family Center, published ory toward a science of human behavior and to
Bowen Family Systems Theory. In 1994, the assist individuals, families, communities, and
first issue of Family Systems: A Journal of Nat- organizations in addressing major life challenges
ural Systems Thinking in Psychiatry and the through understanding and improving human
318 Bowen Family Systems Therapy with Couples
relationships. The Center carries out its mission References

locally, nationally, and internationally through
training and online programs, conferences, Bowen, M. (1966). The use of family theory in clinical
practice. Comprehensive Psychiatry, 7, 345–374.
research, clinical services, website, and publica-
Bowen, M. (1978). Family therapy in clinical practice.
tions. In 2016, Bowen’s book was translated into New York: Jason Aronson.
Spanish and an online program in Spanish was Kerr, M. E., & Bowen, M. (1988). Family evaluation: An
added. approach based on Bowen theory. New York/London:
W.W. Norton.
The Bowen Center seeks to fulfill this mission
Noone, R. J., & Papero, D. V. (Eds.). (2015). The family
by: emotional system: An integrative concept for theory,
science, and practice. Lanham: Lexington Books.
Papero, D. V. (1990). Bowen family systems theory. Bos-
– Maintaining and developing practices of scien- ton: Allyn and Bacon.
tific inquiry through collaboration and interac- Titelman, P. (2014). Differentiation of self: Bowen family
tion with scientists and active participation in systems perspectives. New York: Routledge.
scholarly pursuits
– Contributing to the development of Bowen
Theory in the effort to move toward a science
Bowen Family Systems
of human behavior through promoting
Therapy with Couples
research and writing, fostering thoughtful
interchange among Bowen theorists, and
Susan Regas1 and Ronda Doonan2
maintaining viable contact with the natural 1
sciences
Los Angeles, CA, USA
– Contributing to the development of leadership 2
Community Memorial Health Systems, Ventura,
of Bowen theorists locally, nationally, and
CA, USA
internationally through training and
collaboration
– Presenting Bowen Theory and its applications
Bowen Couple Therapy is more about the nature
as a resource to address major life challenges
of being human than about couples or couple
for individuals, families, organizations, and
therapy. Murray Bowen conceptualized the
communities
couple and the family as an emotional unit and
– Financially sustaining and enhancing the
the family members were part of that unit and not
Bowen Center and its mission
just autonomous psychological individuals.
– Engaging with the communities in the
Furthermore, there is the assumption that each
Washington/Baltimore area through education
family member is a product of evolution and that
and service
their behavior is regulated by the same processes
that regulate behavior in all living systems. He
Bowen Family Systems Theory consists of based his theory on observable facts rather than
eight interrelated concepts and was developed on subjective experiences and feelings.
as a natural systems theory of human behavior. Bowen proposed that any change in the emo-
A new form of psychotherapy, based on the tional functioning of each family member affects
theory, was developed by Bowen, which is everyone in the system. The emotional function-
applicable for individuals, couples, and fami- ing of every person impacts the occurrence of
lies. The family is seen as the client regardless health problems or psychological issues in every
of the number of individuals involved in the other member. Feelings move from individual to
therapy sessions. The application of the theory individual by means of predictable and patterned
has extended beyond therapy to include emotional reactions such as distance,
organizations, congregations, and societal conflict, over functioning, underfunctioning, or
process. triangling.
Bowen Family Systems Therapy with Couples 319
Bowen did not limit his focus to the couple. embedded in all living systems. In fact, it is the
Past and present forces mold what makes one natural growth process that moves partners
partner distance from the relationship and another toward individuality.
partner neglect their own personal development The most fundamental feature of being human
and focus on the relationship. This circular or is the struggle to balance two basic instinctual B
multiple causality thinking replaced cause and forces: the need to be an individual and the need
effect thinking. According to Bowen, there was to be connected to others. Differentiation is the
not any one person or relationship that caused the ability to balance these two forces which is a
couple’s relationship problem. The person or rela- lifelong journey. No one is ever fully differenti-
tionships were the receptors, medium, and con- ated. Differentiation is conceptualized on a con-
tributors of larger multigenerational processes. tinuum and is determined by the amount of
Bowen considered the three-generational emo- chronic anxiety in the relationship, the intensity
tional process the best way to understand the of internal and external life stressors, and the
couples’ presenting problem. Because the system individual’s ability to handle these influences.
has significant impact on a person’s behavior and Therefore, individuals are viewed as more or less
emotions, one must see the big picture and assess differentiated.
this context to understand what is going on with The instinctual individuality and togetherness
the couple. The clinician then helps each partner forces often exist outside our awareness. They are
become aware of how their issues are connected driven by acute and chronic anxiety. Acute anxi-
to the multigenerational processes and family ety is the response to real or imagined threat
dynamics. It is important to see how one couple’s whereas chronic anxiety is an ongoing state of
problem fits within the broader fabric of the fam- tension after that threat has abated. Anxiety
ily systems rather than trying to identify and focus strengthens the togetherness force and diminishes
on the individual with the problem. When partners the individuality force in close relationships.
can see and understand the system and at the same The level of differentiation establishes the
time work on self, this can produce a powerful threshold for the tolerance for anxiety. Below the
impact on the couple and individual. threshold, a partner can maintain awareness of
thinking and feeling and can employ cognitive
skills to regulate self and guide behavior. Once
Case Conceptualization the tolerance for anxiety threshold is crossed over,
the partner loses the ability to self-regulate,
There are four concepts in Bowen theory along becomes increasingly reactive, and behaves
with anxiety that play important roles when work- instinctively and automatically.
ing with couples: differentiation, triangles, Partners want a deep connection with others,
nuclear family emotional process, and emotional attachment, and benefit from the relationship and,
cutoff. over time, long to be free, to be the captains of
their own ships, and to direct their own lives. With
less differentiation, partners place greater value on
Level of Differentiation and Chronic the relationship and fear the discomfort of being
Anxiety alone. They will sacrifice individuality and auton-
omy to preserve the connection. Compared to
Bowen couple therapy rests on the concept of more differentiated couples, they depend on the
differentiation of self. Differentiation is the ability relationship for their stability and sense of well-
to define a self in the context of close relation- being.
ships. It includes the ability to adapt to life, to Poorly differentiated people are overwhelmed
cope with life challenges, and reach one’s goals. by anxiety. This anxiety gets triggered around
Differentiation is often referred to as emotional issues such as money, parenting, sex and
maturity. It is the instinctual force that is in-laws. The intensity of feelings makes it very
difficult to think clearly and as a result partners Differentiation creates a clarity that allows
respond with emotionally based actions. As peo- individual and families to reduce the reactivity
ple become more anxious, they pursue contact and anxiety associated with survival in natural
with important others and become less responsi- systems. Differentiation allows couples to make
ble for oneself in the attempt to fit with others. conscious choices about how to respond.
Immaturity is revealed in partner’s difficulty in Differentiation of self affects the relationships
establishing and following through on their own people form. Couples are attracted to each other
goals, insisting that others do things or make because they are at the same basic emotional level
decisions for them, requiring partners to soothe of differentiation. An individual with a low level
their anxiety and boost their self-worth. That of differentiation needs a partner who is seeking
dependence becomes evident when partners are the same level of emotional fusion, one who will
expected to be available to them in exactly the sacrifice their own self for the sake of the relation-
way one expects or there is a significant reactivity ship. Individuals with higher levels of differenti-
to perceived mistakes or failings on the part of the ation are not interested in participating in a
partner. In contrast, immaturity can also be relationship that would require the loss of self.
reflected in the inability to set limits with others Consequently, people choose partners at the
and in the need to take care of others who are same level of differentiation as themselves.
capable of taking care of themselves. Less differ-
entiated people depend heavily upon relationships
with others to provide direction, soothing, and Nuclear Family Emotional Systems
well-being.
Although better differentiated people are sub- When there is undifferentiation, the couple’s
jected to the togetherness pressure, they are able to functioning is more or less chaotic. Emotional
separate their own thinking from the opinions of and instinctual forces tend to govern people and
other important people. At higher level of differ- relationships. Thoughtful communication and
entiation, people are less fused in their close rela- problem-solving appear only fleetingly when the
tionships. They are able to accept those close to anxiety in the system is low and things are calm
them thinking, feeling, or behaving different from and disappear into reactivity-driven confusion as
themselves and yet maintain a connection. More anxiety increases.
mature partners have well-defined boundaries. Most adults have unresolved issues with their
A well-developed inner guidance system with parents and bring those unresolved issues into
thought-out beliefs and values guide them. These their committed relationship. These unresolved
values and opinions are not inflexible but the cross-generational issues lead to physical, psy-
differentiated individual knows what they believe chological, or social problems in the couple.
and why. They also lead to patterns of behavior.
Since they are able to preserve intellectual Bowen describes patterns that partners use to
functioning, they are able to make decision from manage the intensity of the psychological and emo-
a place of strength versus a fear of losing the tional system oneness. These patterns occur along a
relationship. continuum. The most intense and dysfunctional
With an inner guidance system, mature part- patterns exist at the lowest end of the continuum
ners care less about what others think of them. of differentiation.
Time is not devoted to seeking acceptance. This As tension increases, one typical pattern that
mitigates the relationship of having the pressure partners may engage in is conflict, a process that
of being responsible for the others’ self-worth and ranges from simple squabbling to domestic vio-
anxiety regulation. lence. Secondly, the couple may also distance
In order to have a successful relationship, from one another. This distance can range from
people need to work at a high level of silence to excessive activities like reading or com-
differentiation. puter use to actual avoidance of one another.
Often conflict and distance occur alternately in the maintaining a one-to-one relationship and rapidly
same relationship. bring in a third person when conflict or distance
A third pattern is over functioning–under- occurs in the relationship. In the short term, the
functioning. In this pattern, one of the partners triangulation relieves the pressure on the relation-
appears to give up responsibility for oneself to ship by spreading the anxiety among three people B
the other. Either partner can take the lead in the instead of two. Triangulation is a quick-fix solu-
process as anxiety and tension mount. The over- tion that only circumvents the anxiety rather than
functioning partner can act more convincingly solving a problem. Once the anxiety in the dyad
and inflexibly and the other yields to that pressure has been reduced to a tolerable level, the entity
rather than oppose it. Or the underfunctioning who is triangulated may be easily villainized or
partner can appear increasingly powerless and cut off. Some triangles may be difficult for a
dependent, requesting that the other take charge. couple to identify as they may have begun their
As is the case with the patterns of conflict and relationship as a triangle. For example, the rela-
distance, this pattern becomes more and less pro- tionship that begins as an affair for one or both
nounced with increasing and decreasing anxiety. partners or a relationship founded in a significant
These patterns can be found in all couples other relationship (e.g., best friend’s sibling).
varying with the intensity of the fusion and anxi- Triangulation is a fundamental process in nat-
ety at play. Bowen noted that most families use a ural systems. Everyone triangulates to some
combination of them. As a result, these observable degree. However, when this becomes the primary
patterns of behavior can shift, reducing the likeli- means for dealing with dyadic tension, the part-
hood that any one becomes disabling. The inten- ners of the dyad never actually resolve the tension
sity of the process in any nuclear family appears to themselves, and pathological patterns emerge.
be governed by the degree of undifferentiating or
immaturity, the degree of emotional contact or cut
off with the extended families of the partners, and Emotional Cutoff
the degree of stress and anxiety in the system.
Emotional cutoff is a way of distancing from the
togetherness in the family of origin. It varies in
Emotional Triangles intensity along the continuum of differentiation
and reflects the unresolved issues with the family
Bowen identified emotional triangles as one of the of origin. Families with high levels of differentia-
most important dynamics to assess because they tion are able to grow up, leave home, choose their
are the basic building blocks of families. It is the own life partners, form their own families where
smallest viable relationship unit and he saw them they are self-supporting individuals while at the
as inherently unstable over time as a result of same time staying connected to their family of
conflict, overly involved connection, or increase origin. Families with low levels of differentiation
in anxiety. have children who feel hampered in moving
The human dyad is so unstable that when two toward independent adulthood. Depending on
people who are important to each other develop the intensity between the generations, they may
problems, which they invariably do, they auto- be dependently connected to the family or cut off
matically look around for a third person, activity, with minimal connection. In committed relation-
or topic to include into the anxious situation in ships where there has been cut off from other
some way. This alleviates tension in the dyad and generations, anxiety will usually increase and
rebalances the dyad emotionally. there are more social, physical, or psychological
The emotional triangle occurs automatically symptoms in the couple. A pattern or cycle of
with increasing or decreasing anxiety along the cutoff/fusion may be observed over the life cycle
differentiation continuum. At the lowest end of of a relationship or within families as a way of
the continuum, they have the most difficult time managing intense anxiety.
Differentiated individuals are more able to Acquiescence as well as reactivity is often used
stand on their own and are less enmeshed in the to keep anxiety away. When anxiety is low, cou-
family emotional system. When one does not have ples may display an acceptance for difference.
emotional dependence, that does not mean there is However, this tolerance for difference disappears
distance. Just the opposite, if there is less emo- as the couple becomes more anxious. Anxiety
tional dependence, there is more space for open- increases the togetherness pressure which triggers
ness and true intimacy in the emotional system. reactivity and the use of distance and avoidance.
The less differentiated individual is more depen-
dent on their partner for their sense of satisfaction
Two-Person System and well-being. They are willing to trade individ-
ual sense of “self” for the perceived security of
Bowen theory views relationship difficulties as togetherness.
emerging from a mixture of level of differentia- Emotionally, mature relationships entail two
tion plus intensity of anxiety in the relationship people with a high level of differentiation and
field. Each person brings reactivity from their own well-defined boundaries. This means there is less
family system and exposes them as anxiety trading away of self in the relationship. As a
increases in the current relationship. Over time, result, there is greater cooperation and altruism.
the love relationship develops its own reactive This teamwork is achieved as a thoughtful choice
patterns based on past and present experience. and guided by inner principles not by automatic
Each partner struggles to be a self and a partner accommodation response. Those individuals with
at the same time. The difficulties develop when greater ability to differentiate between thinking
the effort to be autonomous conflicts either with and feeling have more tools to meet relationship
one’s own or one’s partner’s desires for connec- challenges competently.
tion. Under these conditions anxiety increases and
problems occur.
Bowen believed that people who married or Goal Setting
formed long-term intimate relationship selected
as partners those who had about the same level Bowen theory views relationship difficulties
of differentiation as themselves. Bowen hypothe- emerging from a mixture of level of differentia-
sized that partners meet and develop relationships tion of self plus intensity of anxiety in the rela-
because they are similar in the way they function tionship field. Consequently, there are two basic
emotionally, in their tolerance of anxiety, and goals in treatment.
ability to tolerate similar levels of intimacy and The first goal is to increase differentiation
distance. which is the ability to stay separate and autono-
Two undifferentiated selves fuse into a two- mous while still connected to important others.
some that begins to govern behavior. They appear The clinician helps in raising level of differentia-
to be so tightly connected and form such intense tion in both partners as well as in their relation-
relationships that they act as one person. In this ship. With increased differentiation, partners can
state of fusion, each reflexively depends on manage their relationship issues more calmly and
the other for support, direction, and her or his thoughtfully and can reduce their reactivity to
own sense of well-being. Low level of differenti- each other. As a result, there will be less blaming,
ation carries with it anxiety which when conveyed conflict, and distancing. If each partner takes
in relationships creates significant difficulties. responsibility for their own part in the relationship
Their emotional or automatic functioning is problems, they will be able discover a solution
fused with their intellectual functioning. The together.
arrival of differences between partners produces The second goal is to reduce the anxiety felt by
pressure on the one perceived as different to adapt each partner and in the relationship. This follows
and fit more comfortably with the other. from the first goal since as differentiation
increases, anxiety decreases. Both reducing anxi- The genogram allows the coach to get an
ety and reactivity while increasing their differen- understanding of the level of differentiation by
tiation of self in their important relationship is key. the way the couple describe their functioning
When these are realized, they are better able to and the functioning of their families of origin.
find balance between self and togetherness and Furthermore, the goal is to help the individ- B
tolerate facing the difficult gridlock issues in ual learn about self and understand one’s own
their relationship in order to find solutions. patterns. Genogram making is not about
It is important that each partner have these rehashing past grudges. Instead, the focus is on
goals for themselves. The goal cannot be to self instead of others. The objective is to move
change the relationship or the partner. Each part- to a different level of comfort and responsibility
ner is asked to observe how their own behavior in one’s own family and to become a more
and reactions contribute to or impair them achiev- mature person in one’s relationship and family
ing their goal. Once a goal for self is established, of origin.
the coach can ask each partner to reflect on what Through the use of the genogram, the couple
they are doing toward their goal and with what becomes aware that they are living out patterns
effects. and rules long established in their families of
origin. This increased awareness allows each part-
ner to consciously choose alternative ways for
Assessment relating and handling problems that may have
previously been unclear or never even considered.
Genograms Being able to visualize family of origin dynamics
A very important way of assessing couples’ may lead to greater willingness to take action.
dynamics is through the use of genograms. This conscious and intentional approach to relat-
Genograms are a type of family tree that ing and problem solving comes from the strength
specifically maps key multigenerational pro- in each partner rather than the weaker and col-
cesses. This provides insight for both therapist lapsed “that’s just how it is” patterns that have
and the partners regarding the emotional dynam- caused chaos in the relationship.
ics that contribute to the presenting problem.
Genograms are used to identify problematic
multigenerational patterns that surround the pre- Therapeutic Relationship
senting complaint such as conflict, over functioning,
or level of differentiation. Coach
The therapist creates the genogram with the Bowen referred to the therapist as a coach.
couple that includes at least three generations of A coach is an active expert of both individual
the family of both partners. It places each indi- players and the team. A coach does not assume
vidual in a nuclear family but also it charts responsibility for fixing the presenting problem or
important facts such as education, achievements, for changing the relationship. The coach assumes
physical and mental illnesses, occupations, that the couple can tackle their own problems
where people live, immigration, and health sta- successfully. The coach takes responsibility for
tus. It records dates of birth, deaths, divorce, and providing a structure that allows the partners to
marriages. It can also include information about think more objectively.
how the couple met and how they decided to The coach facilitates partners focusing on self
commit to each other and any separations, previ- rather than on others. The couple talks directly to
ous serious/long-term committed relationships, the coach rather than to each other. They talk with
children, abortions, or mischarges. In addition, therapist about how to manage themselves less
emotional facts regarding relationship patterns reactively in relationships. As one of them talks
such as conflict, distance, violence, abuse, cutoff, to the coach, the other sits back, thinks, and
and fusion are all recorded. listens.
The basic principle governing this approach The higher one’s differentiation, the more the
derives from the observation that tension between therapist can maintain a non-anxious presence
two can resolve if both can remain in good contact with the clients. Non-anxious presence does not
with an emotionally objective and neutral third mean a cold detached stance but rather an emo-
person or coach. The coach reduces the direct tionally engaged yet nonreactive stance. The
exchange between the partners that results in the therapist does not react to attacks or take sides.
emotionally driven chain reaction while urging When the therapist can tolerate the anxiety in
each partner to witness their own reactivity. the room, they do not try and fix the client or
As each partner becomes a better observer of the rescue them from tough feelings. The therapist
process, anxiety and tension decreases. With does not try and liberate the couple from anxiety
the decrease in anxiety, each can observe more when they feel overwhelmed by disappointment
of the reactive process in self and in the other. anger, fears and other strong emotions. If the
therapist is differentiated enough they are able
to tolerate the feelings that the couple is trying
Differentiation and the Person of the to avoid and coach them through the arduous
Therapist process of separating self from others and
thoughts from feelings. If the coach soothes
The primary tool for transforming couples is the and calms the couple anxieties and fear, no
therapist’s own personal level of differentiation. growth occurs.
In fact, the differentiation of the therapist and
the emotional being of the coach is seen as tech-
nique. The coach’s ability to embody and live the Interventions
theory is key.
If the therapist works to enhance their level of Encourage Differentiation of Partners
maturity, they will interact with the clients in a Most people tend toward fusion and less differenti-
way that will automatically facilitate clients level ation. Encouraging differentiation of self is a tech-
of differentiation. Murray Bowen believed that nique that encourages people to hold on to their
individuals can only differentiate as much as the individual opinions and feeling states while in a
therapist has differentiated. So if the coach is relationship with their partner. If the partners work
going to assist the couple they must continually on their own level of differentiation, their relation-
work on developing themselves. ship will get better. Even if one person works to raise
While what the therapist does is important, their level of maturity, the relationship will do better.
how the therapist ‘is’ in relation to the couple is A partner cannot change their half of the relationship
most important. The emotional system of the ther- without changing the relationship.
apist can be triggered when sitting with the cou- When one partner changes their focus from the
ple’s distress and anxiety. If the coach takes sides faults of their partner to their own functioning
or overfunctions, they become part of the prob- in the relationship and their own life goals,
lem. But when the therapist focuses on his/her differentiation is enhanced. In small steps, one
own reactivity and anxiety tolerance, their ability partner begins to change behavior based on their
to sit with an emotionally charged couple observations about the relationship process and
improves. The therapist’s goal is to get greater can see more clearly how the partner responds
clarity and objective thinking during a session as reciprocally to one’s own behavior.
opposed to responding out of an emotional reac- In time, the partner begins to convey
tion to the couple. Emotional objectivity is the views based on self-knowledge. These beliefs
goal. If the coach can relate to each partner as begin to guide behavior. These are considered to
more of a self, they aid in facilitating and encour- be “I-positions” or “I-statements.” This is what
aging more solid self to emerge in relationship I think, this is what I believe, and this, therefore, is
with each other. what I am going to do. These statements
Bowen Family Systems Therapy with Families 325
demonstrate a sense of responsibility for self and Termination

the ability to act responsibility toward others.
The clinician serves as a consultant or coach to The time frame for therapy is specified by the cou-
this process. Rather than providing an answer, the ple. The goal is for them to move as quickly as
clinician challenges each partner to manage reac- possible toward their goals. Often the couple begins B
tivity more effectively, to take more responsibility with weekly meetings. When the presenting prob-
for self, to avoid infantilizing others while lem becomes less of an issue, the anxiety is lower,
remaining interested and committed to the welfare and/or the relationship runs more smoothly, couple
of their partner. Provided the clinician has worked may come less frequently. They move to every other
on differentiation of self in her/his own family, the week schedule. Some come monthly or even yearly.
coach can outline common challenges and suggest The clients are responsible for those decisions.
pathways for progress around obstacles. The pro- Some couples may drop out of therapy but one
ject, however, is the couple’s challenge not the partner may continue on to work on self. Many begin
coach’s. to see Bowen therapy as giving them a lifelong
project where partners continually work on self.
Detriangulation They have learned to have a more solid self and
Detriangulation involves the therapist having a less reactive up close to important people. There is
collaborative alliance with each partner and does always work to be done both for the therapist as well
not tolerate being drawn into the couple’s triangle. as the couple since no one ever gets to the idealized
The therapist declines to be triangulated by refus- level of Bowen’s continuum of differentiation.
ing to take sides. Although it will relieve one When the couple does decide to terminate, the
partner’s anxiety to agree with them, validation therapist often asks to evaluate what changes they
from the therapist can in fact undermine the cli- have made and how they will handle themselves
ent’s autonomy. Instead, the therapist attempts to during the next problem which will inevitably come.
get the partner to validate their own opinion and
take responsibility for what they say and want.
Partners must be coached to approve or disap- Recommended Reading
prove of their own thoughts, opinions, and feel-
ings and take action as needed. Brown, J. (2012). Growing yourself up: How to bring your
best to all of life’s relationships. Wollombi: Exisle
The coach works to keep himself or herself
Publishing Pty Ltd.
detriangulated from the emotional system of the Gilbert, R. M. (1992). Extraordinary relationships: A new
relationship. The anxious couple will automati- way of thinking about human interactions. New York:
cally seek a third person to rebalance the couple Wiley.
Kerr, M. E., & Bowen, M. (1988). Family evaluation: An
relationship. Often this third person is the coach.
approach based on Bowen theory. New York:
The coach must be aware to the challenges of W.W. Norton & Company.
being triangulated in to the relationship and
maintain the detriangulated position in order to
be effective.
This requires that the coach remain emotion- Bowen Family Systems
ally detached from the twosome yet in good con- Therapy with Families
tact with them. Bowen refers to this process as the
magic of family psychotherapy. Heather Katafiasz
Bowen believed that the coach’s efforts to stay The University of Akron, Akron, OH, USA
out of triangles with the couple is a central inter-
vention. Conflict between two people will resolve
automatically if both remain in emotional contact Synonyms
with a third person who can be equally involved
with both without taking sides. Bowen couple theory; Bowen theory
326 Bowen Family Systems Therapy with Families
Introduction Theoretical Framework
Bowen Family Systems Theory fits into the cat- Core Concepts
egory of Intergenerational Family Theories, Bowen Family Systems Theory is a multi-layered
with its emphasis on how family of origin expe- theory comprised of many interconnected con-
riences impact current individual and relation- cepts. At the core are counterbalancing forces;
ship functioning. It is a theory that emphasizes the interpersonal forces of togetherness and sepa-
personal autonomy, as well as balance. Bowen rateness and the intrapersonal forces of thoughts
found inspirations for his theory, not only in the and feelings. These forces exist within a web of
mental health work but also in natural systems. interconnection known as the emotional field
He believed that his theory would be applicable (Friedman 1991). The process of navigating the
to all human systems and, to a much more lim- togetherness and separateness forces has been
ited extent, to all living systems as we are all labeled distance regulation (Kerr and Bowen
connected. 1988). While navigating interactions with others,
people experience a pressure known as Chronic
Anxiety, which is the pressure to fuse with others
(Friedman 1991).
Prominent Associated Figures Fusion can manifest as increasing physical
proximity or aligning one’s own thoughts or feel-
Murray Bowen, the founder of Bowen Family ings to that of others (Bowen 1978). A person
Systems Theory, trained initially as a psychia- experiencing fusion has difficulty separating
trist. While working at the Menninger Institute their thought from their feelings, as well as sepa-
providing therapeutic services to patients diag- rating their thoughts and feelings from that of
nosed with Schizophrenia, he began to involve others. This fusion can become so intense that
the mothers of the patients in the treatment (Kerr members of the relationship experience a loss of
and Bowen 1988). He began to observe how the individual identity, creating a dynamic in which
relationship between mother and adult child any threat toward separation becomes a threat to
impacted the patient’s symptom presentation, the individual identities (Bowen 1978). Fusion
beginning to build the foundations of his theory. inevitably leads to cutoff, which can be either an
Bowen then took on a clinical research position interpersonal or intrapersonal separation from
at the National Institute of Mental Health (Kerr the impact of the other (Kerr and Bowen 1988).
and Bowen 1988), continuing to explore how Cutoff forms a false sense of independence, as the
family relationships in general impacted indi- relationship and impact therein does not cease to
vidual symptoms. In the 1960s, while at exist with the separation. Responses that are
Georgetown University, Bowen established the solely based on thought or emotion, which lead
Georgetown Family Centre. At this point, he to fusion or cutoff, are believed to be based on
transitioned to working with families presenting emotional reactivity (Bowen 1978). Vacillating
with less severe psychological symptoms, between fusion and cutoff can lead to unstable
applying those concepts from earlier in his interactions with others and a sense of mental
career to his work with these families. Bowen instability within oneself.
announced the development of his theory at a Differentiation is the remedy to the struggles
presentation at the Family Research Conference created by chronic anxiety (Kerr and Bowen
in 1967, in which he presented the application of 1988). It is the ability to become aware of the
his theory to his own family of origin experi- chronic anxiety, allowing a person to choose
ences (Bowen 1978). With this presentation, how to interpersonally and intrapersonally react,
Bowen demonstrated that this theory needed to rather than being compelled to have an emotional
not only be utilized by but also lived by the reactive response. Differentiation exists on a con-
therapist. tinuum, with those with higher differentiation
being better able to combat the chronic anxiety, Families pass down patterns of interaction,
while those with lower differentiation more easily such as differentiation level and ways in which
succumbing to the chronic anxiety (Kerr and chronic anxiety is managed through genera-
Bowen 1988). Those with higher differentiation tions in a process known as the multi-
have the ability to maintain a sense of connection generational transmission of emotional B
to others while also being autonomous, as well as processes (Friedman 1991). Families with
the ability to separate their thoughts from their excessive amounts of chronic anxiety, low dif-
feelings as they consider how to react in interper- ferentiation, and limited access resources while
sonal interactions. under stress, such as family life cycle transi-
Differentiation is thought to be a life-long tions, will develop an undifferentiated ego
endeavor that no one can ever truly achieve, and mass (Kerr and Bowen 1988). Parents in these
so must always be practiced. Bowen believed that families then engage in the family projection
to a certain extent, all systems experienced symp- process by including their children in their
toms; however, the extent to which a system under own distance regulation patterns through trian-
stress developed systems depended on differenti- gulation (Bowen 1978). Not all children
ation level and access to resources (Kerr and become triangulated into the parental system,
Bowen 1988). Therefore, those with more such that some children experience more pro-
resources and higher differentiation are the least jected chronic anxiety than others. Those chil-
likely to develop symptoms. Conversely, those dren triangulated more will develop lower
with the least resources and lower differentiation differentiation levels than other children in the
more easily succumb to the pressures of chronic system. Often these children develop symptoms
anxiety, experience more emotional reactivity, as a way to cope with the projected chronic
and are the most likely to develop symptoms. anxiety. Bowen believed that sibling position
Schizophrenia was hypothesized to be linked to (Bowen 1978), along with other contextual fac-
the lowest differentiation levels. tors, may be reason for why one child is trian-
The primary mechanism through which individ- gulated more into the parental subsystem than
uals regulate distance is using the emotional trian- others. Eventually, when these children attempt
gle (Bowen 1978). This involves dispersing the to leave their families, they may feel that their
chronic anxiety that permeates a two-person rela- only course of action will be to cut off because
tionship into three relationships. The third “leg” of they are unable to separate from their family
the triangle need not be a person, as it could also be without their family attempting to fuse again.
something the other two members have in com- As adults, these people will use similar distance
mon, such as a hobby. Emotional triangles are not regulation strategies as their parents (or other
problematic, as they are an effective way to dis- relatives) to navigate the pressures of chronic
perse the chronic anxiety and the most stable form anxiety.
of relationship. However, when they become rigid Bowen believed that these processes occur
and inflexible, the process becomes triangulation, similarly in broader levels of the ecological sys-
which can lead to symptom development (Kerr and tem. The concept of societal emotional pro-
Bowen 1988). Often, in triangulation, two of the cesses suggests that civilizations of people
“legs” of the triangle are able to fuse, while the must also navigate the balance of separateness
third “leg” is cutoff. Symptoms fall into one or and connectedness (Bowen 1978). Attempts at
more of the following categories: relational con- distance regulation under the pressures of
flict, symptom development in one member of the chronic anxiety as a society are reflected in the
couple, or symptom development in a child values and rules created by the people. Bowen
(Friedman 1991). When symptoms are triangu- hypothesized that excessive chronic anxiety and
lated, the focus now becomes solving the symptom lower differentiation as a whole society could
rather than navigating the underlying problem in lead to the societal regression process (Bowen
the primary dyad. 1978).
Theory of Change clients a differentiated stance and aid in alleviat-

Bowen Family Systems Theory is very insight ing the chronic anxiety in the room, allowing
oriented. Therapy is about giving people an clients to learn to react from a differentiated
opportunity to learn more about themselves and stance, as well. Furthermore, Friedman (1991)
their relationships, so they can assume responsi- suggested that therapists must be able to regulate
bility for their own problems (Kerr and Bowen distance with clients; be connected to them as
1988). The therapist’s role is to be a coach and humans, while also being distant enough to pre-
facilitator of the client’s understanding, rather vent triangulation. To create this new emotional
than directing or pushing them (Bowen 1978). triangle without actually being triangulated into
Regardless of the presenting symptom, the focus the system, the therapist must have at least a
of therapy is on helping clients learn to manage higher level of differentiation than the clients.
their emotional reactivity while under the pres- The therapist’s use of self in the room is key to
sures of chronic anxiety, improving their differen- helping clients become more differentiated; there-
tiation, and reducing the need for the symptom fore, any technique has the possibility of being an
in the system. effective intervention during the course of therapy
(Friedman 1991).
The family diagram, which was later altered
Populations in Focus and renamed the genogram, is both an assessment
tool and an intervention designed to gather infor-
Bowen Family Systems Theory was originally mation from clients regarding their family of ori-
designed to explain all emotional systems gin. To complete a genogram, the therapists first
(Friedman 1991), with emotional referring to the elicits from the client information regarding their
connection between living things, and not to be family composition, then adding in contextual and
equated with feelings (Kerr and Bowen 1988). relational information regarding the members
The implication of this original assertion was of the family. The genogram is designed to garner
that the concepts of Bowen’s theory would be insight within clients, while aiding therapists in
universal to all human experiences. Researchers, treatment planning (Guerin and Guerin 2002;
such as Monica McGolrick, have spent decades Kerr and Bowen 1988).
examining and expanding the cross-cultural appli- Once the patterns of emotional reactivity have
cability to Bowenian concepts (Erdem and Safi been identified, therapists can assign relationship
2018). Additionally, more recent theorists have experiments to clients (Guerin and Guerin 2002).
discussed the cross-cultural applicability of As differentiation is a process that must be prac-
Bowen Family Systems Theory with specific tice, these are behavioral tasks focused on helping
populations and have redefined it as a culturally clients practice maintaining a differentiated stance
valid approach (Erdem and Safi 2018). when interacting with others during the time
between sessions. The successes and inevitable
failures of relationship experiments can then be
Strategies and Techniques Used in processed in subsequent therapy sessions.
Model
One major technique of Bowen Family Systems Research About the Model
Therapy is that the therapist forms a new emo-
tional triangle with the client system, attempting Bowen Family Systems Theory is used widely by
to maintain a differentiated stance, or autonomous many therapists as their primary theoretical orien-
I-position, during the session when the chronic tation, but there have not been many empirical
anxiety is palpable (Guerin and Guerin 2002; studies performed supporting the effectiveness
Kerr and Bowen 1988). Bowen believed that of it in clinical practice (Miller et al. 2004).
maintaining this I-position would model for Although there are dearth of empirical studies
on Bowen Family Systems Theory, a great deal regarding Amelia’s ability level. Amelia still lives
of basic research has been done on specific con- at home, and although Amelia works part time,
structs from the theory. Specifically, differentia- she does not contribute financially to the house-
tion, chronic anxiety, emotional reactivity, hold and has no plans to move out. Amelia
triangulation, and the multigenerational transmis- has expressed a desire to attend college and to B
sion of emotional processes have all been studied. individuate from her family. Mary is hesitantly
Research on differentiation has showed that while supportive of this, as she expresses frustration
the hypothesis that married couples would have that she is never able to spend any time with Joe
similar levels of differentiation was supported by without Amelia present and believes their couple
some early research (Miller et al. 2004), it has relationship is suffering. Joe has expressed anxi-
since been countered by later research (Miller ety regarding Amelia moving out of the home, as
et al. 2004). Furthermore, support has been he does not believe the world is safe for her.
found for the inverse relationship between differ- Amelia has a younger brother, who she believes
entiation and trait anxiety (Miller et al. 2004). behaves similarly to her, but does not get into
Research has generally supported the hypothe- trouble because her parents favor him over her.
sized relationship between low levels of differen- When the therapist inquired about the possibility
tiation and psychological symptoms, as well as of the younger brother attending therapy, the par-
physical symptoms (the latter only for women; ents reported that he refused to attend. Joe and
Miller et al. 2004), and the hypothesis that higher Mary brought Amelia into therapy due to chronic
levels of differentiation would be associated with conflict in the home, as they reported Amelia is
better marital quality and less frequent marital disobedient and lazy.
conflict (Miller et al. 2004). The therapist spent the first few sessions
Emotional reactivity research has shown that exploring the history of the family and identifying
one’s emotional reactivity toward one’s parents is a timeline of the “problem.” The family reported
related to psychological distress. While research the problems began approximately 2 years ago,
has not supported the hypothesis that triangulation when Amelia graduated from high school. During
would reduce anxiety for the couple and increase that same year, Mary had a heart attack, which
anxiety in the third party has not been supported, terrified Amelia, who became Mary’s caretaker
mixed results have been found support for the while she recovered. When Mary returned to
relationship between triangulation and physical, work, Amelia’s behavior problems began, as she
emotional, and social symptoms (Miller et al. became defiant regarding her chores and argu-
2004). Finally, mixed results have been found mentative. She also requested to know any and
for the intergenerational transmission of emo- all information regarding the house, Mary’s
tional processes, with some studies showing sup- health, and Mary and Joe’s relationship.
port for this process and other studies finding From a Bowen Family Systems Theory per-
contradictory evidence (Miller et al. 2004). spective, the family has become stagnant in the
launching stage of their family life cycle. Amelia
has become triangulated into Mary and Joe’s rela-
Case Example tionship, as they have been unable to regulate the
chronic anxiety triggered by Amelia’s preparation
Joe and Mary are a married couple who have been to launch and Mary’s health issues. Mary and Joe
together for a total of 23 years. They are a White, projected the chronic anxiety onto Amelia, who
middle-class couple with two children. They pre- has become emotionally reactive, acting out
sented to therapy with their eldest daughter, behaviorally and vacillating between fusion and
Amelia, who is 20 years old. Mary reported that cutoff in her relationships with both of her parents.
Amelia may have been deprived of oxygen at Amelia was “chosen” as the recipient of the
birth and was identified as having a borderline chronic anxiety due to her cognitive delays that
IQ but did not provide any additional information precluded her from a typical launching
experience, as well as her being both the elder and from the family projection process due to her
female child. younger age in the family. Mary’s attempts to
After exploring the timeline of their relation- alter her parenting style from that of her parent
ship, the therapist moved to exploring family of by not engaging in physical discipline suggest that
origin patterns to identify the origination of these she may have developed a higher level of differ-
processes via a genogram. Joe is an only child to a entiation than that of her parents. Additionally,
single mother. He reported that his parents Mary’s protection of her son may be her attempts
divorced when he was very young and he did to stop the cycle of male child maltreatment, as
not have a relationship with his father. Joe her brother development mental health struggles
reported that he lived with his mother until he as an adult, presumably resulting from his mis-
and Mary married, when they were in their mid- treatment as a child.
20s. He further explained that the entire family The family’s close relationship with Joe’s
was very close with his mother, who had provided mother suggest that she may have been triangled
respite for Amelia as a younger child. Joe in during times of stress, perhaps in a functional
explained that mother died suddenly approxi- way, as she was able to mitigate some of the
mately 2.5 years ago. chronic anxiety and her presence was experienced
Mary is the youngest of three children. She has in a positive way by all family members. Her
a brother and a sister. She reported that her father death then represented an emotional loss of that
was an alcoholic and emotionally and physically relationship to everyone in the family, as well as a
abusive, primarily to her older brother, but she and loss of their main strategy to mitigate the chronic
her sister experienced it, as well. She reported anxiety in the family. Amelia then was triangu-
that she did not want to use physical punishment lated in to take the place; however, as she did not
on her children due to her own experiences, but have the resources to manage the chronic anxiety,
wondered if she had used more physical discipline she developed symptoms.
with Amelia, then Amelia would have fewer As they moved into the working phase of ther-
behavioral issues. She also reported that her par- apy, the family therapist focused on improving the
ents argued frequently throughout her childhood, differentiation of the family members both in the
although the majority of it had dissipated by the room, as well as through relationship experiments
time she was in her teenage years, leaving her at home. The therapist further encouraged the
parents’ relationship very disconnected. Mary participation of Joe and Mary’s son, as he plays
reported moving out when she was 18 and that an important role in the family as well. After
their relationship was estranged thereafter with several sessions of encouragement, he finally
only interactions on holidays. began attending therapy. The therapist also
From a Bowen Family Systems Theory Per- began processing the grief over the loss of Joe’s
spective, Mary tends more toward cutoff in her mother with the family, allowing them to experi-
family of origin, as demonstrated by the estranged ence the emotions of that loss in a more differen-
relationship upon launching, while Joe tends more tiated manner. The family was encouraged to
toward fusion in his family of origin, as demon- identify resources, such as case management,
strated by the maintenance of the close relation- that could provide support for Amelia to experi-
ship with his mother into adulthood. This may ment with her independence. The therapist
explain Mary’s higher level of comfort with encouraged Mary to reestablish contact with her
Amelia launching compared to Joe’s hesitancy family of origin and experiment with interacting
as they are both attempting to repeat their family with her parents in a more differentiated manner.
of origin patterns surrounding this issue. Further, Joe and Mary were also encouraged to seek out
it may be that Mary’s family experienced an couple counseling to assist them with improving
undifferentiated ego mass due to the intensity their ability to manage the chronic anxiety asso-
of the symptom development in her family; ciated with transition of the launching years and
however, Mary may have been more protected help them find a healthier balance between
Bowen, Murray 331
separateness and connectedness in their own

relationship. Bowen, Murray
During sessions, the therapist attempted to
maintain a differentiated stance, remaining a neu- Tara Schlussel and Molly F. Gasbarrini
tral coach throughout the process. As they pro- California School of Professional Psychology, B
cessed family of origin experiences, as well as the Alliant International University, Los Angeles,
conflict in their relationship, the chronic anxiety CA, USA
became higher in session. The therapist diffused
this chronic anxiety by creating a new emotional
triangle with the family. The therapist used super- Name
vision and their own therapy to process counter-
transference so that they did not get triangulated Murray Bowen, M.D. (1913–1990)
during session. Additionally, the therapist used
communication skills training to slow down the
communication processes between the family Introduction
members, allowing them to take a differentiated
stance and choose how to react to each other. Murray Bowen is considered one of the founders
While Amelia’s behavior problems were proof systemic therapy and a pioneer of family psy-
cessed as part of the content in session, the goal chology. Bowen developed the theory of triangu-
for Joe, Mary, Amelia, and her brother was to lation and continued to emphasize differentiation
become more differentiated, allowing them to of the self throughout his work. His groundbreak-
communicate about stressors, rather than the ther- ing work with patients with schizophrenia
apist resolving the issue for them. changed the way in which the medical and psy-
chological fields perceived the disorder. Bowen
authored over 50 book chapters, papers, and
Cross-References monographs founded on his research and
clinical work.
▶ Bowen Family Systems Therapy with Couples
▶ Intergenerational Couple and Family Therapy
Education and Career
References Bowen attended primary and secondary school in
his hometown, Waverly, Tennessee. In 1934, he
New York: Jason Aronson. earned a Bachelor in Science from the University
Erdem, G., & Safi, O. A. (2018). The cultural lens approach of Tennessee, Knoxville. In 1937, he earned an
to bowen family systems theory: Contributions of M.D. from the University of Tennessee Medical
family change theory. Journal of Family Theory & School, Memphis. He started his professional
Review, 10, 469. https://doi.org/10.1111/jftr.12258.
Friedman, E. H. (1991). Bowen theory and therapy. training as an intern at Bellevue Hospital in
In A. S. Gurman & D. P. Kniskern (Eds.), Handbook New York City in 1938 and later worked as an
of family therapy (Vol. 2, pp. 134–170). Philadelphia: intern at Grasslands Hospital in Valhalla,
Brunner/Mazel. New York from 1939 to 1941. After his experi-
Guerin, P., & Guerin, K. (2002). Bowenian family therapy.
In J. Carlson & D. Kjos (Eds.), Theories and strategies ence as an intern, Bowen spent 5 years on active
of family therapy. Boston: Allyn and Bacon. duty in the US Army (1941–1946), ranking first
Kerr, M., & Bowen, M. (1988). Family evaluation. Lt. to Major. His experience in the army during
New York: W. W. Norton & Company, Inc. World War II forever impacted his career by
Miller, R. B., Anderson, S., & Keala, D. K. (2004).
Is bowen theory valid? A review of basic research. changing his interest from surgery to psychiatry.
Journal of Marital and Family Therapy, 30(4), Once Bowen’s professional focus changed, he
453–466. began his fellowship in psychiatry, specifically
332 Bowen, Murray
personal psychoanalysis, at the Menninger Foun- clinicians continue to integrate into therapy today.
dation in Topeka, Kansas (1946). After complet- Family Systems Theory underlines the strong ties
ing formal training, Bowen became a staff among family members, stating that individuals
member at the Menninger Foundation and contin- are united in their network of connections. Family
ued to work there until 1954. While holding a Systems Therapy emphasizes the importance of
position at the Menninger Foundation, he also assessing the structure and behavior of the whole
worked at the National Institute of Mental Health family, when aiming to address an individual’s
(NIMH) (1954–1959). After leaving NIMH in inner psyche.
1959, he began working part-time for George- Bowen conceptualized triangulation as an
town University’s Department of Psychiatry. integral part of Systems Theory. He recognized
Bowen became a clinical professor, held the posi- the formation of triangles or involvement of a
tion of director of family programs, and in 1975, third party, when tension between two parties
founded the Georgetown Family Center. During became exceedingly high. Although the inclusion
his time at NIMH, he continued to grow his pri- of a third party alleviates tension, it prevents the
vate practice from his home in Maryland. two original parties from addressing their issues
Among the many awards Bowen has received with one another. Triangulation can be found in
throughout his career, he has been awarded the any two party relationships and was brought to the
Distinguished Alumnus Award from the Univer- forefront of family psychology by Bowen.
sity of Tennessee, Knoxville, and the Alumnus of Bowen highlighted differentiation of self as a
the Year from the Menninger Foundation. He held goal that each member of a family should strive to
positions on many boards including the American achieve. Differentiation emphasizes the impor-
Psychiatric Association, the American Board of tance of each member of a family to view themself
Psychiatry and Neurology and, lastly, was named as independent from their families while
president of the American Family Therapy Asso- maintaining intimate relationships and managing
ciation (1961). reactions and behaviors. When one attains differ-
entiation, they gain emotional maturity and, con-
sequently, are less likely to internalize conflicts
Contributions to Profession and less likely to struggle emotionally.
Bowen further developed his Family Systems
During his time at NIMH, Bowen began research Theory by emphasizing the impact of birth order
that would ultimately become the foundation for on the family dynamic. He asserted that sibling
Bowen Family Systems Theory. During his time position, an individual’s birth order in relation to
at the NIMH, he worked particularly with patients siblings, provided essential information about the
with schizophrenia and their families. His work individual’s emotional reactions and behavior.
with these patients and families revolutionized the While some members of a family may confront
way in which practitioners viewed schizophrenia. their perceived instigator, some members may
While, once perceived as an isolated and individual withdraw from conflict. Emotional cutoff is
diagnosis, Bowen highlighted the impact of family when an individual distances oneself from their
dynamics on the patient’s psychosis. Through his family, in order to avoid potential conflict, dis-
work and research, Bowen claimed that schizo- comfort, or pain.
phrenia was a result of relationship dysfunction Among Bowen’s many contributions to Family
within families, where dysfunction had continued Therapy, he developed The Family Projection
and intensified through generations. Process, which explains the way in which parents
Bowen is known for his contribution to family transfer their emotional difficulties to their child
therapy and development of relevant concepts and or children. The process of projection abides by
theories. His work with patients with schizophre- three steps: (1) the parent is afraid there may be
nia led to further development of Bowen’s family something wrong with their child and, conse-
systems theory and family systems therapy, which quently, aims all focus onto that child; (2) the
Bowlby, John 333
parent perceives the child’s behavior as affirming References

their fear; (3) the parent then interacts differently
with the child believing that, in fact, something is Bowen, M. (1960). A family concept of schizophrenia. In
D. D. Jackson & D. D. Jackson (Eds.), The etiology of
wrong with their child. This process is also
schizophrenia (pp. 346–372). Oxford: Basic Books.
viewed as a self-fulfilling prophecy as the parents https://doi.org/10.1037/10605-012. B
seek to “fix” a problem they perceive their child Bowen, M. (1972). Family therapy and family group ther-
has, but they ultimately cause their child to apy. In H. I. Kaplan & B. J. Sadock (Eds.), Group
treatment of mental illness (Vol. 12). New York: E. P.
develop such problem(s) they most likely
Dutton.
never had. Bowen, M. (1978). Family therapy in clinical practice.
Bowen had an exceptional awareness of paren- New York: Jason Aronson.
tal influence on a child’s emotional and behavioral Bowen, M. (1991). Alcoholism as viewed through family
systems theory and family psychotherapy. Family
development. Multigenerational transmission
Dynamics of Addiction Quarterly, 1(1), 94–102.
process explains how parental level of differenti- Bowen, M., Butler, J., Kerr, M., & Bowen, J. (2013). The
ation transfers across generations, producing origins of family psychotherapy. New York: Jason
noticeable patterns in differentiation among fam- Aronson.
ily members through relationships. It is important
to understand one’s level of differentiation since it
impacts all facets of an individual’s life: relation-
ships, affect longevity, marital stability, reproduc- Bowlby, John
tion, health, educational accomplishments, and
occupational success. In addition to exploring Mary A. Fisher
the process in which differentiation is transmitted Mary Fisher Psychotherapy, PLLC, Salt Lake
by generations, Bowen has also been acknowl- City, UT, USA
edged for his conceptualization of Nuclear Family
Emotional Process and Societal Emotional
Process. Name
Bowen contributed immensely to the field of
psychiatry and psychology, through his research, Bowlby, John
therapy, written works, recorded audio and video-
tapes, and positions held on numerous boards.
Among over 50 works published, Bowen’s con- Introduction
tributions can be further studied in The Origins of
Family Psychology (2013) and Family Therapy in The father of attachment theory, John Mostyn
Clinical Practice (1978). Bowlby, was born in 1907 in London to Anthony
Alfred Bowlby, a surgeon of renown, whose mil-
itary service and medical practice frequently sep-
Cross-References arated him from his family, and Mary Bridget
Mostyn, whom Bowlby characterized as stable
▶ Differentiation of Self in Bowen Family and sensible. The couple married and started
Systems Theory their family unusually late in life, but as was
▶ Emotional Cutoff in Bowen Family Systems customary among middle- and upper-class
Theory Edwardians, the rearing of Bowlby and his five
▶ Family Projection Process siblings was conducted almost entirely by nurse-
▶ Family Therapy maids. Minnie, the nursemaid who had daily
▶ Multigenerational Transmission Process in charge of Bowlby, left the household when he
Bowen Therapy was 4 years old, the effects of which may have
▶ Triangles and Triangulation in Family Systems inspired him to assert that the loss of a “loving
Theory nanny” in young childhood “can be almost as
334 Bowlby, John
tragic as the loss of a mother” (Bowlby 1958, individuals in childhood and beyond, Bowlby
p. 7). After being sent to boarding school to qualified as an analyst in 1937. He began training
avoid the threat of air raids on London, and later in child analysis under Melanie Klein soon after.
naval training as a cadet, Bowlby determined that While he disagreed with her prohibitions against
a military path would offer him little opportunity interacting with mothers of the children he was
to fulfill his ambition to improve society. Despite a analyzing, he recognized her influence, particu-
lack of passion, but believing his father would larly valuing her belief in infants’ capacity to form
approve, he enrolled at Trinity College at Cam- relationships. A year later, he met and married
bridge in 1925 to study medicine. Ursula Longstaff, one of the intelligent and cul-
tured daughters of a well-known alpinist.
Longstaff would collaborate with him on his biog-
Career raphy of Darwin; write articles for popular press
on pregnancy, breastfeeding, and parenting; and
Having developed an interest in experimental and assume the majority of the care of their four chil-
developmental psychology, Bowlby diverted dren. Like his father, Bowlby was separated from
from his original plan to carry on with his father’s his family during World War II for service as a
perceived wish. He found philosophical align- military psychologist, though the relationships he
ment when he volunteered at Priory Gate, a school developed during this time facilitated a post-war
for maladjusted children, during which time he appointment as head of the children’s department
interacted with troubled children with unstable of the Tavistock Clinic. There he formed his own
parental figures, an experience that evoked the research unit, and appointed Mary Ainsworth,
suspicion that problems arise from early experi- developmental psychologist and developer of the
ences of loss and emotional deprivation. Strange Situation procedure. This finally made
Because it was a prerequisite to training in possible the empirical testing of his ideas.
psychiatry, Bowlby begrudgingly completed his
medical studies in 1933. He began research and
clinical work at the Maudsley Hospital for adults, Contributions to Profession of Couple
where he conducted research on the relationship and Family Therapy
between early loss and psychosis. At the same
time, Bowlby began psychoanalytic training at During his time at the London Clinic, Bowlby
the British Psycho-Analytical Society. In 1936, authored several papers describing the effects of
he became involved in the London Child Guid- maternal deprivation on the personality develop-
ance Clinic, where he worked with children who ment of children: the first two using psychoana-
had been separated from their parents during the lytic concepts and the latter two delineating his
war. The Clinic employed a multidisciplinary ideas on how many psychological disorders in
approach and no singular theoretical basis, childhood are rooted in real world separation and
wherein he reported he “learned far more loss, which drew criticism from his psychoana-
from. . .two social workers than I learned from lytic colleagues. From this work, however,
my psychiatric colleagues” (Senn 1977, p. 9). Bowlby wrote a report, Maternal Care and Men-
These two social workers introduced him to the tal Health (1951) by request of the World Health
concept that children’s problems are rooted not Organization, which was translated into 14 lan-
only in early experiences of loss but in unresolved guages (Bretherton 1992) and was published in
conflict from their parents’ own childhoods. popular press as Child Care and the Growth of
Despite conflicts with his training analyst, who Love (1953). In these papers, Bowlby highlighted
may have viewed him as depressed and unable to psychological concerns over economic, medical,
form relationships, and the Society’s reigning and other such concerns as central to social prob-
Kleinian view that focused on unconscious fanta- lems, making recommendations for preventing
sies to the exclusion of the real life problems of and ameliorating the effects of parent-child
Boyd-Franklin, Nancy 335
separation. These works have influenced policies References

worldwide, particularly with regard to foster care
and child psychotherapy. Bowlby, J. (1958). Can I leave my baby? London: The
National Association for Mental Health.
During his time at the Tavistock Clinic,
Bretherton, I. (1992). The origins of attachment theory:
Bowlby’s documentary film, in collaboration John Bowlby and Mary Ainsworth. Developmental B
with social worker, analyst, and conscientious Psychology, 28, 759–775.
objector, James Robertson, A Two Year Old Goes Holmes, J. (1993). John Bowlby and attachment theory.
New York: Routledge.
to Hospital (1952) demonstrated a child’s protest,
Karen, R. (1994). Becoming attached: First relationships
despair, and final detachment at being separated and how they shape our capacity to love. New York:
from her mother for 8 days during a minor medical Oxford University Press.
procedure. Criticized by the British Psycho- Senn, M. E. (1977). Interview with Dr. John Bowlby.
Washington, DC: National Library of Medicine.
Analytical Society for its focus on actual experi-
Unpublished manuscript.
ences, it nonetheless impacted hospital protocols van Dijken, S. (1998). John Bowlby: His early life:
regarding parental visitation and care. A biographical journey into the roots of attachment
Bowlby presented a synthesis of the previous theory. London: Free Association Books.
research and thought, including Mary
Ainsworth’s work, regarding attachment in a tril-
ogy, Attachment (1969), Separation: Anxiety and
Anger (1973), and Loss: Sadness and Depression Boyd-Franklin, Nancy
(1980). Bowlby’s posthumously published biog-
raphy of Charles Darwin (1991) explored the Shalonda Kelly
roots of the naturalist’s illnesses in his early his- Rutgers, the State University of New Jersey,
tory of maternal deprivation, which drew together New Brunswick, NJ, USA
both Bowlby’s mother’s love of nature and the
essential theme of his career of children’s early
experiences with their parents. Name
Bowlby understood that his work had social
impact, despite criticism and conflict with psycho- Nancy Boyd-Franklin, Ph.D.
analysis, and believed that deprived children
would grow up to be parents who are impaired
in their ability to care for their children, and that Introduction
society could be improved by altering this cycle.
His work, collaboration, and mentorship gave rise Dr. Nancy Boyd-Franklin is an African-
to new generations of clinicians and researchers American family therapist, psychologist, and a
who applied attachment theory to the study of Distinguished Professor at Rutgers University in
adults and adult relationships cross-culturally. the Graduate School of Applied and Professional
Psychology (GSAPP). Her pioneering work on
the treatment of African-American and other eth-
Cross-References nic minority families has made a significant con-
tribution to the literature on multiculturalism and
▶ Ainsworth, Mary race within the family therapy field. Prior to the
▶ Attachment Theory 1980s, race was often ignored in the mental
▶ Attachment-Based Family Therapy health and family therapy literature and practice.
▶ Circle of Security Dr. Boyd-Franklin’s groundbreaking body of
▶ Circle of Security: “Understanding Attachment work and her innovative Multisystems Model
in Couples and Families” have contributed to a definitive shift in the field
▶ Emotionally Focused Couple Therapy to a strength-based and culturally sensitive
▶ Tavistock Clinic approach to treatment.
336 Boyd-Franklin, Nancy
Career (Includes Education, Professional Contributions to the Profession

Training, Positions)
Her seminal work, Black Families in Therapy:
Dr. Boyd-Franklin has transformed the field of A Multisystems Approach (1989), was one of
family therapy over the course of her 40-year the most influential books on African-American
career. Dr. Boyd-Franklin received her B.A families to appear in the clinical literature. This
Cum Laude from Swarthmore College and comprehensive book provided in depth discus-
herM.S. and Ph.D. in Clinical Psychology sions illustrating cultural and racial issues in ther-
from Teachers College, Columbia University. apy including: racism, racial identity, skin color,
She received extensive family therapy training extended family networks, and informal adoption.
during her internship at the Philadelphia Child This was one of the first books in the field
Guidance Clinic, training with the renowned to provide an exploration of the role of religion
Salvador Minuchin, Harry Aponte, and Jay and spirituality in clinical work with African
Haley, as well as during her subsequent training Americans.
in the Family Studies Section, Bronx Psychiat- The second edition of her book, Black Families
ric Center at the Albert Einstein College of in Therapy: Understanding the African American
Medicine. She has held academic positions Experience (2003), significantly expanded on the
at the department of psychiatry at the University first edition to areas impacting these families in
of Medicine and Dentistry of New Jersey therapy such as welfare reform, child welfare,
(UMDNJ) in Newark, and she currently teaches adoption, managed care, and affirmative action.
and supervises in the clinical and It focused on the socioeconomic diversity among
school psychology doctoral programs at African-American families with broader chapters
GSAPP. on poor, inner city clients, and middle class fam-
An internationally recognized lecturer and ilies in predominantly White communities. Issues
author, Dr. Boyd-Franklin has written numer- such as gender dynamics and couple therapy,
ous articles and book chapters on issues related racial profiling, violence, and the cultural diver-
to treatment approaches with multicultural sity of the Black community including Caribbean
populations. She has received many awards for and biracial families were explored.
her outstanding contributions to the field from Another major contribution of Dr. Boyd-Frank-
professional organizations including: the Amer- lin’s first book and her impressive list of other
ican Psychological Association, the American publications has been the development of her Mul-
Family Therapy Academy, the American Psy- tisystems Model. This is an innovative theoretical
chiatric Association, the National Council of approach for conceptualizing clinical interventions
Schools of Professional Psychology, the Asso- at multiple ecosystemic levels. Building upon
ciation of Black Social Workers, the Associa- Bronfenbrenner’s (1977) ecostructural framework,
tion of Black Psychologists, and the Teachers Dr. Boyd-Franklin applied this model to the reali-
College Multicultural Roundtable. For exam- ties of clinical practice with diverse clients.
ple, in recognition of her body of scholarly Acknowledging that everyone is embedded within
work on the treatment of African-Americans multisystemic contexts (individual, family, com-
and other ethnic minority families, the Ameri- munity, school, work, etc.), this model accounted
can Family Therapy Academy (AFTA) pre- for the impact of these systems on poor and ethnic
sented her with the “Pioneering Contribution minority families. It clarified the vulnerability of
to the Field of Family Therapy Award” in such families to the intrusion of powerful external
1991. As a result of her family-centered systems including the health, mental health, school,
approach to families with HIV and AIDS, she child welfare, police, juvenile justice, and prison
was invited by President Bill Clinton to partic- systems. Her work has also documented the puni-
ipate in the first White House Conference on tive effects of racism and poverty on the mental
AIDS in 1995. health of families of color.
Bradbury, Thomas N. 337
A number of her publications have expanded Boyd-Franklin, N., & Bry, B. H. (in press). Working with
her work on the Multisystems Model to other at-risk Adolescents: Home-based family therapy and
school-based achievement mentoring. New York:
ethnic minority populations. Her book, Children, Guilford Press.
Families, and HIV/AIDS: Psychosocial and Ther- Boyd-Franklin, N., Steiner, G., & Boland, M. (Eds.).
apeutic Interventions (Boyd-Franklin et al. 1995), (1995). Children, families and HIV/AIDS: Psychoso- B
was the first book to broaden the definition of cial and therapeutic issues. New York: Guilford
Press.
pediatric AIDS to conceptualize it as a multi- Boyd-Franklin, N., Cleek, E., & Wofsy, M. (2013).
generational family disease and one of the first Therapy in the real world: Effective treatments
to argue for a family-centered approach to treat- for challenging problems. New York: Guilford Press.
ment with African-American, Latino, and Haitian
children and families living with HIV and AIDS.
Dr. Boyd-Franklin’s Multisystems Model has
been widely applied in the treatment of at-risk
youth. In 1993, she co-founded with Dr. Brenna Bradbury, Thomas N.
Bry the Rutgers/Somerset Counseling Program for
at-risk adolescents and their families, which she Joanne Davila
directed for over 20 years. This work contributed Stony Brook University, Stony Brook, NY, USA
to her book, Reaching Out in Family Therapy:
Home-based, School and Community Interventions
(Boyd-Franklin and Bry 2000). She has just com- Name
pleted a new book on this topic entitled, Working
with At-Risk Adolescents: Home-based Family Thomas N. Bradbury, Ph.D. (b. 1959)
Therapy and School-based Achievement
Mentoring (Boyd-Franklin and Bry in press).
Her book, Therapy in the Real World: Effective
Treatments for Challenging Problems (Boyd- Introduction
Franklin et al. 2013), expands her work to inter-
ventions with individuals, families, groups, and Dr. Bradbury is a nationally and internationally
multisystemic agencies. renowned clinical scientist who had dedicated his
career to the study of intimate relationships. His
research focuses on how relationships, especially
marriages, develop and change over time, naturally
Cross-References
and through intervention. To date, he has over
170 publications, which have been cited widely.
He has won numerous prestigious awards, including
Therapy
the Distinguished Scientific Award for Early Career
▶ Cultural Identity in Couples and Families
Contributions from the American Psychological
▶ Culture in Couple and Family Therapy
Association (APA), and the Reuben Hill Award
from National Council on Family Relations, and
awards from the International Network on Personal
References
Relationships, the Association for Behavioral and
Boyd-Franklin, N. (1989). Black families in therapy:
Cognitive Therapies, and APA Division 12 (Clinical
A multisystems approach. New York: Guilford Press. Psychology). He was awarded an honorary doctor-
Boyd-Franklin, N. (2003). Black families in therapy: ate, the Laurea Honoris Causa, from Catholic Uni-
Understanding the African American experience versity in Milan in 2013. Dr. Bradbury has mentored
(2nd ed.). New York: Guilford Press.
Boyd-Franklin, N., & Bry, B. H. (2000). Reaching out in
numerous graduate and postdoctoral students, most
family therapy: Home-based, school, and community of whom have gone on to faculty positions in the
interventions. New York: Guilford Press. USA and abroad.
338 Bradbury, Thomas N.
Career support, and physical aggression. This research has

yielded a clear picture of the circumstances under
Dr. Bradbury received his Ph.D. in clinical psy- which relationships have the potential to work or
chology in 1990 from the University of Illinois at fail, and it has provided a continued impetus for
Urbana-Champaign, where he worked closely ongoing work in the field.
with Professor Frank Fincham. Since 1990 he Importantly, the vast majority of Dr. Bradbury’s
has been a faculty member in the Department of research has been prospective and longitudinal in
Psychology at UCLA, earning tenure in 1994 and nature, allowing him to truly examine develop-
Full Professor in 1998. In 2006, Dr. Bradbury ment and change over time, particularly from the
also was appointed as an Affiliated Professor in newlywed stage, through the transition to parent-
the Department of Psychology, University of hood, and into later marital stages. This has allo-
Fribourg, Switzerland, and in 2016 he was wed him to identify factors that contribute not
appointed Honorary Professor at the Education only to where people start or end in marriage,
University of Hong Kong. He has served as a but to how they get from one point to the next.
consultant and scientific advisor for numerous Dr. Bradbury’s most recent work involves inves-
national and international organizations fostering tigating interventions designed to improve relation-
marital, relationship, and family health. ship functioning. One of his most
important contributions in this area has been to
challenge the status quo which contends that com-
Contributions to Profession munication-based interventions are widely effective
in helping couples succeed. Dr. Bradbury’s work
Dr. Bradbury’s contributions are many. Early in has demonstrated that this is not the case. Not only
his career, with Fincham, he conducted ground- do communication training programs yield small
breaking research on the attributions people make changes in actual communication, those changes
about partners’ behavior and how this impacts do not predict changes in outcome over time, and
marital well-being. Prior to this work, marital such training programs are not at all helpful for
research heavily emphasized behavior to the individuals who are disadvantaged to begin with,
exclusion of cognition. Dr. Bradbury’s work was such as couples with physical aggression or alcohol
instrumental in broadening the scope of how mar- use, the very couples who may be most in need of
ital functioning is understood by drawing atten- help. This work has significant implications for
tion to the importance of how people view and public policy targeted at marital and family success.
understand partners’ behavior.
Soon thereafter, Dr. Bradbury proposed his
highly influential Vulnerability-Stress-Adaption Cross-References
(VSA) model of marital functioning, which
provided the field with a guiding paradigm ▶ Fincham, Francis
for conceptualizing how multiple factors – including
individual characteristics of the partners, environ-
mental stressors, and couple interaction processes – References
interact to impact relationship satisfaction and sta-
bility. Within the context of the VSA model, Bodenmann, G., Meuwly, N., Germann, J., Nussbeck, F. W.,
Heinrichs, M., & Bradbury, T. N. (2015). Effects of
Dr. Bradbury’s research has shed light on key factors stress on the social support provided by men and
that affect marital satisfaction and outcome, includ- women in intimate relationships. Psychological
ing: individual vulnerabilities, such as attachment Science, 26, 1584–1594.
insecurity, neuroticism, avoidance, and negative Bradbury, T. N., & Fincham, F. D. (1990). Attributions in
marriage: Review and critique. Psychological Bulletin,
family of origin experiences; stressors, such as dis- 107, 3–33.
crimination, racism, and financial strain; and inter- Bradbury, T. N., Fincham, F. D., & Beach, S. R. H. (2000).
action processes, such as positive affect, social Research on the nature and determinants of marital
Braverman, Lois 339
satisfaction: A decade in review. Journal of Marriage Contributions to the Profession

and the Family, 62, 964–980.
Karney, B. R., & Bradbury, T. N. (1995). The longitudinal
course of marriage and marital instability: A review of Lois was a powerful early voice in examining
theory, method, and research. Psychological Bulletin, the ways in which gender constructs family life,
118, 3–34. both in the assumptions that women are respon- B
Williamson, H. C., Altman, N., Hsueh, J., & Bradbury, T. N. sible for their children’s psychological well-
(2016). Effects of relationship education on couple
communication and satisfaction: A randomized con- being, the ways in which unequal financial
trolled trial with low-income couples. Journal of power affect personal power in the relationship,
Consulting and Clinical Psychology, 84, 156–166. and how early theories of family therapy ignore
the gendered realities of family life.
In 1987, she became the founding editor of
the Journal of Feminist Family Therapy and
Braverman, Lois
remained its editor until 1992. This journal pro-
vided a critical voice for deconstructing and
Ellen Berman
enriching the prevailing therapy models of
University of Pennsylvania, Philadelphia,
the time.
PA, USA
She was also active on the boards of Family
Process, Affilia: Journal of Women and Social
Work, and the Journal of Marital and Family
Introduction
Therapy.
As a leader, Lois was active in the governing
Lois Braverman has been a critical voice in
bodies of AFTA from 1991 on, including two
the development of feminist family therapy, and
terms as Program Chair, and served as President
in developing the field of family therapy through
from 2003 to 2005. During this term, she began
her superb organizational/leadership skills at the
multiple initiatives including the AFTA mono-
American Family Therapy Academy (AFTA), and
graph series, the early career member program,
leading the Ackerman Institute for the Family.
and the Endowment Initiative.
At the Ackerman Institute for the Family, she
Career has been instrumental in developing a new state
of the art training facility, increasing the number
Lois Braverman received her Master’s degree of clinical research projects that received
in social work from the University of Iowa in national and international attention, dramati-
1976. In 1983 she became the Director of the cally increasing the diversity of the faculty,
Des Moines Education Center at the University administrative staff, and professional trainees,
of Iowa School of Social Work, where she was and developing the next generation of family
responsible for the masters of social work pro- therapy teachers and trainers. She worked with
gram for 124 graduate students and reshaped the Ackerman’s faculty to examine how
clinical curriculum to reflect systemically orien- marginalization and racism impacted the rela-
ted practice. Along with three colleagues, she tional life of families.
founded and became Director of the Des Moines She has received numerous awards including:
Family Therapy Institute in 1984, a family ther-
apy training institute for post-masters practi- 2011 University of Iowa Distinguished Alumni
tioners which brought family therapy training Award
throughout the state of Iowa. After practicing in 1994 Innovative Contribution to Family Therapy –
Iowa for 30 years, she moved to New York City American Family Therapy Academy
in 2006 to become the President/CEO of the 1990 Distinguished Alumna Award, University of
Ackerman Institute for the Family, one of the Iowa School of Social Work
premier training institutes in the country. 1981 Danforth Foundation Associate
340 Bray, James
References family and health psychology, including divorce,

remarriage and stepfamilies, intergenerational
Braverman, L. (1986a). The depressed woman in context: family relationships, adolescent substance use,
A feminist family therapist analysis. In M. Ault-Riche
and screening and brief interventions for sub-
(Ed.), The family therapy collections: Women’s issues and
family therapy. Rockville: Aspen Systems Corporation. stance use. He is a pioneer in collaborative
Braverman, L. (1986b). Social casework and strategic ther- healthcare and primary care psychology and sev-
apy. Social Casework: The Journal of Contemporary eral as president of the American Psychological
Social Work, 67, 234–239.
Association in 2009.
Braverman, L. (1986c). Reframing the female client’s profile.
Affilia: Journal of Women and Social Work, 1(2), 30–40.
Braverman, L. (1986d). Beyond families: Strategic family
therapy and the female client. Family Therapy, 13(2), Career
143–152.
Braverman, L. (Ed.). (1988a). Women. Feminism and fam-
ily therapy. New York: Haworth Press.. Bray received his doctorate in clinical psychology
Braverman, L. (1988b). Beyond the myth of motherhood. In from the University of Houston in 1980. Follow-
M. McGoldrick, C. Anderson, & F. Walsh (Eds.), Women ing a postdoctoral fellowship in Family Therapy
in families (pp. 227–243). New York: W.W. Norton Press.
at the Texas Research Institute of Mental Sci-
Braverman, L. (1989). Mother-guilt. The Family Therapy
Networker, 13(5), 46–47. ences, he was appointed faculty at Texas Woman’s
Braverman, L. (1990). Jewish mothers. Journal of Femi- University (TWU) – Houston Center and
nist Family Therapy., 2(2), 9–14. remained there for 6 years. In 1987, Bray joined
Braverman, L. (1991). It’s bigger than both of
the Department of Family Medicine at Baylor
us. In T. Goodrich (Ed.), Women and power: Perspec-
tives for therapy. New York: W.W. Norton.. College of Medicine in Houston, Texas, where
Braverman, L. (1992). The magical properties of worrying. he continues to engage in research, teaching, and
Lilith, Spring, 31–32. patient services.
Braverman, L. (1995). Mothering and motherhood: Clini-
Bray has received numerous awards including
cal implications. In J. Van Lawick & M. Sanders (Eds.),
Gender and beyond. Amsterdam: Dutch Associate for Family Psychologist of the Year from the Society
Marital and Family Therapy. of Family Psychology, election into the National
Renee, R., Braverman, L., & Zuo, M. (2017). Interrogating Academies of Practice for Psychology, the Karl
the Limits of Trauma Language: A conversation on
F. Heiser Presidential Award for Advocacy on
sexual abuse narratives and storytelling. Guernica.
July1. https://www.guernicamag.com/interrogating- Behalf of Professional Psychology, and the Edu-
the-limits-of-trauma-language. cation Advocacy Distinguished Service Award
from the American Psychological Association.
Bray, James Contributions to the Profession

Susan Nash
Bray has made numerous contributions through
Department of Family and Community Medicine,
his research, teaching, publications, and
Baylor College of Medicine, Houston, TX, USA
leadership.
Family System Measurement. At TWU he
worked with Donald Williamson researching
Name
intergenerational family relationships and per-
sonal authority in the family system (PAFS).
James Houston Bray, Ph.D. (1954–)
They developed the Personal Authority in the
Family System Questionnaire (PAFS-Q), which
Introduction has been used in studies across the world.
Stepfamily Research. Bray’s “Developmental
James H. Bray is a distinguished American psy- Issues in Stepfamilies” research project investi-
chologist who has made major contributions to gated the social, emotional, and behavioral
Bray, James 341
development of children in stepfamilies and first Leadership Organizing Committee; President of

marriage families. Funded by the NIH National the Texas Psychological Association (2015),
Institute of Child Health and Human Develop- President of the American Society for Advance-
ment, this project was one of the first longitudinal ment of Pharmacotherapy (2014); and President
studies on the effects of divorce and remarriage on of the Division of Professional Practice of the B
children and adolescents. This groundbreaking International Association of Applied Psychol-
work was subsequently summarized in his book: ogy. He also served as treasurer for five APA
Stepfamilies: Love, Marriage and Parenting in divisions (34, 37, 43, 46, 55); member-at-large,
the First Decade. Division of Psychotherapy (29), Media Psychol-
While at Baylor, Bray completed the “Step- ogy (46), and Psychopharmacology (55).
family Project” and focused on the collaboration Bray is a fellow of 12 APA Divisions: 5 –
between psychologists and family physicians. Evaluation, Measurement and Statistics; 7 –
Through partnership with John Rogers, MD, Developmental Psychology; 12 – Society of
they completed one of the first demonstration pro- Clinical Psychology; 29 – Division of Psycho-
jects on teaching psychologists to collaborate with therapy; 31 – State, Provincial and Territorial
primary care physicians. Their “Linkages Project” Psychological Association Affairs; 34 – Society
demonstrated that collaboration between behav- for Environmental, Population and Conserva-
ioral health professionals and primary care physi- tion Psychology; 37-Society for Child Family
cians facilitates positive gains and is possible in Policy and Practice; 38 – Health Psychology;
both rural and urban areas. 42 – Psychologists in Independent Practice; 43 –
Bray and his colleagues (Paul Baer, Greg Getz, Society for Family Psychology; 46 – Media
Gerald Adams, Amy McQueen, Susan Nash) Psychology; and 55 – American Society for the
conducted a series of NIAAA funded studies on Advancement of Pharmacotherapy.
adolescent alcohol use. The Baylor Adolescent Bray is also licensed as a private pilot with an
Alcohol Project used measures and methods instrument rating and enjoys studying oenology
developed in previous research to investigate in his spare time. He is married to Elizabeth
how family relationships, peers, and the develop- Mason Bray, the owner of an HR consulting
mental process of individuation influence adoles- firm. He has three children and two
cent drinking in junior high and high school aged stepchildren.
students. The research also examined ethnic dif-
ferences in adolescent drinking. He continues to
apply these findings in his clinical work in com-
Cross-References
munity, private, and mental health clinics.
Bray has published over 200 articles, tests,
▶ Stepfamilies in Couple and Family Therapy
book chapters, books, and reviews. He has been
on the editorial boards of several leading journals:
Family Process, Journal of Family Psychology,
References
Psychotherapy, Families Systems and Health,
Monographs of the Society for Research in Child Bray, J. H. (2004). Personal authority in the family system
Development. He is the coeditor of Primary Care questionnaire manual (2nd ed.). Houston: D-Boy
Psychology (2004) and the Handbook of Family Productions.
Bray, J. H. (2010). The future of psychology practice and
Psychology (2009). science. American Psychologist, 65, 355–369.
Leadership and Service. Active in APA gov- Bray, J. H., & Berger, S. H. (1993). Developmental issues
ernance since 1988, Bray has been involved in in stepfamilies research project: Family relationships
practice, science, education, and state issues. He and parent-child interactions. Journal of Family Psy-
chology, 7, 76–90.
has served on the Board of Educational Affairs;
Bray, J. H., & Kelly, J. (1998). Stepfamilies: Love, mar-
Rural Health Task Force and Committee on riage, and parenting in the first decade. New York:
Rural Health; Primary Care Task Force; State Broadway Books. Paperback edition, April 1999.
342 Breunlin, Douglas C.
Stiefouder en stiefkinderen (Dutch ed.). Amsterdam: and over 60 articles and chapters on subjects
Forum, 1999. related to family therapy training, theory develop-
Bray, J. H., & Maxwell, S. E. (1985). Multivariate analysis
of variance. Thousand Oaks: Sage. ment, and the integration of psychotherapies. He
Bray, J. H., & Rogers, J. C. (1997). The linkages project: continues to practice, teach, write, and conduct
Training behavioral health professionals for collabora- research at TFI.
tive practice with primary care physicians. Families,
Systems, & Health, 15, 55–63.
Bray, J. H., & Stanton, M. (Eds.). (2009). Handbook of
family psychology. London: Wiley-Blackwell. Career
Bray, J. H., Williamson, D. S., & Malone, P. E. (1984).
Personal authority in the family system: Development Douglas C. Breunlin completed undergraduate
of a questionnaire to measure personal authority in
intergenerational family processes. Journal of Marital work at the University of Notre Dame where he
and Family Therapy, 10, 167–178. received a BS degree in aeronautical engineering
Bray, J. H., Adams, G., Getz, J. G., & Baer, P. E. (2001). and a BA in Arts and Letters. These studies pro-
Developmental, family, and ethnic influences on ado- foundly impacted his contributions to the field of
lescent alcohol usage: A growth curve approach. Jour-
nal of Family Psychology, 15, 301–314. couple and family therapy, the former through
Bray, J. H., Adams, G. A., Getz, J. G., & McQueen, precise thinking about problem solving and the
A. (2003). Individuation, peers and adolescent alcohol latter through an appreciation of the complexity of
use: A latent growth analysis. Journal of Consulting the human experience. Following a career as an
and Clinical Psychology, 71, 553–564.
Bray, J. H., Kowalchuk, A. K., Waters, V., Laufman, L., & aeronautical engineer at the National Aeronautics
Shilling, E. H. (2012). Baylor SBIRT medical resi- and Space Administration (NASA), he completed
dency training program: Model description and initial graduate training in social work at Case Western
evaluation. Substance Abuse, 33, 231–240. Reserve University where he developed a love of
Frank, R., McDaniel, S. H., Bray, J. H., & Heldring,
M. (Eds.). (2004). Primary care psychology. systems theory and family therapy. Following
Washington, DC: American Psychological graduation, he accepted a position as a family
Association. therapist at The Family Institute in Cardiff,
Wales, where he later became the Director of
Student Unit Training. Living abroad fueled his
interest in the impact of culture on family systems.
Breunlin, Douglas C. The Institute’s focus on training inspired his com-
mitment to study the training process.
William P. Russell Breunlin then returned to the States where, for
The Family Institute at Northwestern University, 12 years, he worked at the Institute for Juvenile
Evanston, IL, USA Research (IJR) in the Family Systems Program
(FSP), first as a family therapy trainer, then as
Director of FSP, and finally as the Training Direc-
Name tor for IJR. During the FSP years, he was fortunate
to work with prominent family therapists Richard
Douglas C. Breunlin Schwartz, Celia Falicov, Howard Liddle, and
Betty MacKune-Karrer. This highly creative
group did seminal work together for over a
Introduction decade. The group published in the areas of train-
ing and training research, theory development,
Douglas C. Breunlin is a Clinical Professor of and integration of family therapy models.
Psychology at the Family Institute at Northwest- In 1990, Breunlin accepted the position of
ern University (TFI). He has enjoyed a 42-year Chief Operating Officer at The Family Institute
career as a marriage and family therapist. He has at Northwestern University (TFI) (formerly the
spent his career working at major centers devoted Family Institute of Chicago). He worked closely
to family therapy and has published four books with William Pinsof, TFI Chief Executive Officer,
Breunlin, Douglas C. 343
to establish TFI as one of the premier family (Breunlin 1988). Drawing on Bateson’s theory
therapy centers in the world. This work included of negative explanation, he incorporated and artic-
creating a formal relationship with Northwestern ulated the concept of constraint within family
University and building a state-of-the-art facility systems theory (Breunlin 1999). He expanded
on the Northwestern campus. He also began a the important concept of interactional sequence B
quarter century collaboration with Pinsof to by cataloging sequences according to their peri-
develop a comprehensive integrative perspective odicity (Breunlin and Schwartz 1986). He devel-
on the practice of psychotherapy. Breunlin and oped the concept of a metaframework, that is, a
Pinsof were later joined by William Russell, Jay framework of frameworks, to enable systemic
Lebow, Cheryl Rampage, and Anthony Chambers family therapists to draw ideas about domains of
in the work to refine and advance the integrative human functioning from the various models of
perspective. In 2009, Breunlin became the Pro- family therapy.
gram Director for the Master of Science in Mar- While serving as director of the Clinical
riage and Family Therapy, a program that is Externship at The Family Systems Program at
jointly operated by TFI and Northwestern Univer- IJR, Breunlin recognized the need for students to
sity. During his tenure at TFI, Breunlin also cre- be able to integrate the models of family therapy
ated the Peaceable Schools Initiative and served being taught. With colleagues Richard Schwartz
as the director of the Family Business Program. and Betty MacKune-Karrer, he expanded the con-
Research studies were published from the prod- cept of a metaframework into an integrative per-
ucts of both programs. spective and a book titled: Metaframeworks:
Breunlin has served on the editorial boards of Transcending the Models of Family Therapy
Family Process, Journal of Marital and Family (Breunlin et al. 1992).
Therapy, Journal of Family Therapy, and Couple Breunlin continued to maintain an interest in
and Family Psychology. He also served as secre- integration once he moved to The Family Institute
tary, treasurer, and board member for the Ameri- at Northwestern University. In 2009, he, along
can Family Therapy Academy. with William Pinsof, William Russell, and Jay
Lebow, formed a task force to explore the meta-
integration of Breunlin’s “Metaframeworks Per-
Contribution to the Profession spective” and Pinsof’s Integrative Problem-
Centered Therapy (Pinsof 1995). This work cul-
Mr. Breunlin has published extensively on the minated in the publication of two articles in Fam-
training and supervision of marriage and family ily Process on a new perspective called
therapists. He is coeditor (with Howard Liddle “Integrative Problem-Centered Metaframeworks”
and Richard Schwartz) of The Handbook of Fam- (Breunlin et al. 2011; Pinsof et al. 2011) and a
ily Therapy Training and Supervision, the first chapter on this approach in Sexton and Lebow’s
such text in the field (Liddle et al. 1988). With Handbook of Family Therapy (Russell et al.
Richard Schwartz, he developed one of the first 2015). The group added members Cheryl Ram-
instruments to evaluate the outcome of family page and Anthony Chambers and further expli-
therapy training (Breunlin et al. 1983). He worked cated the perspective in a book titled Integrative
with Howard Liddle, Richard Schwartz, and John Systemic Therapy: Metaframeworks for Problem
Constantine to develop the first formal program to Solving with Individuals, Couples, and Families
train family therapy supervisors (Liddle (Pinsof et al. 2017).
et al. 1984). Breunlin also coedited (with Jay Lebow and
Mr. Breunlin has maintained a strong interest Anthony Chambers) The Encyclopedia of Couple
in theory development in the field of marriage and and Family Therapy (Lebow et al. 2017). This
family therapy. He advanced the stage-transition online and hardbound encyclopedia has over
model of development to include the concept of 1,000 entries authored by prominent figures in
microtransitions and developmental oscillations the field of couple and family therapy.
344 Brief Relational Couple Therapy
Throughout his career, Breunlin has Pinsof, W. M. (1995). Integrative problem centered
maintained a substantial clinical practice. Many therapy: A synthesis of family, individual, and biolog-
ical therapies. New York: Basic Books.
of the ideas reflected in his writing and teaching Pinsof, W., Breunlin, D., Russell, W., & Lebow, J. (2011).
derive from his clinical experience. Integrative problem centered metaframeworks (IPCM)
therapy II: Planning, conversing, and reading feedback.
Pinsof, W., Breunlin, D., Russell, W., Lebow, J.,
Cross-References Rampage, C., & Chambers, A. (2017). Integrative sys-
temic therapy: Metaframeworks for problem solving
with individuals, couples and families. Washington,
▶ Family Institute at Northwestern University DC: APA Books.
▶ Integrative Problem-Centered Metaframeworks Russell, B., Pinsof, W., Breunlin, D., & Lebow, J. (2015).
▶ Integrative Systemic Therapy Integrative problem centered metaframeworks (IPCM)
therapy. In T. Sexton & J. Lebow (Eds.), Handbook of
▶ Pinsof, William M.
family therapy (pp. 530–544). New York: Routledge.
▶ Russell, William P.
▶ Schwartz, Richard C.
▶ Theory of Constraints in Couple and Family
Therapy
Brief Relational Couple
Therapy
References
Douglas Flemons and Shelley K. Green
Breunlin, D. C. (1988). Oscillation theory and family
Nova Southeastern University, Fort Lauderdale,
development. In C. J. Falicov (Ed.), Family transitions: FL, USA
Continuity and change over the life cycle
(pp. 133–155). New York: Guilford.
Breunlin, D. C. (1999). Toward a theory of constraints.
Journal of Marital and Family Therapy., 25(3),
In keeping with other brief therapy models –
365–382. including MRI (developed by the clinicians at
Breunlin, D. C., & Schwartz, R. C. (1986). Sequences, the Mental Research Institute, e.g., Watzlawick
toward a common denominator of family therapy. Fam- et al. 1974), Strategic Therapy (Haley 1987),
ily Process, 25, 67–87.
Breunlin, D. C., Schwartz, R. C., Krause, M., & Selby, L.
Solution-Focused Brief Therapy (SFBT) (e.g., de
(1983). Evaluating family therapy training: The devel- Shazer 1985), and the Milan Associates (e.g.,
opment of an instrument. Journal of Marital and Fam- Boscolo et al. 1987) – Brief Relational Couple
ily Therapy, 9(1), 37–48. Therapy (BRCT) is a systemic approach signifi-
Breunlin, D. C., Schwartz, R. C., & Karrer, B. (1992).
Metaframeworks: Transcending the models of family
cantly influenced by Gregory Bateson’s revolu-
therapy. San Francisco: Jossey-Bass. (Paperback edi- tionary systemic ideas (Bateson 2000) and Milton
tion, 1997, Portuguese edition, 2000, Artmed Erickson’s innovative hypnotherapy and psycho-
Editorial). therapy methods (Erickson 1980; Flemons 2002;
Breunlin, D. C., Pinsof, W., Russell, W., & Lebow, J.
(2011). Integrative problem centered metaframeworks
Flemons and Green 2007, 2018; Haley 1986).
(IPCM) therapy I: Core concepts and hypothesizing.
Lebow, J., Chambers, A., & Breunlin, D. (Eds.). (2017). Introduction
Encyclopedia of couple and family therapy. New York:
Springer.
Liddle, H. A., Breunlin, D. C., Schwartz, R. C., & Con- As brief therapists, BRCT clinicians are committed
stantine, J. A. (1984). Training family therapy supervi- to working as efficiently as possible (Fisch et al.
sors: Issues of content, form and context. Journal of 1982). Aware that both therapist- and client-
Marital and Family Therapy, 10(2), 139–150.
Liddle, H. A., Breunlin, D. C., & Schwartz, R. C. (Eds.).
expectancy contribute significantly to therapeutic
(1988). Handbook of family therapy training and outcome (Kirsch 1999), they are careful not to
supervision. New York: Guilford. assume that long-standing and/or particularly
Brief Relational Couple Therapy 345
distressing problems necessarily require longer regardless of the consequences, to protect them-
durations of treatment (O’Hanlon and Wilk 1987). selves. One or the other (or both) may also feel the
They search for and highlight the strengths and need to protect the children, the other person,
resources of couples – noting their areas of exper- and/or the relationship.
tise and any previous successes in solving This assumption of the therapists about the B
problems – and they offer possible understandings necessity of safety is an example of reframing, a
(or framings – see below) of the problem for therapeutic technique derived from Bateson’s
clients to consider. They acknowledge their own (2000) recognition that the way an item of percep-
expertise in helping couples change, but they tion or experience is contextualized or categorized
make clear that they don’t have privileged access (i.e., “framed”) is integral to its meaning. When the
to a “correct” view of the clients’ situation. This context or category (the frame) is changed, the
nonnormative stance means the therapists never meaning changes, and this in turn changes the expe-
take a position on what the clients “should” do, rience itself. For example, when clients’ intransi-
and they don’t advocate for “better” or more gence on an issue is framed (by themselves, by
“open” communication. Any ideas the therapists their partner, and/or by a professional) as petty stub-
offer are posed tentatively and are qualified as bornness, they can’t change their mind without los-
provisional. ing face, without admitting, if only tacitly, that they
BRCT therapists make suggestions for experi- have been inappropriately and unnecessarily resis-
ments the clients might undertake (either in the tant. However, if the importance of safety is
session or back at home) to gather information underscored and their behavior is reframed as one
about consistencies and variations in the problem of many ways of ensuring this safety, then a change
the clients have identified. However, they avoid of mind is not an admission of blame and it doesn’t
offering “first-order” solutions (Watzlawick et al. have to entail a loss of face. In this way, clients are
1974), that is, ideas for interventions that don’t differ provided the freedom to safely change from this
significantly from what the couple has already tried way of feeling protected to that way.
or what others (whether friends, family members, or BRCT therapists work to create the conditions
other therapists) have already suggested. As MRI for clients to safely experience the vulnerability of
theorists pointed out long ago, problems are gener- interpersonal intimacy. Such intimacy – first,
ated and maintained by ineffective solution attempts perhaps, with the therapist and then with the
applied to life difficulties (Watzlawick et al.). partner – is engendered through conversations
Committed to developing an insider’s apprecia- organized by the therapists’ commitment to
tion of the pattern, the “logic,” of the couple’s inter- empathic knowing. Contrary to what is commonly
action, BRCT therapists concur with the MRI understood, empathy does not involve therapists
emphasis on “speaking the client’s language” and asserting that they understand what the clients are
attending to the client’s beliefs, values, and prior- describing:
ities (Fisch et al. 1982). Their goal is to make Joanne: I can’t take it anymore. I’m ready to leave.
“contextual sense” of the couple’s fights but also If I’m not screaming at Tony, I’m screaming in my
of the stubborn commitments of each partner. head: Enough! Enough already!!
Rather than attempting to correctly diagnose Therapist: I hear what you’re saying. I get that
you’re upset.
pathology in how people think and/or what they
do, BRCT therapists go in search of the legitimacy Rather than claiming to understand, BRCT ther-
of each partner’s positions and actions, as well as apists demonstrate it by offering back empathy-
the legitimacy of the couple’s interactive pattern informed descriptions of, and hunches about, what
of relating. The therapists operate from the they have distilled from the clients’ stories.
assumption that the fighting and the suffering Joanne: I can’t take it anymore. I’m ready to leave.
reflect both partners’ fundamental need for safety If I’m not screaming at Tony, I’m screaming in my
and their willingness to do whatever it takes, head: Enough! Enough already!!
Therapist: You’re at your wits’ end! And there’s Joanne: I do! Why is it up to me, the one working
no respite. Screaming inside, screaming outside – you her butt off and paying the bills, to also have to make
must be exhausted. dinner?! If he doesn’t care about me, well, whatever,
Joanne: Yes, but I’m too wired to feel the but at least he could do it for the girls – they need to
exhaustion. eat!
Therapist: So stressed. Kind of like feeling per- Therapist: It seems to you like a no-brainer. If
petually charged with an electric current? only for the kids!
Joanne: So much. And I’m afraid of a spike Joanne: Yes. Exactly.
taking me out. Therapist: (turns to Tony) Do you agree with
Joanne that most nights when she gets home she is
Attending carefully to both the content and the the one to start in on making dinner?
Tony: Such a heroic figure. Fighting the good
emotional complexities of the stories, therapists
fight all day at work, only to arrive home and start
offer their emerging empathic grasp of what the dishing it out as she walks in the front door.
clients are saying. As clients listen and respond to Therapist: Comes in like she’s spoiling for a
these comments, agreeing with some and fight? You must have to gird yourself for her arrival.
disagreeing with or correcting others, therapists Tony: You said it!
Therapist: I imagine the wine helps with that.
use the feedback to adjust what they are under- Tony: Oh yeah. I hear the car door, and I know
standing (and thus saying). Through such recursive the fireworks are about to begin.
dialogue, therapists derive a more accurate grasp of Therapist: Feels safer in your room?
Tony: Let’s just say there’s no “Hello, how was
the clients’ experience, and clients feel better heard
your day?” No “How’d the writing go?” No “How
and understood, allowing them to relax into are the girls?”
trusting someone who is essentially a stranger. Therapist: You’d like to feel Joanne’s interest in
This interactive unfolding of empathic know- you and the girls be more important than her con-
cern about whether you’re fulfilling your assigned
ing is particularly important when working with
duties.
couples, as conflict is common. Rather than trying Tony: Yes!
to maintain a neutral position that neither partner Therapist: You want to feel like her husband and
would take issue with, BRCT therapists adopt co-parent, not her employee.
Anderson and Goolishian’s (1986) commitment Tony: Exactly.
Therapist: And Joanne, I imagine you’d love to
to “multi-partiality” with couples who are holding walk in the door and encounter a husband who is
divergent views and are telling demonstrably dif- happy you’re home and invites you to join him in
ferent versions of fights and disagreements. The sharing some wine and finishing off dinner
preparations.
therapist stays actively engaged at all times, mak-
Joanne: That would be wonderful.
ing empathic statements that the one partner can Therapist: You don’t want to be in the position
agree with, acknowledging that the other partner of assigning duties.
views the situation fundamentally differently, Joanne: Not at all. But he doesn’t step up, so
what I’m supposed to do?
empathizing with the second partner’s view and
Therapist: It has felt like you’ve had no choice.
experience, going back and doing the same with Joanne: Right.
the first partner, and so on: Therapist: Man, it would feel so much better to
not feel compelled to ride him.
Joanne: I race home as soon as I can, but it is often Joanne: You can’t imagine the relief.
after six. By then Tony, who isn’t working and has Therapist: Let’s talk about what the first step in
no other responsibilities, should at least have dinner that direction might look like.
on, if not have the girls fed. But nine times out of
ten, he hasn’t even figured out what he’s going to Such empathy-infused conversations help each
cook. Is he at least helping them with their home-
partner to feel understood, and they can facilitate
work? No! He’s in his room on his iPad, drinking
his first glass of wine for the evening. descriptions in positive terms of what each person
Therapist: You arrive home frazzled and needs and what he or she might be willing and
exhausted, and it seems only reasonable that Tony able to do differently in the service of making
would show appreciation for all you do by helping
change possible. The conversations also provide
with the kids – with cooking and homework. It
sounds like you experience his being in his room a foundation for the therapist to introduce subtle
as an affront. shifts in how the problem is understood. The
therapist framed Tony’s drinking of wine and each other’s responses. It doesn’t take long, par-
retreating to his bedroom as methods of protection ticularly at times of high stress, for the communi-
or coping. Such characterizations are supportive cations to become fraught – knotted in a way that
rather than critical, and, as such, they make it feels difficult if not impossible to untangle.
possible for Tony to make different choices in BRCT therapists thus conceive of themselves B
the future without losing face. Implied in the as disentanglement consultants. This is an impor-
therapist’s comments is the idea that if Tony has tant distinction: When couples localize a problem
been protecting himself from Joanne in these (usually each partner locates it inside the other
ways, perhaps he could find other ways of feeling person – “We’d be fine if only it weren’t for my
safe. Perhaps he could shift from protecting him- partner’s pathology”), they typically come to ther-
self from her to protecting himself with her. The apy with a request to have the problem controlled,
therapist also described Joanne feeling like she contained, or cured. But such goals are
had no other choice than to tell Tony what he unattainable, and they lead to solution behaviors
needed to do. This is different from describing that tend to exacerbate the suffering (Watzlawick
her as actually not having any other choice. The et al. 1974). All problematic solution attempts
description implies that there is flexibility avail- stem from a desire to distance from whatever is
able; she just hasn’t recognized it, yet. Thus, the deemed undesirable; treating the problem as
conversation has brought the couple to a place other, clients want to be rid of it. Paying heed to
where they can safely explore other possibilities. Milton Erickson’s admonition (in Rossi and Ryan
The relational orientation of BRCT therapists 1986) that the clinician’s task is “that of altering,
is grounded in Bateson’s (1991) recognition that not abolishing” (p. 104; italics in the original),
we “live in a world that’s only made of relation- BRCT therapists shift the clients’ goal from want-
ships” (p. 287). Information, the “stuff” of mind, ing to be free of the problem to finding freedom in
is composed not of things but of differences or relation to it. Problems are altered when the cli-
distinctions (Bateson 2000; Flemons 1991), and a ents’ experience has changed – when they are able
difference is nothing (a no-thing) other than a to do something different in the relationship and in
relationship – a boundary that separates (and relation to the problem, which then allows them to
thus identifies) an object from what it isn’t. view the relationship and the problem differently,
According to Bateson (2000), mind is not synon- or when they come to a different view of their
ymous with brain but is, rather, a system- partner and the struggle they’ve been having
emergent phenomenon, formed and maintained together and this shift in perspective frees them
in communicational loops within and between up to engage differently.
brain and body, and within and between perceiv- BRCT therapists have no interest in couples
ing organisms in an ecosystem: “The individual achieving “insight.” This would imply that there
mind is immanent but not only in the body. It is exists one “right” understanding of the clients’
immanent also in pathways and messages outside situation and their participation in it, and that
the body; and there is a larger Mind of which the finding and embracing this understanding would
individual mind is only a sub-system” (2000, itself be somehow therapeutic. Instead, the focus
p. 467). is on the clients finding it possible to orient differ-
For BRCT therapists, the relevant loops of this ently to themselves and each other, allowing for a
larger mind are those within and between partners shift in their pattern of interaction and/or in the
and among the partners and the therapist. The discovery of exceptions to their problem.
information shared along these circuits is some-
times rational, but it is always relational. Both
partners are communicating back and forth – or, Case Study
more accurately, round and round – within them-
selves (between brain and body) and with each A BRCT therapist began seeing Stephen, a
other, responding to each other’s responses to 50-year-old physician, after Stephen’s wife,
Rachel, also a doctor, discovered his 4-year affair Rachel (crying): I hate that I still love him. If
with a drug rep, Sandra, who still often visited his I could leave him and tell him to go to hell I would.
But I still love him. I want this marriage.
practice. Rachel worked at a hospital serviced by Therapist: You feel so caught, wanting, but so
a different rep, so she didn’t know Sandra per- far unable, to cast him aside. The connection is
sonally, but when she discovered the texts and strong. You just want to be rid of him and you just
emails that confirmed the betrayal, she was able want him.
Rachel: (quietly) Yes, both.
to use social media to familiarize herself with a Therapist: And (turns to Stephen) as hard as it is
woman she considered her nemesis. to imagine ending your relationship with Sandra,
As therapy began, Stephen was still very here you are with Rachel, receiving her pain and
much involved with Sandra and reluctant to end anger, accepting it.
Stephen: I hate hurting you, Rachel. I’m truly
it, although Rachel was demanding that he do sorry. I just can’t promise you right now that I will
so. The couple had played mixed-doubles tennis never see her again. She’s not a bad person. I don’t
for many years, successfully competing nation- want to devastate her.
ally when they were younger and, until recently, Rachel: (yelling) But you’re devastating me!
Therapist: (to Stephen) You don’t want to hurt
still actively involved in senior competitions. either of them.
The revelation of the affair had rocked this Stephen: No, I don’t.
world, where both were minor celebrities, as Therapist: (to Rachel) And you’re caught by the
well as the local medical community, where irony that Stephen’s commitment not to be hurtful
wounds you to your core.
they were respected as a successful dual-career Rachel: It stabs me in my heart.
couple. Therapist: . . . So very, very painful. And no
The therapist saw Stephen alone for several easy answers. Rachel, what do you know about
sessions as he oscillated between guilt over hurt- yourself, and about Stephen, that gives you hope
you can recover from this betrayal, whether or not
ing Rachel and a desperate desire to continue the marriage itself survives?
seeing Sandra. After a number of weeks, Stephen Rachel: I don’t know (more crying); I am just
announced that he wanted to fix his marriage, and not willing to give up. Not yet, not after 20 years.
he asked Rachel to join the therapy. They began I still love the bastard, stupid as that sounds.
working towards rebuilding their fractured rela-
tionship, but the progress was touch-and-go. While Stephen remained stuck, not knowing
Despite his reassurance to Rachel that he would how or whether to end his relationship with
end the affair, Stephen held back from cutting off Sandra or to divorce his wife, the therapist saw
all contact with Sandra, and, he said, he could do Rachel for several sessions, helping her to find
nothing about the fact that his office was still part her way through the anger and confusion she
of her drug-rep responsibilities; he couldn’t stop was experiencing. She remained unconvinced
her from dropping off samples and requesting that she and Stephen could ever make the pro-
time with the docs. This devastated Rachel, gress necessary to reconcile and rebuild their
who would threaten to leave, but she didn’t fol- relationship, and the therapist respected this
low through, as she truly wanted to save the questioning. Blind-sided by the affair and pub-
marriage. lically humiliated when it had become known to
Rather than urging Stephen to end all contact both the professional and tennis communities,
with Sandra and reclaim his marriage, and rather she had, she said, “gone underground,” losing
than urging Rachel to fight harder for her husband or her voice and becoming an invisible passenger
make good on her threats, the therapist, eschewing in a relationship that felt out of control. Nor-
any position of authority from which to tell them mally a strong and productive person, Rachel
what they should do, instead maintained a stance of felt she had lost her balance, resulting in her
deep empathy for both partners. acting in ways that she didn’t recognize or
Therapist: Rachel, this is such familiar territory for
respect. She wanted to stop alternating between
you, and yet you never give up hope. Even in the berating Stephen about the affair and begging
midst of your devastation, you reach out to Stephen. him to end it.
Therapist: It makes sense to me that you would be The couple came in together to the next
out of touch with your usual mojo – you are accus- appointment 3 weeks later. They had spent two
tomed to being a vibrant part of a dynamic, and very
public, relationship. So who is Rachel outside of the weekends together, talking intensely about issues
Rachel-and-Stephen duo? they had not discussed in many years, and Ste-
Rachel: Exactly! I hate it; I feel invisible, and phen said he had not been in touch with Sandra for B
then I hate him. And I have no voice! No vote! The several weeks. During this session, the couple
son of a bitch does exactly as he pleases, and I have
to accept the fallout. He just gets away with it! described an ongoing challenge that Stephen con-
sidered a catalyst for his affair. For several years,
Rachel had been closely monitoring Stephen’s sex with Rachel had felt like “an obligation,” and
computer and cell-phone communications with at some point along the way, he’d found himself
Sandra, focusing on that to the exclusion of most unable to maintain an erection during intercourse.
everything else, save for her patients. She and the He’d started avoiding sex with her altogether, and
therapist explored expanding the scope of her they’d become “like roommates,” and this had
interests to include activities of her own she compromised not only their physical closeness
cared about. but also their emotional connection. With Sandra,
he’d had “no problems in the penis department.”
Therapist: Certainly, right now Stephen is calling This had been both exciting and relieving for him,
the shots on what happens with this other relation- proving that he didn’t have a physical problem.
ship. What parts of your life are still yours? What
matters to you now in the areas of your life that you
Now that they were having unprecedented
are in charge of? intense, intimate dialogues, this topic was on the
Rachel: I’m still a doctor, and I’m still an athlete. front burner, and they were concerned it could be
I have a professional identity separate from him, but a deal breaker, even as they both gained confi-
we’ve been tennis partners for forever. I haven’t
played singles for as long as I can remember, and
dence that they could save their marriage. Rachel
I don’t remember the last time I competed with a was not the least bit interested, she said, in staying
different partner. in a sexless marriage. Turning to Stephen, she was
clear and forceful: “You can take your obligation
The therapist acknowledged how difficult it and shove it up your ass!” She was no longer
would be for Rachel to find anything as arresting concerned, she said, about whether he considered
as the status of Stephen’s relationship with her sexy enough; she found herself sexually
Sandra; nevertheless, they explored the possi- attractive and, if he didn’t, she knew she would
bility, however slim, of her experimenting with find someone else who would. Rachel had found
reclaiming a life that didn’t have Stephen at the her voice, her strength, and her independence. She
center. When she returned a few weeks later, was clear that she wouldn’t tolerate any commu-
Rachel described an experience much different nication between Stephen and his lover, but she
from what she would have predicted. She’d also said that she was firing herself as a “private
started thinking a lot about personal agency, investigator.” If Stephen chose to be with her, he
and she’d decided to do something about had to be all-in; if he waffled, or if she discovered
it. She moved fulltime into a nearby condo that he was lying, she’d immediately file for divorce. If
she and Stephen owned on the beach, she started he wanted to work towards rebuilding trust and to
playing women’s doubles tennis, and she risk reigniting their sexual relationship, she would
blocked both Stephen and Sandra on Facebook. consider it; otherwise, she was moving forward on
She and Stephen had gone to dinner twice, but her own. Stephen found the difference in Rachel
only when it was convenient for her; a few other both intriguing and terrifying.
times when he’d suggested they meet, she’d
been too busy with work or other involvements Therapist: (to Stephen) What’s it like to have these
conversations with Rachel now, and to anticipate
to agree. She said she’d become much less reac- being sexual with her?
tive to him – her anger had transported her into Stephen: Talking to her is incredibly arousing;
living rather than stewing. she’s strong and demanding and sexy. I’ve never
been so attracted to her, intellectually. But I don’t Stephen. I’m wondering how your body may
trust that’s going to make the difference for me respond differently now, Stephen, given that you
physically. And the thing is, I know there is nothing would no longer be “cheating” when being sexual
wrong with me physically. I can perform, believe with Rachel.
me! Rachel: Sweet. My philandering husband has a
Rachel: Well, imagine how terrifying that is for monogamous dick. Who knew?
me, Stephen! How can I risk making myself vul-
nerable to you, knowing that if I’m not sexy By reframing Stephen’s erection difficulties as
enough, you’ll just go back to her! a sign of his faithfulness, if only to his lover,
the therapist offered Stephen and Rachel (and
These significant changes in their ways of relat- Stephen’s mindful body) a way forward. Given
ing to each other, and in Rachel’s ways of relating to the intimacy and vulnerability generated by their
Stephen, to his affair, and to her own sexuality, new conversations, and given Stephen’s commit-
opened the door to different ways of conceptualizing ment to direct his faithfulness towards his wife,
their past struggles. The therapist acknowledged the they could expect his “monogamous penis,” not
differences and offered a reframe of Stephen’s past weighted down by guilt, to rise to the occasion.
difficulty in maintaining an erection with Rachel.
Therapist: So, what incredible risks you are both
Therapist: How very difficult for both of you to taking – finding the freedom to talk about sex when
imagine enjoying sexual encounters together while it has been a taboo topic – and act! – for so many
worrying that if Stephen can’t get it up, this would years.
mean the end of your relationship. These are incred- Rachel: Yes, it’s terrifying, but I’m not going to
ibly high stakes, and a lot of pressure to put on one go back underground. This is our only chance.
organ and one experience. Stephen, I have a ques- Therapist: There is tremendous risk for both of
tion for you. you, but what I notice is that you are each finding
Stephen: Shoot. the strength to embrace risk in new ways. I wonder
Therapist: You said before that sex with Rachel how you will find desire in that risk, and where that
had starting feeling like an obligation. desire will take you both.
Stephen: That’s right.
Therapist: And then at some point after that, you
The couple continued to attend therapy,
started having erection difficulties during
intercourse. sometimes weekly, sometimes sporadically, for
Stephen: Yes. the next 3 months. Rachel stayed in the condo
Therapist: Do you remember when that started? until she decided it was emotionally safe to
Rachel: It didn’t happen all of a sudden, but it
move home, and they started playing tennis
got pretty quickly to where it was happening a lot,
and then he just avoided sex altogether. together again, though with a different set of
Therapist: That sound about right to you, interpersonal rules. Stephen had always been a
Stephen? fierce competitor; when one of them would
Stephen: Pretty close, yeah.
make a mistake, he’d be quick to anger and
Therapist: And when did that start?
Rachel: Must have been about four years ago. unrestrained in voicing his criticism. He
Therapist: Makes sense. About the time the wouldn’t hold onto his rancor, but his words
affair started. and tone of voice would ring in Rachel’s ears,
Rachel: Son of a bitch!
and she was no longer willing to be subjected to
Therapist: Sure, but this is what I’m thinking. It
seems to me, Stephen, that while you were involved his temper. She agreed to play again with him in
with Sandra, being sexual with Rachel felt to your competition, but only if he approached winning –
penis like “cheating” on Sandra. While obviously and losing – with more acceptance and kindness.
disturbing to you both, the one thing your lack of an
He took up her challenge and worked, mostly suc-
erection accomplished during your relationship
with Sandra was to keep you from betraying her, cessfully, with the therapist on altering his orientation
or from giving false hope to Rachel. Perhaps there to the game.
was some wisdom in the choice your penis was They also ventured into a sexual relationship,
making at the time. You weren’t being monoga-
full of apprehension and anticipation, facing their
mous, but it was. Now, however, much has changed
between you two, and, Rachel, you now have begun greatest fear – that Stephen would not be able to
to embrace your own sexual identity apart from be fully sexual with Rachel. The results were often
Brief Strategic Couple Therapy 351
wonderful, sometimes disappointing, and at one therapy (Rev. ed., pp. 126–170). New York: W. W.
point devastating, but the act of taking the risks Norton.
Flemons, D., & Green, S. (2018). Therapeutic quickies:
together allowed them to find mutual respect and Brief relational therapy for sexual issues. In S. Green &
desire, both of which had been absent from their D. Flemons (Eds.), Quickies: The handbook of brief sex
relationship for many years. In their final session, therapy (3rd ed., pp. 126–170). New York: W. W. B
they described their evolving sexual connection, Norton.
Haley, J. (1986). Uncommon therapy: The psychiatric
their commitment to saving their marriage, and techniques of Milton H. Erickson, M.D. New York:
their success on the courts. The yelling was Norton.
absent, and, continuing to untangle themselves Haley, J. (1987). Problem-solving therapy. New York:
from the effects of the affair, they were finding Jossey-Bass.
Kirsch, I. (Ed.). (1999). How expectancies shape experi-
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O’Hanlon, B., & Wilk, J. (1987). Shifting contexts: The
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Rossi, E. L., & Ryan, M. O. (Eds.). (1986). Mind-body
▶ Brief Strategic Couple Therapy communication in hypnosis. New York: Irvington.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change:
▶ Collaborative Couple Therapy Principles of problem formation and problem resolu-
▶ Couple Therapy tion. New York: W. W. Norton.
▶ Empathy in Couple and Family Therapy
▶ Neutrality of Therapist in Couple and Family
Therapy
▶ Reframing in Couple and Family Therapy
Brief Strategic Couple
Therapy
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352 Brief Strategic Couple Therapy
colleagues at the Mental Research Institute Prominent Associated Figures

(MRI) in Palo Alto, CA (Weakland et al. 1974;
Watzlawick et al. 1974; Fisch et al. 1982). The Richard Fisch, John Weakland, Paul Watzlawick,
hallmark of this approach is conceptual and Don Jackson, Jay Haley, Cloe Madanes,
technical parsimony: Therapy aims to resolve Wendell Ray.
the presenting complaint as quickly and effi-
ciently as possible by interrupting ironic pro-
cesses, which in couples take the form of
interaction cycles centered on well-intentioned
but persistently applied “solutions” that keep
Brief strategic couple therapy is the pragmatic
problems going or make them worse. The
embodiment of a systemic “interactional view”
approach is “strategic” because the therapist
that explains behavior – especially problem
intervenes to interrupt ironic processes deliber-
behavior – in terms of what happens between people
ately, on the basis of a case specific plan that
rather than within them (Watzlawick and Weakland
sometimes includes counterintuitive sugges-
1978). The interactional view grew from attempts
tions (e.g., to “go slow” or engage in behavior
by members of Gregory Bateson’s seminal research
a couple wants to eliminate). Referring to “stra-
group (which included Weakland, Haley, and MRI
tegic therapy” alone, however, risks confusing
founder Don D. Jackson) to apply ideas from cyber-
the MRI model with a related but substantially
netics and systems theory to the study of communi-
different approach to treating couples and fam-
cation. After the Bateson project ended, Watzlawick
ilies developed by Jay Haley (who coined the
et al. (1967) brought many of these ideas together in
term “strategic therapy”) and his associate Cloé
the landmark book, Pragmatics of Human Commu-
Madanes (Haley 1987). More importantly, by
nication. Around the same time, Fisch, Weakland,
emphasizing style and tactics of intervention,
and Watzlawick formed the Brief Therapy Center*
the label “strategic” distracts attention from the
(BTC) at MRI to study ways of doing therapy
more fundamental principle of ironic problem
briefly, and over three decades the BTC team treated
maintenance on which the MRI group* based
over 500 unselected cases, representing a broad
their approach.
range of problems, for up to 10 sessions [Rohrbaugh
Although the focus here is couple therapy, this
and Shoham 2015]). The Center’s pattern of practice
can be an arbitrary delimitation. As a general
remained remarkably consistent, with the three core
approach to problem resolution, the MRI model*
members (Fisch, Weakland, and Watzlawick) par-
approaches couple problems in essentially the
ticipating regularly until Weakland’s death in 1995.
same way it does to other complaints. Further-
From this work emerged a model of therapy that
more, because practitioners of this therapy are
focuses on observable interaction in the present,
inevitably concerned with interpersonal problem
makes no assumptions about healthy or pathological
maintenance, they typically focus on couple and
functioning, and remains as close as possible to
family interaction even when working with “indi-
practice.
vidual” problems such as depression, anxiety,
At the heart of the model are two interlocking
addictions, and various health complaints – yet
assumptions about problems and change:
to optimize cooperation, they may avoid framing
intervention as “couple therapy” when working Regardless of their origins and etiology – if, indeed,
these can ever be reliably determined – the prob-
with what clients prefer to view as “individual” lems people bring to psychotherapists persist only if
complaints (Rohrbaugh and Shoham 2011). they are maintained by ongoing current behavior of
Coupled with the predilection of brief strategic the client and others with whom he interacts. Cor-
therapists to see people in conflict individually respondingly, if such problem-maintaining behav-
ior is appropriately changed or eliminated, the
as well as conjointly, this makes it difficult to problem will be resolved or vanish, regardless of
distinguish between what is and is not couple its nature, or origin, or duration. (Weakland et al.
therapy. 1974, p. 144)
Together, these assumptions imply that how a take many forms and are essentially non-
problem persists is much more relevant to ther- normative. Thus, patterns such as quiet detach-
apy than how the problem originated, and that ment or volatile engagement might be
problem persistence depends mainly on social dysfunctional for some couples but adaptive
interaction, with the behavior of one person for others. What matters is the extent to which B
both stimulated and shaped by the response of interaction patterns based on attempted solu-
others (Weakland and Fisch 1992). Moreover – tions keep a complaint going or make it
and this is the central observation of the Palo worse – and the topography of relevant
Alto group – the continuation of a problem problem-solution loops can vary widely from
revolves precisely around what people currently couple to couple.
and persistently do (or do not do) to control, Furthermore, because the “reality” of problems
prevent, or eliminate their complaint. Although and change is constructed more than discovered,
Fisch, Weakland, and associates did not them- the therapist attends not only to what clients do
selves use the term “ironic process,” it captures but also to how they view the problem, them-
well their assertion that problems persist as a selves, and each other. Especially relevant is cli-
function of people’s well-intentioned ents’ “customership” for change and the
attempts to solve them, and that focused inter- possibility that therapy itself may play a role in
ruption of these solution efforts is sufficient to maintaining (rather than resolving) problems.
resolve most problems (Shoham and Rohrbaugh
1997).
A problem, then, consists of a vicious cycle Populations in Focus
involving a positive feedback loop between some
behavior someone considers undesirable (the In principle, this therapy is applicable to any cou-
complaint) and some other behavior(s) intended ple that presents a clear complaint and at least one
to modify or eliminate it (the attempted solution). customer for change. In practice, however, strate-
Given that problems persist because of people’s gic interventions appear to be more effective, at
current attempts to solve them, therapy need con- least relative to straightforward emotion- or skill-
sist only of identifying and deliberately focused interventions, when clients are more
interdicting these well-intentioned yet ironic rather than less reluctant to change (Fisch and
“solutions,” thereby breaking the vicious cycles Schlanger 1999; Rohrbaugh and Shoham 2015).
(positive feedback loops) that maintain the For example, the ironic process model is central to
impasse. If these solutions can be interrupted, team-based family consultation for couples cop-
even in a small way, then virtuous cycles may ing with health problems, which is indicated when
develop in which less of the solution leads to first line medical or behavioral approaches have
less of the problem, leading to less of the solution, not been successful (Rohrbaugh and Shoham
and so on (Fisch et al. 1982). 2011, 2017).
Importantly, brief strategic couple therapy Brief strategic therapy is probably least appli-
attaches little importance to goals such as pro- cable to couples whose concern is relationship
moting personal growth, working through enhancement, prevention of marital distress, or
underlying emotional issues, or teaching cou- personal growth. This is because problem-focused
ples better problem solving and communication therapy requires a complaint and would rarely
skills. Theory is minimal and nonnormative, continue more than a few sessions without one.
guiding therapists to focus narrowly on the pre- In fact, the ironic process idea sensitizes us to
senting complaint and relevant solutions, with therapeutic excess and the possibility of therapy
no attempt to specify what constitutes a normal itself becoming a problem-maintaining solution.
or dysfunctional marriage. Regardless of In this framework, intervention should be propor-
whether the locus of a complaint involves one tionate to the complaint – and as a general rule,
or several people, ironic processes in couples less is best.
Strategies and Techniques Used in for change. In theory, this practice should not
Model decrease the possibility of successful outcome,
since the interactional systems view assumes that
The basic formula for conducting brief strategic problem resolution can follow from a change by
therapy involves the following: (1) define the any participant in the relevant interactional sys-
complaint in specific behavioral terms; (2) clarify tem. Another reason to see partners separately,
minimum goals for change; (3) investigate solu- even when both are customers, is to preserve
tions to the complaint; (4) formulate ironic maneuverability. If the partners have sharply dif-
problem-solution loops (how more-of-the-same ferent views of their situation, for example, sepa-
solution leads to more of the complaint, etc.); rate sessions give the therapist more flexibility in
(5) specify what less-of-the-same will look like accepting each viewpoint and framing sugges-
in particular situations (the strategic objectives); tions one way for her and another way for him.
(6) understand clients’ preferred views of them- The split format also helps the therapist avoid
selves, the problem, and each other; (7) use these being drawn into the position of referee or possi-
views to frame suggestions for less-of-the-same ble ally while working to promote change in what
solution behavior; and (8) nurture and solidify happens between the partners. A final reason for
incipient change. Sessions do not necessarily seeing spouses separately is to facilitate assess-
occur on a weekly basis, but rather reflect a sched- ment. For example, many strategic therapists
ule intended to maximize the likelihood that make a point of seeing each partner alone, at
change will be durable. Thus, when the treatment least briefly, to inquire about their commitment
setting formally imposes a session limit (e.g., to the relationship and assess the possibility of
10 sessions), the meetings may be spread over spousal abuse or intimidation.
months or even a year. A typical pattern is for The therapist’s main task is to persuade at least
the first few sessions to be at regular (weekly) one participant in the couple (or most relevant
intervals and for later meetings to be less frequent interactional system) to do less of the solution
once change begins to take hold. Therapy ends behavior that keeps the complaint going. While
when the treatment goals have been attained and this does not require educating clients, helping
change seems reasonably stable. Termination them resolve emotional issues, or even working
usually occurs without celebration or fanfare, with both members of a couple, it does require
and sometimes clients retain “sessions in the working with the customer and preserving maneu-
bank” should they want to return or feel appre- verability. The customership principle means sim-
hensive about discontinuing contact. Whenever ply that the therapist works with the person or
possible – particularly in training or research persons most concerned about the problem (the
settings – therapy occurs in a team format with a “sweater” or sweaters). Preserving maneuverabil-
one-way mirror or closed circuit video set-up, ity means that the therapist aims to maximize
allowing team members to phone in suggestions possibilities for therapeutic influence, which in
or consult with the therapist during breaks in the this model is his or her main responsibility. It
session. also means that the therapist avoids taking a firm
As a treatment for couples, this approach dif- position or making a premature commitment to
fers from most others in that the therapist is will- what clients should do, so that later, if they do not
ing, and sometimes prefers, to see one or both do what is requested, alternate strategies for
partners individually. The choice of individual achieving less-of-the same will still be accessible.
versus conjoint sessions is based on three main Despite this preoccupation with controlling the
considerations: customership, maneuverability, course of therapy, good strategic therapists rarely
and adequate assessment. Thus, a brief strategic exert control directly in the sense of offering
therapist would rather address a marital complaint authoritative prescriptions or assuming the role
by seeing a motivated partner alone than by strug- of an expert. Much more characteristic is what
gling to engage a partner who is not a “customer” Fisch et al. (1982) call taking a one-down
position, which involves an unassuming, would not want to make any direct suggestion that
unknowing stance of empathic curiosity when the wife change in these ways. The most relevant
investigating behavioral sequences around the ironic patterns are current ones (what one or both
complaint, or soft-selling specific suggestions in partners continue to do about the complaint now),
order to promote client cooperation and avoid the but the therapist investigates solutions tried and B
common countertherapeutic effects of overly discarded in the past as well, because these give
direct or prescriptive interventions. Empathic hints about what has worked before, and may
restraint, exemplified by injunctions to go slow, work again.
is a related stance strategic therapists use to neu- The final assessment goal – grasping clients’
tralize apprehension and/or resistance to change. unique views, or what Fisch et al. (1982) call
The main goals of assessment are to (1) define “patient position” – is crucial to the later task of
a resolvable complaint; (2) identify solution pat- framing suggestions in ways clients will accept, so
terns (ironic problem–solution loops) that main- that they will behave in less-of-the-same ways that
tain the complaint; and (3) understand clients’ interrupt ironic processes. Assessing these views
unique language and preferred views of the prob- depends mainly on paying careful attention to
lem, themselves, and each other. The first two what people say. For example, how do they see
goals provide a template for where to intervene, themselves and want to be seen by others? What
while the third is relevant to how. do they hold near and dear? How do they see
The therapist begins by getting a very specific, themselves as a couple, in terms of values, flavor,
behavioral picture of the complaint, including or unique style? When are they at their best, and
who sees it as a problem, and why it is a problem what do others notice at those times?
now. A useful guideline for behavioral description Brief strategic therapists employ a variety of
is having enough details to answer the question, strategies to interrupt ironic patterns of couple
“If we had a video of this, what would I see?” interaction by inducing one or both partners to
Later the therapist also tries to get a clear behav- do less of the same solution behavior. For exam-
ioral picture of what the clients will accept as a ple, consider variations of the familiar demand-
minimum change goal. For example, “What withdraw sequence, where one partner either
would he (or she, or the two of you) be doing (a) pushes for change while the other partner
differently that will let you know this problem is refuses to respond; (b) attempts to initiate discus-
taking a turn for the better?” sion, which the other avoids; (c) offers criticisms
The next step requires an equally specific against which the other defends; or (d) accuses the
inquiry into the behaviors most closely related to other of thinking or doing something that he or she
the problem, namely, what the clients (and any denies. Each of these variations fits the ironic
other concerned people) are doing to handle, pre- problem-solution formula because more demand
vent, or resolve the complaint, and what happens leads to more withdrawal, which leads to more
in response these attempted solutions. From demand, and so on. If the demand side partner is
this should emerge preliminary formulations of the main customer for change and pursues this
problem-solution loops, particularly of the spe- by exhorting, reasoning, arguing, or lecturing
cific solution behaviors that will become the (a solution pattern that Fisch et al. (1982,
focus of intervention. The therapist (or team) can pp. 139–152) call “seeking accord through oppo-
then develop a picture of what “less of the same” sition”), achieving less of the same may depend
will look like – that is, what behavior, by whom, in on helping him or her suspend overt attempts to
what situation, will suffice to reverse the problem- influence the other partner – for example, by
maintaining solutions. Understanding ironic declaring helplessness, taking a one-down posi-
solution patterns also helps the therapist be clear tion, or performing a diagnostic (observational)
about what positions and suggestions to avoid. task to find out “what he’ll do on his own” or
For example, if a husband has been persistently “what we’re really up against.” How the therapist
exhorting a wife to eat or spend less, the therapist frames such suggestions depends on “patient
position” (what rationale the client will buy). Thus, willing to do it and I will, but let’s face it, I don’t
an extremely religious wife might be amenable to enjoy this.” In other complaint-maintaining
silently praying for her husband rather than exchanges, one partner may be domineering or
exhorting him, or an outraged spouse might accept explosive and the other placating or submissive.
redefinition of the partner’s stubbornness as moti- Here, less of the same usually requires getting the
vated by underlying pride. Because proud people submissive, placating partner to take some asser-
need to discover and do things on their own with- tive action. In contrast, an intervention for com-
out feeling pressed or that they are giving in, it bative couples embroiled in symmetrically
makes sense to encourage such a person’s partner escalating arguments might involve getting at
through discouragement and restraint – which in least one partner to take a one-down position, or
effect reverses the former solutions to stubborn prescribing the argument under conditions likely
behavior (Fisch et al. 1982). When interventions to undermine it.
such as these succeed in interrupting an ironic Finally, although interventions for marital
pattern, if only temporarily, the therapist is in a complaints usually focus on one or both partners,
position to nurture and solidify incipient change. there are circumstances in which other people –
When the demand–withdraw pattern involves relatives, friends, or even another helper – figure
criticism and defense or accusation and denial, prominently in this approach to couple therapy,
both partners are more likely to be customers for especially when the third party is a central cus-
change, which can be introduced through either or tomer for change. For example, a mother under-
both of them. One strategy here focuses on getting standably concerned about her daughter’s marital
the defending partner to do something other than difficulties may counsel or console the daughter in
defend – for example, by not responding, simply ways that unwittingly amplify the problem or
agreeing with the criticism, or helping the criti- make the young husband and wife less likely to
cizer “lighten up” by not taking the criticism seri- deal with their differences directly. In this case,
ously (“I guess you’re probably right. Therapy is brief therapy strategic might focus first on helping
helping me see I’m not much fun and probably too the mother reverse her own solution efforts and
old to change”). Another is a conjoint intervention take up later (if at all) the interaction between the
the MRI group called “jamming” (Fisch et al. young spouses, which is likely to change when the
1982), where the therapist asks the defending mother becomes less involved.
party to deliberately engage in some approxima-
tion of the censured behavior (e.g., sometimes
acting “as if” she is attracted to other people and Research About the Model
sometimes not) while the accuser tests his or her
perceptiveness about what the defender is “really” Although most research on brief strategic couple
experiencing. The effect of such a prescription can therapy has been qualitative, it is noteworthy that
be to free the defender from (consistently) the original description of brief, problem-focused
defending and the accuser from accusing because therapy by Weakland et al. (1974) included tenta-
verbal exchanges (accusations and denial) in the tive 1-year outcome percentages for the first
“jammed” circuit have less information value. 97 cases seen at the MRI Brief Therapy Center.
When ironic patterns include the paradoxical A later analysis of 285 BTC cases seen through
form of communication Fisch et al. (1982) called 1991 found problem resolution rates of 44%,
“seeking compliance through voluntarism” (e.g., 24%, and 32% for success, partial success, and
“You should do this only because you really want failure, respectively – figures very similar to those
to”), the therapist may invite the person who is Weakland and colleagues had reported a15 years
asking for something to do so directly, even if earlier (Rohrbaugh et al. 1992; Rohrbaugh and
arbitrarily, or persuade the nonrequesting partner Shoham 2015), Thus, at least two-thirds of the
to take the edge off the paradoxical “be spontane- BTC cases reportedly improved, and the average
ous” demand by saying something like, “I’m length of therapy was six sessions. Interestingly,
about 40% of these early cases involved some early days of their relationship had resurfaced.
form of couple complaint, and couple cases were Whereas the intervention served to interdict the
more likely to be successful when at least two wife’s attempted solution of pursuing discussion,
people (the two partners) participated in treat- it also interrupted the heaviness and deadly seri-
ment. This analysis did not, however, evaluate ousness in the couple’s relationship (Rohrbaugh B
the potentially confounding role of customership and Shoham 2015, p. 344).
or the possibility that the absent partners were as
uncommitted to the relationship as they appar-
ently were to therapy.
Cross-References
Other research relevant to this model has
focused on the role of ironic processes in problem
▶ Bateson, Gregory
maintenance and change. For a summary, see
▶ Brief Strategic Couple Therapy
Rohrbaugh and Shoham (2011, 2017).
▶ De Shazer, Steve
▶ Haley, Jay
▶ Jackson, Donald
Case Example
▶ Papp, Peggy
▶ Paradoxical Directive in Couple and Family
In a case treated at the MRI Brief Therapy Center,
Therapy
the wife, herself a therapist and the main com-
▶ Restraining in Couple and Family Therapy
plainant, would repeatedly encourage her inex-
▶ Second-Order Change in Couple and Family
pressive husband to get his feelings out,
Therapy
especially when he came home from work
▶ Symmetrical Relationships in Couples and
“looking miserable.” When the husband
Families
responded to this encouragement with distraught
▶ Watzlawick, Paul
silence, the wife would urge him to talk about his
▶ Weakland, John
feelings toward her and the marriage (thinking
that this topic would bring out positive associa-
tions on his part and combat his apparent misery).
References
In a typical sequence, the husband would then
begin to get angry and tell the wife to back off. Fisch, R., & Schlanger, K. (1999). Brief therapy with
She, however, encouraged by his expressiveness, intimidating cases: Changing the unchangeable. San
would continue to push for meaningful discus- Francisco: Jossey-Bass.
sion, in response to which – on more than one Fisch, R., Weakland, J. H., & Segal, L. (1982). The tactics
of change: Doing therapy briefly. San Francisco:
occasion – the husband stormed out of the house Jossey-Bass.
and disappeared overnight. The intervention that Haley, J. (1987). Problem – Solving therapy: New strate-
eventually broke the cycle in this case came from gies for effective family therapy (2nd ed.). San
Fisch, who entered the therapy room with a sug- Francisco: Jossey-Bass.
Rohrbaugh, M. J., & Shoham, V. (2011). Family consulta-
gestion: In the next week, at least once, the hus- tion for couples coping with health problems: A social-
band was to come home, sit at the kitchen table, cybernetic approach. In H. S. Friedman (Ed.), Oxford
and pretend to look miserable. The wife’s task, handbook of health psychology (pp. 480–501).
when she saw this look, was to go to the kitchen, New York: Oxford University Press.
Rohrbaugh, M. J., & Shoham, V. (2015). Brief strategic
prepare chicken soup, and serve it to him silently, couple therapy: Toward a family consultation approach.
with a worried look on her face. The couple came In A. S. Gurman, D. K. Snyder, & J. Lebow (Eds.),
to the next session looking anything but misera- Clinical handbook of couple therapy (5th ed.,
ble. They reported that their attempt to carry out pp. 335–357). New York: Guilford Publications.
Rohrbaugh, M. J., & Shoham, V. (2017). Family consulta-
the assignment had failed because she – and then tion for change-resistant health and behavior problems:
he – could not keep a straight face, yet they were A systemic-strategic approach. In L. E. Beutler,
delighted that the humor so characteristic of the A. J. Consoli, & B. Bongar (Eds.), Comprehensive
358 Brief Strategic Family Therapy
textbook of psychotherapy (2nd ed.). New York: model’s theory and techniques (Szapocznik et al.
Oxford University Press. 2003). As described below, the current BSFT inter-
Rohrbaugh, M.J., Shoham, V., & Schlanger, K. (1992). In
the brief therapy archives: A request on the don D, vention emerged from a rich history of treatment
jackson memorial award. Mental Research Institute, development that included theoretical principles,
Palo Alto, CA. clinical experience and experimentation, empirical
Shoham, V., & Rohrbaugh, M. J. (1997). Interrupting treatment research, and implementation science. It
ironic processes. Psychological Science, 8, 151–153.
Watzlawick, P., & Weakland, J. H. (Eds.). (1978). The should be noted that in the BSFT model, “family”
interactional view. New York: Norton. is defined as all individuals who “function” in the
Watzlawick, P., Beavin, J., & Jackson, D. D. (1967). Prag- role of family members, and “parents” are defined
matics of human communication. New York: Norton. as those adults who function in parenting roles.
Watzlawick, P., Weakland, J. H., & Fisch, R. (1974).
Change: Principles of problem formation and problem
resolution. New York: Norton.
Weakland, J. H., Fisch, R., Watzlawick, P., & Bodin, A. Prominent Associated Figures
(1974). Brief therapy: Focused problem resolution.
Weakland, J. H., Fisch, R., & Watzlawick, P. (1992). Brief In the 1970s, Szapocznik and colleagues investi-
therapy–MRI style. In S.H. Budman, M.F. Hoyt, & gated how family intergenerational and cultural
S. Friedman (Eds.), The first session in brief therapy conflict in Cuban families in Miami were causing
(pp. 306–323). New york: Guilford press. adolescents to develop problem behaviors such as
drug use, delinquency, and conduct problems
at school and at home (Szapocznik et al. 1978b).
To help these families, the BSFT intervention was
Brief Strategic Family Therapy developed as an integration of Minuchin’s (1974)
Structural Family Therapy and Haley’s (1976)
Austen R. Anderson1, Stephen K. Denny1, Strategic Family Therapy. The model was initially
Joan A. Muir2 and José Szapocznik1 designed to be culturally specific to the prefer-
1
University of Miami, Miami, FL, USA ences of Cuban immigrant families in Miami
2
Brief Strategic Family Therapy Institute ® (Szapocznik et al. 1978a). These families pre-
(BSFT ®), University of Miami Miller School of ferred treatments that were focused on the present,
Medicine, Miami, FL, USA were practical in that they focused on fixing pre-
senting problems (i.e., family conflict and adoles-
cent drug use), and involved a therapist who, in
Name of Model accordance with a hierarchical view of relation-
ships, acted as an expert in directing the family to
Brief Strategic Family Therapy arrive at solutions to their problems. The inte-
grated structural and strategic therapies matched
these families’ preferences and resulted in a
Introduction culturally relevant family-based intervention.
The core BSFT intervention has been refined,
The Brief Strategic Family Therapy (BSFT) model improved, and more widely disseminated to
is an evidence-based intervention used with fami- other cultural groups over the last four decades,
lies of adolescents who are engaging in problem- always using a consistent theoretical framework.
atic behaviors (Horigian et al. 2016). It is usually
delivered weekly for 12–16 sessions, with each
session lasting about 1–1¼ h. It most often occurs Theoretical Framework
at the client’s home, but can also occur at other
places that are convenient for the family, including The BSFT theoretical framework builds on an
schools or community clinics. The intervention is ecological perspective within which the family is
guided by a clinical manual that outlines the understood as the fundamental context for the
Brief Strategic Family Therapy 359
development of children. Specifically, adolescent beneficial or problematic. Families served in

development is influenced by the interactions BSFT treatment are often stuck in maladaptive
that occur within the family and between the fam- interpersonal interactions. That is, interactional
ily and its context (Szapocznik and Coatsworth patterns that do not permit the family to achieve
1999). The evidence suggests that when families their own goals. Despite their maladaptive B
communicate well and are respectful and nurtur- nature, these repetitive patterns of interactions
ing in their interactions; when there is appropriate are often experienced as a stabilizing force
parental involvement, monitoring, and guidance; within the family. This tendency toward stable
when parents collaborate on parenting activities equilibrium (or homeostasis) can explain some
and the implementation of rules, then adolescent families’ willingness to continue to behave in
substance use and related behavior problems are ways that are problematic for the family.
reduced. Alternatively, when families are unable The BSFT intervention is also based on a stra-
to resolve their differences (e.g., blaming to tegic approach to family therapy, meaning that
change the topic of conversation), when affect is the BSFT therapist makes use of treatment plans
chronically negative, and when family members that target the families’ presenting problems using
are unable to communicate directly and with spec- practical interventions. Practical means that
ificity, then adolescents are more likely to engage interventions are selected because they have the
in problematic behaviors. The overarching goal of greatest likelihood of successfully changing fam-
BSFT is to improve the functioning of families by ily interactions. One example is reframing.
changing those patterns of interactions that pre- Reframing, as noted below, is emphasizing one
vent the family from reaching its own goals – aspect of a family’s interaction to encourage more
referred to as “maladaptive” interactions – while positive interactions among family members.
encouraging supportive and nurturing interac- Interactions such as a father being angry with his
tions. As families learn new ways of interacting, daughter may comprise a complex reality. How-
they are able to more successfully pursue individ- ever, the therapist might select one aspect of that
ual and family goals. reality – that the father is worried about the
The BSFT intervention is based on three main daughter – and highlight it in hopes that it could
theoretical principles adapted from structural and lead to more positive interactions (in which father
strategic family therapies: systemic, structural, shares, “Yes, I am worried that she is in trouble
and strategic. These principles provide the frame- with the law, and I want her to succeed in life”).
work for understanding the obstacles that keep the Through these practical interventions, a BSFT
family from achieving its goals (the theory of the therapist strives to bring about changes in the
problem) and the method for bringing about family’s maladaptive patterns of interaction so
change in the obstacles that are keeping the family that the family can function in a way that will
from achieving its goals (the theory of behavior reduce the adolescent’s problem behaviors. Fur-
change). ther, a problem-focused approach targets only
Systems theory posits that the parts of the sys- those repetitive patterns of family interactions
tem are interdependent. Families are social sys- that are directly related to the adolescents’ prob-
tems with interdependent family members. Each lem behaviors. Such problem-focused approach
family member is affected by the other family allows for substantive change in a relatively
members’ actions. For families that are function- short period of time. Hence, the strategic aspect
ing well, this interdependency can lead to the of the BSFT model means that interventions are
successful attainment of family and individual planned and focused on changing those interac-
goals for family functioning and healthy adoles- tions that prevent the family from achieving its
cent development. goals of eliminating the problem behavior. Strate-
Structural refers to the family’s habitual gic also means that interventions are practical,
repetitive patterns of interactions. These repeti- meaning that they are most likely to achieve
tive patterns of interactions can be either a desired outcome.
Taken together, these principles offer a theo- therapist to build a therapeutic relationship with
retical framework for understanding the develop- all members of the family and with the family
ment of adolescent problem behaviors (stemming system itself. Joining is especially important in
from maladaptive family interactions such as neg- the early stages on therapy to build the relation-
ativity within the family, a lack of warmth, poor ship between the therapist and the family. Thera-
boundaries, and a weak executive system) and a pists must show each family member respect and
framework to bring about change. acceptance by validating each person, their con-
cerns, and desired therapy outcomes. Joining
allows the therapist to be viewed as a temporary
Populations in Focus member and leader of the family. Research reveals
that joining is critical throughout therapy to
As mentioned, this intervention was originally ensure successful outcomes (Robbins et al.
developed in the early 1970s to help Cuban immi- 2011b).
grant families who were experiencing intense A second set of techniques is tracking and
intergenerational family conflict related to cultural diagnosing. These interventions often involve
issues, with the goal of reducing conflicts that redirecting the family members to speak directly
gave rise to adolescent problem behaviors such with each other rather than to the therapist when
as drug use, delinquency, and conduct problems in they are describing their family problems. In this
school and in the family. After achieving clinical case, a therapist might direct a son to speak
success with Cuban Americans, the model was directly to his father, rather than allowing the son
subsequently tested on other Hispanic cultural to tell the therapist his complaint about the father.
groups, White Americans, and Black Americans. When the youth speaks directly to his father, the
As a family-based intervention, the model is therapist is able to observe how father and son
best suited to adolescents who can be treated with interact, and more generally how other family
their family members and is thus targeted toward members may interfere when son and father try
adolescents who live with at least one parental to interact directly, hence gaining a better under-
figure (defined as an adult who functions in the standing into how the family members might
role of a family member). In most cases, the interact with each other on a day to day basis.
treatment is used for adolescents (12–17 years With this information, the therapist can identify
old) who are using drugs or are engaging in the family’s repetitive patterns of interactions in
other problematic behaviors such as delinquency ways that prevent the family from achieving its
and conduct problems at school and home. It has goals. In other words, the therapist can diagnose
also been used as an after-care intervention for the family’s problematic patterns of interaction
youth released from residential or probationary which will guide later interventions. Hence it is
settings. the diagnosis of these repetitive patterns of inter-
actions that make it possible to plan the course
of treatment, contributing to the brevity of BSFT.
BSFT Techniques A common pattern that might be diagnosed is
identified patienthood or scapegoating, which
The BSFT techniques build on the work of occurs when one family member is blamed for
Salvador Minuchin (1974) and have been all of the family’s problems. This is often the
adapted for families with troubled externalizing drug using, delinquent, or conduct problem ado-
adolescents. These techniques are organized into lescent. Blaming the adolescent allows the family
four main categories: joining, tracking and diag- to ignore other problems within the family (e.g.,
nosis, reframing, and restructuring. While each of father is depressed, mother is angry). Another
these interventions is important, some are more common pattern of interaction occurs when, in a
critical at different periods of the treatment pro- two parent-figure family, a parent and child are
cess. Joining interventions are those that allow the closer to each other than both parents are together.
This would lead to interactions wherein one par- out adolescents. The intention is to create a new
ent is marginalized and the youth becomes uncon- experience in the family in which parents work
trollable because parents who do not work together (which will require much help in conflict
together typically do not have the power to control resolution, keeping the daughter from sabotaging
an acting out adolescent. the parents, etc.) to manage an out-of-control B
Having obtained an understanding of the fam- youth. These changes, once consolidated, help
ily system, therapists can help reduce overall neg- the family respond more effectively to other chal-
ativity within the family and improve motivation lenges that will emerge in the future.
for change by using reframing techniques.
Reframing takes emotionally charged negative
interactions and, through careful selection of Research About the Model
a transformative frame, offers more positive
meanings that are likely to permit more construc- Research has been conducted on the BSFT inter-
tive dialogue. For example, after a mother says, vention across four decades.
“You’re wasting your life by hanging out with
friends like yours” to her daughter, a therapist BSFT Engagement
could indicate to the mother that “It sounds to In the 1980s when BSFT Engagement was devel-
me like you care about your daughter a lot and oped, the challenge of engaging and retaining
that you would like her to have a happy, healthy, families of drug-using adolescents in treatment
and productive future.” Hearing an angry was experienced across the nation by treatment
criticism – which might normally be met with providers who felt that family therapy was appro-
harsh responses or behavioral acting out – trans- priate for externalizing adolescents, but could not
formed into concern, might reduce the focus on get families into treatment. There was a ground-
the daughter’s problematic friendships and breaking observation that made BSFT Engage-
increase the focus on feelings of love and concern ment possible. As the developers struggled to
that the mother has for her daughter. Reframing is bring families into treatment, they realized that
a powerful way to improve relations in the family, the kinds of interactional patterns they had
and by creating a motivational context for change, observed in therapy were similar, if not identical,
prepares the family to behave in new ways. to the kind of interactional patterns that were
In BSFT treatment, the actions of the therapist keeping families from entering therapy. It was
that are intended to create new ways of interacting thus hypothesized that the symptom of “resistance
are called restructuring techniques. Supplemented to coming to therapy” resulted from the same
with a strong therapeutic relationship, an under- repetitive patterns of interactions that were caus-
standing of the current patterns of interaction, ing other problems in the family such as adoles-
decreased negativity, and the creation of cent drug abuse. To address this challenge, BSFT
a motivation context for change (through developers decided to extend the use of three of
reframing), the therapist is now ready to encour- the BSFT interventions (joining, tracking/diag-
age new ways of interacting using restructuring nosing, and reframing) to the problem of engage-
techniques. For example, in the case of a family in ment. In other words, from the first contact with
which the problem adolescent and one parent are the family, the therapist was tasked with using the
more closely allied than the parents are with each same systemic, structural, and strategic principles
other, it is important to create a stronger bond and interventions to help bring the family into
between the parents, which the therapist can do treatment and to increase the rate of retention
by giving the parents the task of working together into therapy. To accomplish this, the family’s
to agree on the rules they would want to develop “resistance” to entering treatment was
for their daughter. This intervention to change the re-conceptualized and treated in terms of sys-
alliances from mother–child to mother–father fig- temic, structural, and strategic principles. The
ures is frequently needed in families with acting therapist would join with individual family
members who were initially available to the thera- reduced aggression and conduct problems relative
pist by validating that individual’s willingness to to those in Group. Of those who reported marijuana
reach out for therapy, would track and diagnose use, being placed in BSFT treatment resulted in
family interactions, and would reframe negative significantly reduced drug use at termination rela-
statements to increase motivation to attend therapy. tive to those in Group. Family cohesion also sig-
For example, if the person seeking therapy says nificantly improved in BSFT treatment relative to
that she/he cannot bring another family members Group.
in, the therapist determines that that the other fam-
ily member is more powerful than the person seek- BSFT Effectiveness
ing therapy. Then the therapist, with the permission A national, multisite BSFT effectiveness trial was
of the person seeking therapy, will directly reach conducted by randomizing families within each
out to that person(s) to overcome their reluctance to of eight community-based agencies (Robbins
entering treatment. Research on the efficacy and et al. 2011a). BSFT treatment was compared
effectiveness of this engagement process is against the treatments usually offered at each
described below. A case example is clinic (“usual treatment”). The findings presented
also presented below that demonstrates the use of in this section represent findings across African-
BSFT Engagement to bring families into treatment. American, Hispanics, and White American youth
Across three efficacy trials, BSFT Therapy + and their families.
BSFT Engagement proved to be significantly
better at initially engaging families into treatment Engagement and Retention
and retaining them into treatment. This effect was BSFT with BSFT Engagement fully integrated
found when comparing BSFT Therapy + BSFT was significantly more effective than the usual
Engagement to BSFT Therapy alone in a univer- treatment at bringing and retaining families in
sity clinic (Szapocznik et al. 1988), to group ther- treatment in community-based settings. This
apy in a university clinic (Santisteban et al. 1996), increased engagement and retention is especially
and family counseling in a community-based important because families who need care are not
clinic (Coatsworth et al. 2001). always able to bring themselves into treatment.
BSFT Efficacy Drug Use

Two efficacy trials demonstrated that BSFT was At 12 months, the BSFT condition, compared to
more effective than alternative therapy condi- usual treatment, had a lower median number of
tions. In the first study with 6–11-year-old days of drug use (2 vs. 3.5 days of use in the last
Cuban boys, BSFT treatment was more effective 28 days). There was not a difference in the mean
that an individual psychodynamic therapy and a trajectory of use between conditions. In part this
recreation intervention placebo control was the case because drug use values were
(Szapocznik et al. 1989). Both therapies, BSFT generally low and stayed low in both conditions
and individual, showed improved emotional and throughout the 12 months of the study. Low rates of
behavioral problems at post-treatment. However, drug use made it difficult to find significant
at the 1-year follow-up, BSFT had significantly improvements. Moreover, 72% of the adolescents
improved on blind independently-rated family were referred from juvenile justice systems and
functioning, while the families whose children thus were often coming from drug-free settings
were treated with individual therapy had signif- and were often monitored by the juvenile justice
icantly deteriorated in their blind independently- system throughout the 12-month period of the
rated family functioning. study. Subsequent analyses showed that BSFT
A second efficacy trial compared BSFT with an treatment was dramatically more effective than
adolescent problem-solving group control inter- usual treatment in helping adolescents whose par-
vention (Group; Santisteban et al. 2003). Teens ents used alcohol and drugs at baseline (Horigian
who were in BSFT treatment had significantly et al. 2015a).
Family Functioning therapy, prepare treatment plans, and receive con-

Compared to usual treatment, in the BSFT condi- tinued monitoring, feedback, and coaching on
tion, parents rated their family functioning as sig- their BSFT cases. One key factor in reducing
nificantly more improved. therapists’ client loads is the agency’s ability to
obtain funding based on treating each family B
Adherence Affects Outcomes (or case) rather than on a fee-for-service model.
Families treated by therapists who adhered better This is important because when an agency is
to the BSFT techniques of joining, tracking and funded by case, they are evaluated not on the
highlighting, and reframing and restructuring had volume of sessions, but rather on the outcome
all-around better outcomes. That is, better engage- with each of their families. Another important
ment, better retention, greater reductions in drug step in BSFT Implementation is the creation of
use, and more improved family functioning out- BSFT teams that deliver only BSFT and no other
comes (Robbins et al. 2011b). treatments. This has two functions. First, practic-
ing only BSFT allows the therapist to develop
Arrests and Incarceration more fully their skills in the approach. Second,
A follow-up conducted 4–7 years after baseline the team provides a context that supports BSFT
(3–6 years after treatment) revealed that, com- knowledge and practice over time.
pared to usual treatment, BSFT was significantly The process of BSFT implementation includes
more effective in reducing self-reported last-year four main steps: identifying and engaging the
and lifetime arrests and imprisonments (Horigian key agency leaders, assessing agency readiness
et al. 2015b). to adopt BSFT, creating a motivation context for
change in the agency, and obtaining a commit-
BSFT Implementation ment to sustainability. By the time an agency
We have demonstrated that better adherence to the obtains a license to practice BSFT, the agency
model predicted good outcomes for the families will typically have a team of four BSFT therapists
and adolescents treated with BSFT. The challenge including an on-site supervisor who has displayed
in providing evidence-based interventions, like a special aptitude in delivering the BSFT interven-
BSFT, is in implementing the treatment in a way tion. The on-site supervisor takes on the supervi-
that allows for excellent fidelity (Szapocznik et al. sion of the agency’s other BSFT therapists and
2015). To accomplish this, the BSFT Institute continues to receive supervision on their supervi-
was created as the implementation team that sion from the BSFT Institute. Future research
helps agencies adopt BSFT, deliver BSFT treat- will test the efficacy of the BSFT Implementation
ment with fidelity, and enhance the likelihood of model on successful adoption, fidelity and
sustainability. Adoption requires the agency’s sustainability.
readiness to make organizational changes needed
to successfully implement BSFT. Fidelity requires
that therapists adhere to BSFT theoretical princi- Case Example
ples and techniques. As part of this process, agen-
cies, rather than therapists, are certified to provide The Lewis family was referred by the school
BSFT because therapists need a supportive orga- because the daughter’s school performance had
nizational structure to have good outcomes with deteriorated, and the daughter had shared with
the families with whom they work. Finally, sus- the school counselor that she had frequent fights
tainability requires that agencies involve funders with her mother. The BSFT therapist received
in observing BSFT outcomes. the referral and called the family. The mother
Thus, for agencies to be licensed to provide answered the call. After speaking with the mother,
BSFT, they must be able to limit the case load of the therapist scheduled a family session. The ther-
their therapists to 10–14 cases to allow adequate apist learned during this first call that the family
time to travel to families’ homes to deliver consisted of a mother and a father figure, a
14-year-old son, and an 11-year-old daughter. In Fortunately, when the therapist came to the
BSFT treatment, the sessions can take place at the house, she found the father at home. The thera-
home if that is more convenient to the family. The pist was very surprised when the father told him
mother stated, however, that she did not want that he wanted to participate, but had been told
therapy in the home, so the therapist scheduled by the mother that therapy was only going to
their first session for his office. The therapist made focus on the mother–daughter relationship. The
it clear to the mother that she would like to meet mother and daughter were not at home, and the
with all four members of the family and asked the therapist worked out a time to come back to the
mother if she thought there would be any prob- house when everyone would be home.
lems for the whole family to attend. The mother In the next session, the therapist decided not
said, “It will be fine. I’ll get us all to come.” to confront the mother. Rather, she expressed
At the first session, only the mother and the how happy she was that everyone was able to
11-year-old daughter arrived for treatment. The be present at the session. She indicated that she
therapist inquired about the father and son, and was now ready to begin therapy and told the
the mother explained that they were not able to family that she was here to help them, asked
come that evening, but they would be available how she could best help them. Mom immediately
the following week. To explore the obstacles that said that daughter was not doing well at school
may have obstructed the son and father to join and had been very rebellious with her. The ther-
therapy, the therapist mostly asked relational ques- apist requested that the mother say this directly to
tions about how things worked in the family, focus- the daughter. Mom said, “I have told her a mil-
ing on bringing the father to the session: “Tell me lion times,” but the therapist responded, “If you
what you said to your husband when you invited don’t mind, I would like for you to tell her in my
him to treatment?” The mother said that she told presence.” The daughter responded with consid-
father that everyone was expected to come to the erable anger. The therapist then asked the dad for
session. “How did he respond?” the therapist help. “Dad, what do you think makes your
asked. He said he could not do it this week but he daughter so angry?” to which the father
would come next week. The therapist out of an responded that he did not think that his daughter
abundance of caution said to the mother, “If you liked sleeping in the same bed with the mother.
don’t mind, I will give a call to your husband. Apparently, the mother did not want to sleep in
I would personally like to emphasize how impor- the same bed as her husband and had brought the
tant it is for him to come. If he is not able to come at daughter to sleep with her, and the father now
the time of the session, we will change the session slept in the daughter’s bed.
for a time that works for him.” The therapist was It was clear that the mother and daughter had
surprised when mother refused to give him the a very strong bond and were overly involved with
father’s phone number; she said that father did each other, while at the same time, the mother was
not want to come to therapy, but that she and her trying to marginalize the dad, and that the dad was
daughter were committed to getting help. unhappy with his sleeping arrangement (and
It became clear to the therapist at this point that more). It did not take much training to know that
the mother did not want her husband in treatment, the mother and father’s marital problems were
and the therapist was well aware that BSFT treat- affecting the daughter who had become triangu-
ment requires working with whole families. At lated between the mother and father in a very
that point the therapist said that she would like literal sense – she had been forced to take her
to explore other ways to reach the father, and father’s place in the marital bed.
purposely left it vague. The therapist intentionally This example demonstrates why it is so crit-
did not say what she had in mind because she did ical in BSFT to see the entire family. Only when
not want the mother to block her. The therapist the whole family is together, is it possible to
planned to drop by the house in the evening, learn about the patterns of interactions that are
hoping to find the father. linked to the youth’s presenting problems.
When all family members are not present, the of Consulting and Clinical Psychology, 79(6),
therapist is unable to diagnose the true family 713–727. https://doi.org/10.1037/a0025477.
Robbins, M. S., Feaster, D. J., Horigian, V. E.,
interactions. Puccinelli, M. J., Henderson, C., & Szapocznik, J.
(2011b). Therapist adherence in brief strategic family
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by grants UL1TR000460 and U10DA013720 to José value structure: Treatment implications. Journal of
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366 Bronfenbrenner, Urie
for child rearing in 1970, at the height of the Cold

Bronfenbrenner, Urie War. It was a piece of academic work that
foreshadowed two critical elements of what
David Hauser and Dan Gill would become Bronfenbrenner’s lasting theoreti-
The Family Institute at Northwestern University, cal contributions: the importance of environment
Evanston, IL, USA and ecology in shaping human development and a
recognition of the myriad of different compli-
cated, systemic, and interacting variables that
Introduction influence a person’s development.
It was his 1978 book “The Ecology of Human
Urie Bronfenbrenner was a psychologist and Development,” that remains Bronfenbrenner’s
human development theorist. His theory and writ- lasting legacy, a major contribution to the grow-
ing evolved into what became known as “the ing field of family therapy in the 1970s, as well as
ecology of human development.” Bronfenbrenner the fields of psychology and human
also notably had a significant impact in public development.
policy as it relates child development in the
United States, consulting with congress in the
1960s to help design and construct the Head Contributions to Profession
Start program which has provided hundreds of
thousands of under-resourced children access to As a theory, The Ecology of Human Development
early childhood education. built upon foundations laid by the early pioneers
of systems theory like Gregory Bateson and
Ludwig von Bertalanffy and groundwork for
Career more modern family systems psychotherapy
theories like integrative systems theory (IST,
Bronfenbrenner was born in Moscow, but he and formerly Integrated Problem-Centered Meta-
his family moved to the United States when he frameworks (IPCM)). Bronfrenbrenner used ele-
was 6 years old. His father was a neuropatholo- ments of systems theory to suggest that multiple
gist, who spent a good deal of his career advocat- complex and interacting systemic layers shape
ing for under-resourced children in New York a child (or person) in their development.
City. Bronfenbrenner went on to attend Cornell Bronfenbrenner posited that humans are shaped
University for undergraduate study, majoring in by four layers of different systems of influence:
music and psychology. He then earned a master’s most immediately the microsystem (often includ-
in education at Harvard University and finally a ing influence from family, siblings, peers, school),
Ph.D. in developmental psychology from the Uni- the mesosystem (the interaction of different micro-
versity of Michigan. He had brief stints as a mil- system variables upon the individual), the exo-
itary psychologist in World War II and as an system (slightly more distant shaping variables
assistant professor at the University of Michigan. such as an individual’s neighborhood or parent’s
In 1948 he moved back to join the faculty at work environment, mass media, or local politics),
Cornell University where he spent the remainder and lastly the macrosystem (variables such as
of his career, some 50 years, as a professor of social conditions, laws, political climate, culture,
human development. or the economy).
In his unique experience having been born in A helpful analogy utilized in understanding
the Soviet Union, but growing up in the United and demonstrating Bronfenbrenner’s ecological
States, Bronfenbrenner penned “Two Worlds of systems theory is that of the famous “Russian
Childhood: U.S. and U.S.S.R.,” a timely cross- nesting dolls” (the oblong-shaped wooden dolls
cultural comparison of child development that usually are grouped in 4–5 dolls, each nesting
between these two nations’ different approaches or sitting inside the larger doll). The idea is that an
Browning, Scott 367
individual lay at the middle of all of the compli- Fox, M. (2005, September 27). Urie Bronfenbrenner,
cated environmental systems around them. Each 88, an authority on child development. New York Times.
Woo, E. (2005, September 27). Urie Bronfenbrenner, 88;
layer provides some level of influence on an indi- co-founder of Head Start urged closer family ties. Los
vidual’s development. The closer the systemic Angeles Times.
layer to the individual, the stronger the influence B
upon the individual’s development. Thus, the
microsystem (including family, school, and
peers) is a stronger shaping agent in an individ- Browning, Scott
ual’s development than the exosystem, where
influence is still present, but not as strong as a Amy Roth
shaping agent. Chestnut Hill College, Philadelphia, PA, USA
Later in the development of this theory,
Bronfenbrenner added another systemic layer of
influence upon human development, which he Introduction
termed the “chronosystem.” The chronosystem
accounted more for the role of time and its impact Scott Browning is a licensed psychologist, profes-
on development, as well as the patterning of envi- sor, researcher, mentor, and a member of several
ronmental events and transitions over the life professional organizations. Browning’s vast con-
course. tributions to the field of family therapy include the
Bronfenbrenner’s ecological theory continues following subject areas: the diverse and changing
to hold importance in assessment and family ther- family, increasing and measuring empathy, chil-
apy models. His theories specifically hold much dren with developmental disorders, therapy out-
relevance in family therapy. Similar to the use of comes, and the dynamics and treatment of
biopsychosocial assessments or integrative sys- stepfamilies.
tems therapy (IST), Bronfenbrenner’s ecological
theory offers a systematic framework for synthe-
sizing the seemingly endless number of potential Career
environmental variables that can impact a per-
son’s development, but doing so in a way that Browning received his Ph.D. in clinical psychol-
can increase understanding of a person, while ogy from the California School of Professional
also respecting the complexity of a human life. Psychology in 1986, which he followed with a
John Hopkins sociologist, Melvin L. Kohn, and postdoctoral fellowship at the Philadelphia
former Bronfenbrenner student at Cornell put it Child Guidance Clinic. He has been a professor
best, Bronfenbrenner’s work impelled social and in the Chestnut Hill College Clinical Psychology
behavioral scientists to “realize that interpersonal Doctoral Program since 1988 and was chair of
relationships, even [at] the smallest level of the the Masters and Doctoral Programs from 1995 to
parent-child relationship, does not exist in a social 2001. His clinical experience includes providing
vacuum but are embedded in the larger social therapy in the private practice setting since
structures of community, society, economics and 1988, where he specializes in family therapy,
politics.” school-related concerns, remarried families and
couples, adult individuals, adolescents and chil-
dren, and consultation and supervision. Addi-
References tionally, he was the director of the counseling
center at Chestnut Hill College from 1989
Bronfenbrenner, U. (1970). Two worlds of childhood: to 1997.
U.S. and U.S.S.R. New York: Simon and Schuster.
Browning also has extensive experience
Bronfenbrenner, U. (1979). The ecology of human devel-
opment: Experiment by nature and design. Cambridge, supervising and mentoring clinical psychology
MA: Harvard University Press. students and early career psychologists, as well
368 Buber, Martin
as consulting with psychologists in a variety of References

settings, including the Psychological Services
Clinic of Chestnut Hill College, the Counseling Browning, S., & Artelt, E. (2011). Stepfamily therapy:
A 10-step clinical approach. Washington, DC: APA
Center for Families and Individuals, and with the
Books.
Anti-Violence Partnership. Browning, S., & Pasley, B. K. (2015). Contemporary fam-
ilies: Translating research into practice. New York:
Routledge Press.
Browning received diplomat-awarded fellow Buber, Martin

status from the American Board of Professional
Psychology in Couples and Family Psychology. Brittany Salerno1 and Molly F. Gasbarrini2
1
Further, he is a board member of the Stepfamily Clinical Psychology, California School of
Association of America and is considered a Professional Psychology at Alliant International
national expert on stepfamily therapy. His University, Los Angeles, CA, USA
2
most prolific work is the coauthored book titled California School of Professional Psychology,
Stepfamily Therapy: A 10-Step Clinical Alliant International University, Los Angeles,
Approach (APA Books, 2011), which created a CA, USA
paradigm shift within the psychological com-
munity regarding the treatment of stepfamilies.
He has authored numerous articles and chapters Name
on empathy, marriage and family therapy, and
stepparenting. He is also a regular presenter at Martin Buber
national conferences on these topics.
Further, Browning’s contributions to family
systems theory include Contemporary families: Introduction
Translating research into practice (Routledge
Press, 2015). To create this book, Browning coor- Martin Buber (born February 8, 1878, Vienna,
dinated several experts of diverse family compo- Austria – died June 13, 1965, Talbiya, Jerusalem)
sitions to write about the research and clinical was a Jewish philosopher, educator, and political
implications of their respective fields. This publi- activist. As a philosophical anthropologist, Buber
cation serves as a reference tool that informs psy- was interested in studying the wholeness of man
chologists about the nuances of several specific by first understanding one’s own experiences with
family types and informs the way psychologists solitude and then recognizing one’s self in relation
work with these families. to the world. Buber is mostly known for his work I
Browning has also made international contri- and Thou (1923).
butions to the field of psychology. During a
sabbatical from Chestnut Hill College, he was a
visiting senior researcher at the Universita Career
Cattolica del Sacro Cuore, where he taught a
20-hour seminar, conducted two full-day work- From 1897 to 1899, Buber completed courses in
shops in Napoli and Milano, and sat on the philosophy and art history at University of Leip-
doctoral commission for their Department of zig, and he worked in the psychiatric clinics of
Psychology. He also organizes and hosts an Wilhelm Wundt and Paul Flecksig. In 1899, he
annual study abroad program for Italian psy- attended the University of Zürich and then stud-
chology graduate students at Chestnut Hill ied at the University of Berlin until 1901. Buber
College. also attended the University of Vienna in 1904.
Buber, Martin 369
He was an editor of the weekly paper Die Welt incorporating the philosophies of I-It and espe-
and became a leader in the Zionist movement, a cially I-Thou relationships in a psychotherapy
Jewish nationalist movement that supports the environment were explained by Buber. He
Jewish homeland of Palestine. In addition to believed that a therapist may analyze an
editing, he lectured, published journals, and impaired client, but doing so may only promote B
produced an art exhibition centered on the Jew- healing to an extent. A more successful tech-
ish culture. He continuously wrote dialogues on nique involves the therapist acknowledging the
religious phenomenology, his most famous sum of the client’s qualities, perceiving the cli-
work being Ich und Du (translated as I and ent’s wholeness, and building a therapeutic-
Thou) which was completed in 1923. While he relationship that is reciprocal. He supported
was in Germany he promoted Jewish studies by mutual, genuine communication as a way for
being appointed the first lecturer in “Jewish the client to reconnect with oneself and with
Religious Philosophy and Ethics” at the Univer- others.
sity of Frankfurt in 1923, reopening the Free Buber was first to use “dialogue” as a rela-
Jewish House of Learning in 1933, developing tional term. His idea of focusing psychotherapy
the Central Office for Jewish Adult Education in on the I-Thou relationship is valuable for recon-
1934, and establishing the School for the Edu- ciling the dynamic in various relationships, such
cation of Teachers of the People in 1949. In as families and couples. According to his philos-
1961, he co-translated the Hebrew Bible into ophy of dialogue, love is an expression of each
German. Buber was Chair of the Department other’s unity of being. Buber acknowledged the
of Sociology of Hebrew University, an advocate essence of confirmation and that there is no unity
of Jewish-Arab unity, and a multiaward winner in a relationship without confirming the other
for many of his works. person’s existence and becoming. The term
“imagining the real” is used by Buber when a
person can understand the other person’s point of
Contribution to Profession view without abandoning one’s own opinions.
This act of inclusion to understand both the
Buber’s work centered around existentialism. other’s uniqueness and their unity accomplishes
A focus of this is the development of human confirmation. In a relationship, such as in the
existence measured by the approach in which case of love, both persons imagining the other’s
individuals engage in dialogue with the world. feelings without giving up one’s own allow for
He is responsible for acknowledging the I-Thou reflection of similarities and differences in per-
relationship, in which a person perceives his or spectives. Buber put forward the collaboration of
her own existence (I) separate from external inclusion and mutuality as being the source of a
nature (Thou). He believed that to progress genuine dialogue. He shared his dialogical
away from the disparaged I-It relationship, in approach in lectures he gave at the Washington
which a person develops experiences through School of Psychiatry, and he has continued to
the observance of others and perceives others influence the psychology world.
as objects to fulfill his or her needs, a person
must acknowledge both oneself and the other
person as participants in the relationship. This
understanding of existing as a subject in a rela- Cross-References
tionship with an external subject, rather than
with a perceived object, encourages dialogue ▶ Collaborative and Dialogic Therapy with Cou-
involving each other’s whole being. Although ples and Families
the ideal relationship is I-Thou, Buber noted the ▶ Dialogical Practice in Couple and Family
importance of I-It relationships, as they provide Therapy
space to analyze the world. The advantages of ▶ “I-Thou” in Couple and Family Therapy
370 Bug-in-the-Ear Supervision
References clients include an alteration in therapist’s behavior

that leads to changes in client behavior (Smith
Buber, M. (1957). Guilt and guilt feelings. Psychiatry, 20, et al. 1998). Some opposition to BITE* supervi-
114–129.
sion also exists. Criticisms of BITE* include
Buber, M. (1958). I and thou. (trans: Smith, R. G.).
New York: Charles Scribner’s Sons. (Original work (a) the supervisee is forced to listen to a supervisor
published 1923). instead of the clients (Russell 1976); (b) it is a
Buber, M. (1965a). Between man and man. (trans: Smith, disruption to session processes (Liddle and Halpin
R. G.). New York: Macmillan. (Original work
1978); and (c) the range of communication the
published 1947).
Buber, M. (1965b). The knowledge of man: A philosophy of supervisor can use is limited to terse comments
the interhuman. M. Friedman, (Ed.), (trans: Friedman, (Berg 1978).
M., & Smith, R. G.). New York: Harper & Row. The first journal articles on the topic appeared
in the early 1970s (Boylston and Tuma 1972;
Mathis 1971) and have continued to be published
in professional journals every decade since that
Bug-in-the-Ear Supervision time (e.g., Kaplan 1987; Smith et al. 1998;
DeRoma et al. 2007; Boyle and McDowell-
Linda Wark Burns 2015).
Indiana University – Purdue University, There isn’t a singular theoretical affiliation of
Fort Wayne, IN, USA BITE* with therapy models. It has been used with
supervisees who are employing group therapy
(Tauber 1978), psychodynamic psychotherapy
Synonyms and Acronyms (Singer 1990), rational-emotive therapy (Young
1986), and behavioral therapy (Haney et al. 1975).
Audio-cuing; BIE; Bug-in-the-ear technology;
BITE*; Earphone; Third ear; Third ear mechani-
cal device; Third mechanical ear Description
In this particular type of live supervision intru-

Theoretical Context sion, the therapist conducts a therapy session
wearing an ear piece similar to those worn by
The intention of the bug-in-the-ear in the clinical television news reporters. The equipment used
professions is to improve the abilities of super- includes a wireless radio receiver and fits into
visees. It is part of the evolution of live supervi- the ear. The supervisee hears short comments
sion wherein an intrusion is made by a supervisor from a supervisor who attempts to provide helpful
during an ongoing therapy session to assist the guidance during the therapy session.
student therapist. Therapy trainees receive instant
help or suggestions which, in turn, can provide
clients with immediate help from a more experi- Applications
enced vantage point. Authors have described
mutual benefits of this method for both therapy According to professional literature, the bug-in-
trainee and clients. Benefits for trainees include the-ear method has been used in training clinics in
help with blind spots and instant support from several clinical professions (Friedberg and
supervisors (DeRoma et al. 2007) as well as min- Brelsford 2013), in special education classrooms
imal disruption (Carmel et al. 2016). Benefits for (Alila et al. 2015), in music therapy education
(Adamek 1994), in live Internet supervision
(Rousmaniere and Frederickson 2013), and as a
Submitted by: Linda Wark, Ph.D., Associate Professor, supervisory method with parents and their chil-
Indiana Purdue Fort Wayne, Fort Wayne, Indiana. dren (Mathis 1971).
Bug-in-the-Ear Supervision 371
Clinical Example ear”. American Journal of Psychiatry, 129(1),

124–126.
Carmel, A., Villatte, J. L., Rosenthal, M. Z., Chalker, S., &
The supervisor asks a student therapist if he would Comtois, K. A. (2016). Applying technological
be willing to try a different method of live super- approaches to clinical supervision in dialectical behav-
vision. She explains the history of the bug-in-the ior therapy: A randomized feasibility trial of the bug-in- B
ear method and discusses how it can be useful and the-eye (BITE) model. Cognitive and Behavioral Prac-
tice, 23(2), 221–229.
that, overall, supervisees do not find it disruptive Champe, J., & Kleist, D. M. (2003). Live supervision:
(Champe and Kleist 2003). She believes that any A review of the research. The Family Journal:
annoyance can be reduced when the method is Counseling and Therapy for Couples and Families,
used properly. For example, sensitivity to the 11(3), 268–275.
DeRoma, V. M., Hickey, D. A., & Stanek, K. M. (2007).
supervisee’s experience with live supervision or Methods of supervision in marriage and family thera-
to the supervisee’s temperament (Mauzey et al. pist training: A brief report. North American Journal of
2000) may facilitate adjustment to this method. Psychology, 9(3), 415–422.
She also explains that, in her experience, clients Friedberg, R. D., & Brelsford, G. M. (2013). Training
methods in cognitive behavior therapy: Tradition and
accept methods of live supervision more often invention. Journal of Cognitive Psychotherapy, 27(1),
than not (Locke and McCollum 2001). The super- 19–29.
visee agrees to work with the bug-in-the-ear Haney, J. N., Sewell, W. R., Edelstein, B. A., & Sartin,
method for two client sessions. After that, they H. H. (1975). A portable, inexpensive, walkie-talkie-
type “bug-in-the-ear”. Behavior Research Methods &
agree to evaluate its continued use. Instrumentation, 7(1), 19–20.
The supervisee becomes acquainted with the Kaplan, R. (1987). The current use of live supervision
equipment in preparation for the client family within marriage and family therapy. The Clinical
therapy session. A student friend of the supervisee Supervisor, 5(3), 43–52.
Liddle, H. A., & Halpin, R. J. (1978). Family therapy
takes the role of a client so the supervisee can training and supervision literature: A comparative
experience listening to his “client” and tuning review. Journal of Marriage and Family Counseling,
into a supervisor’s message. The supervisor 4(4), 77–98.
adjusts her delivery based on feedback from the Locke, L. D., & McCollum, E. E. (2001). Clients’ views of
live supervision and satisfaction with therapy. Journal
supervisee. They meet for a session with specified of Marital and Family Therapy, 27(1), 129–133.
clients and agree that except for urgent situations, Mathis, H. I. (1971). Training a “disturbed” boy using the
the supervisor will speak to the supervisee no mother as therapist: A case study. Behavior Therapy,
more than two times during the session. The ses- 2(2), 233–239.
Mauzey, E., Harris, M. B. C., & Trusty, J. (2000). Com-
sion with the clients proceeds. paring the effects of live supervision interventions on
novice trainee anxiety and anger. The Clinical Super-
visor, 19(2), 109–122.
References Rousmaniere, T., & Frederickson, J. (2013). Internet-based
one way mirror supervision for advanced psychother-
Adamek, M. S. (1994). Audio-cueing and immediate feed- apy training. The Clinical Supervisor, 42(1), 40–55.
back to improve group leadership skills: A live super- Russell, A. (1976). Contemporary concerns in family ther-
vision model. Journal of Music Therapy, 31(2), apy. Journal of Marriage and Family Counseling, 2,
135–164. 243–250.
Alila, S., Määttä, K., & Uusiautti, S. (2015). How does Saba, G. W., & Liddle, H. A. (1986). Perceptions of pro-
supervision support inclusive teacherhood? Interna- fessional needs, practice patterns and critical
tional Electronic Journal of Elementary Education, issues facing family therapy trainers and supervisors.
8(3), 351–362. The American Journal of Family Therapy, 14(2),
Berg, B. (1978). Learning family therapy through simula- 109–122.
tion. Psychotherapy: Theory, Research & Practice, Singer, J. L. (1990). The supervision of graduate students
15(1), 56. who are conducting psychodynamic psychotherapy. In
Boyle, R., & McDowell-Burns, M. (2015). Modalities of R. C. Lane (Ed.), Psychoanalytic approaches to super-
marriage and family therapy supervision. In K. B. Jor- vision (pp. 165–178). New York: Brunner/Mazel.
dan (Ed.), Couple, marriage, and family therapy super- Smith, R. C., Mead, D. E., & Kinsella, J. A. (1998). Direct
vision (pp. 51–70). New York: Springer. supervision: Adding computer assisted feedback and
Boylston, W. H., & Tuma, J. M. (1972). Training of mental data capture to live supervision. Journal of Marital and
health professionals through the use of the “bug in the Family Therapy, 24(1), 113–125.
372 Building Strong Families
Tauber, L. E. (1978). Choice point analysis – formulation, developers and their associated teams were credited
strategy, intervention, and result in group process. The with development and ongoing guidance through-
International Journal of Group Psychotherapy, 28(2),
163–184. out the pilot and evaluation of the BSF project.
Young, R. A. (1986). The function of supervision and
means of accessing interview data. The Clinical Super-
visor, 4(3), 25–37. Theoretical Framework
The model for the BSF project had three compo-

nents: (1) Individual-Level support from Family
Building Strong Families Coordinators, (2) Instruction for Healthy Rela-
tionships and Marriage, and (3) Assessment and
Shawndeeia L. Drinkard referral to Family Support Services (Dion et al.
Alliant International University, Los Angeles, 2010). The goal of the family coordinators was to
CA, USA help individuals and couples identify and find
resources for issues that may impede the couples’
ability to be successful in the BSF project. The
Name of Model BSF project primarily used group-based educa-
tion to address various topics based on literature
Building Strong Families that would predict relationship satisfaction and
marriage stability (Dion et al. 2010).
Introduction
Populations in Focus
The Building Strong Families project was jointly
developed in 2002 by the Office of Planning, As stated earlier, the BSF project was designed for
Research, and Evaluation, Administration for Chil- unmarried, romantically involved couples who
dren and Families (ACF), and the US Department of had recently had or were expecting a baby.
Health and Human Services. The project was devel- Recruitment for participants was primarily in
oped to address the high rates of children in the low socioeconomic neighborhoods. The project
United States who are born to unmarried parents model required each participating program to
(Dion et al. 2010). Current and past literature sug- link families to community resources to help
gests that children born to unmarried parents are at a them be successful (e.g., employment services,
higher risk for many negative outcomes such as additional educational resources, housing
living in poverty and experiencing barriers to quality resources, and/or child care resources).
education than children who are raised by their
married biological parents. To address these con-
cerns, the Building Strong Families (BSF) project Strategies and Techniques Used in
was initiated to serve unmarried, romantically Model
involved couples who were expecting a baby or
had recently had a baby (Dion et al. 2010). Eight organizations volunteered to implement
the BSF project nationwide. The participating orga-
nizations were: (1) Georgia State University, Latin
Prominent Associated Figures American Association, Atlanta, GA, (2) Center for
Urban Families, Baltimore, MD, (3) Family Road of
According to the BSF project report, the developers Greater Baton Rouge-Baton Rouge, LA, (4) Healthy
of the BSF curriculum were: Julie and Families Florida, Florida: Orange and Broward
John Gottman, Bernard Guerney, Mary Ortwein, Counties, (5) Healthy Family Initiatives, Houston,
Pamela Jordan, and Pamela Wilson. These TX, (6) Healthy Families Indiana, Indiana: Allen,
Building Strong Families 373
Marion, and Lake counties, (7) Public Strategies, Oklahoma City suggested that the project had a
Inc., Oklahoma City, Oklahoma, and (8) Healthy positive impact on relationship outcomes (Dion
Families San Angelo, San Angelo, TX. Each of the et al. 2010).
partnering organizations complied with a set of Some reflections given by the authors of the
research-based project guidelines. Although there project report on the outcomes include thoughts B
were key topics that each program needed to cover about the pressure that may have been felt by fathers
in their group sessions, individual programs had the participating in the project (Dion et al. 2010).
opportunity to develop their own curriculum to A possible explanation for their deceased involve-
address these topics in session. ment in their children’s lives could be that after
Potential participants were screened to assess hearing about the importance of fatherhood and
their fit for the project (Dion et al. 2010). Couples the pressure that comes with the role, they felt it
presenting with evidence of violence were not eligi- would be best to remove themselves from their
ble for BSF and were referred to other services. The children’s lives. Another reflection of the project
BSF project had three main components: (1) group was that it was geared toward couples with limited
sessions that focused on building and maintaining economic resources which may have been a barrier
relationship skills for the couple, (2) individualized to marriage for them. Research suggests that low-
support from family coordinators, and (3) assess- income couples tend to want both partners to be
ment for and referrals to outside support services. economically stable prior to marriage (Dion et al.
The project was intended to be intensive, having 2010). The Building Strong Families project pro-
couples attend 30–42 h of group sessions for the vided information regarding helpful considerations
duration of the project. Among the couples whom that need to be made when working with minority
participated in groups, there was an average of couples and those couples with limited economic
21 attended group sessions. Overall, 55% of the prospects. Some resources that describe the Build-
couples that participated in BSF attended a group ing Strong Families project include: Dion and
session during the project (Dion et al. 2010). Hershey (2010), Hershey and Alan (2006), and
Wood et al. (2014). Following the Building Strong
Families project, other programs were launched that
Research About the Model placed more of an emphasis on offering low-income
couples both employment- and relationship-related
The outcomes of BSF were reviewed after 3 years services. The Building Strong Families project
of project implementation (Dion et al. 2010). The paved the way for future programs to address these
impact of the project was measured on three sep- issues and support families in new ways.
arate aspects of the family: (1) the status and
quality of the couples’ relationship, (2) parenting
and father involvement, and (3) child well-being. Cross-References
At the 3 year follow-up for the project, the project
had no effect on the quality of the couple relation- ▶ PREP Enrichment Program
ships or on the likelihood that couples would get
married. Additionally, the BSF project had no
effect on the couples’ co-parenting relationship References
and showed a slight negative effect on some
Dion, M. R., & Hershey, A. M. (2010). Relationship
aspects of father involvement. Finally, the project education for unmarried couples with children: Parental
had no effect on the family stability or economic responses to the building strong families project.
well-being of children. Notably, results from the Journal of Couple and Relationship Therapy, 9(2),
3-year follow-up suggested that the BSF project 161–180.
Dion, M. R., Avellar, S., & Clary, E. (2010). The building
may have led to a slight reduction in children’s strong families project: Implementation of eight
behavior problems. Interestingly, results from the programs to strengthen unmarried parent families.
project implemented by Public Strategies, Inc. in Washington, DC: Office of Planning, Research, and
374 Byng-Hall, John
Evaluation, Administration for Children and Families, Clinic, he was exposed to and strongly influenced
US Department of Health and Human Services. by Salvador Minuchin’s approach, when the
Hershey, M., & Alan, A. H. H. Z. (2006). Implementing
healthy marriage programs for unmarried couples famous family therapist spent two sabbatical
with children early lessons from the building strong periods of leave from the Philadelphia Child
families project. Washington, DC: Mathematica Policy Guidance Clinic at the Tavistock. In addition, he
Research. established close collaborative links with another
Wood, R. G., Moore, Q., Clarkwest, A., & Killewald, A.
(2014). The long-term effects of building strong American Mary Main who had developed the
families: A program for unmarried parents. Journal of Adult Attachment Interview and also visited the
Marriage and Family, 76(2), 446–463. Tavistock Clinic on several occasions.
Byng-Hall, John Contributions to the Profession
Renos K. Papadopoulos Essentially, Byng-Hall’s own approach falls

University of Essex, Colchester, UK within the broadly defined framework of Struc-
tural Family Therapy, which he combined with
John Bowlby’s attachment theory. He had an
Name enormous respect for Gregory Bateson’s ideas,
and he incorporated them in his own unique
John Byng-Hall blend of therapy that emphasized the importance
of “rewriting family scripts.”
For Byng-Hall, a “family script” is a scenario
Introduction that develops imperceptibly within families; it
provides the context within which meaning is
John Byng-Hall is a British family therapist and constructed in families and, in turn, dictates rela-
psychiatrist. Born in Kenya to an old aristocratic tionships, roles, and identities. As such, a family
English family, he worked for most of his active script may either promote development of its
professional life at the Tavistock Clinic in members or it may thwart and retard development,
London, where he was instrumental in developing fostering dysfunctionality.
a systemic clinical service for families, as well as Byng-Hall, using the Structural Family Ther-
training courses in family therapy. A person of apy tradition of enactment, emphasized the grad-
genuine kindness and gentle authority, as a clini- ual enactment of the re-edited scripts during
cian, his work was characterized by authentic therapy, introduced in a most sensitive and
engagement with the families, and, as a teacher, human way. In clarifying the way he modified
he was most inspirational. His role in introducing Structural Family Therapy, he wrote characteris-
family therapy in the UK has been considerable. tically that he had to adapt it to his own “personal
style,” explaining that “My style is more quiet
insistence than of dramatic intervention . . . I like
Career to let things happen more slowly. . . What is more
important is that [the parents] . . . feel respected
John Byng-Hall’s first encounter with family instead of criticized” (Byng-Hall 1995, p. 169).
therapy was during his early work as a Byng-Hall was able to develop further the con-
psychiatrist with severely disturbed adolescents cept of “family scripts” and locate it in the wider
at the Hill End Adolescent Unit in North contexts of narrative approaches that emerged in
London (1969–1972), when he saw adolescents Family Therapy. With his colleague and collabo-
with their families for therapy with his more rator at the Tavistock Clinic, Renos
experienced colleague Dr. Peter Bruggen. Papadopoulos, they edited a book (“Multiple
Subsequently, when he moved to the Tavistock Voices”) exploring the various applications of
Byng-Hall, John 375
the narrative in systemic thinking. More specifi- Cross-References

cally, they examined how “stories develop and in
turn affect the clinical work in relation to four ▶ Schemas in Families
interconnected domains: (a) the therapists’ own ▶ Structural Family Therapy
personal stories about their background and train- B
ing, (b) the story of the institutional setting which
provides contexts within which they work, (c) the References
narrative of the actual therapeutic or research
material, and (d) in the background, the general Byng-Hall, J. (1995). Rewriting family scripts.
Improvisation and systems change. London: The
theoretical paradigms and sociopolitical stories
Guildford Press.
and myths of the time” (1997, pp. 3–4). Papadopoulos, R. K., & Byng-Hall, J. (Eds.). (1997).
In retirement, John Byng-Hall is able to enjoy Multiple voices. Narrative in systemic family psycho-
his serious hobby of painting. therapy. London: Duckworth.
C
Cahiers critiques de thérapie Initially 15 issues were published on an annual

familiale et de pratiques de basis directed by Mony Elkaïm. After an interrup-
réseaux (Journal) tion of 2 years, from 1994 to June 1996, a new
publisher was found (De Boeck, Brussels), and
Edith Goldbeter the journal moved to biennial publication with
Institut d’Etudes de la Famille et des Systèmes Edith Goldbeter as editor-in-chief.
Humains, Brussels and ULB, Brussels, Belgium
Location
Name of Journal
The journal’s editorial office is located in
Brussels.
Cahiers critiques de thérapie familiale et de pra-
tiques de réseaux.
Introduction
Mony Elkaïm presented his project at the opening
of the first issue of the magazine as follows:
The journal Cahiers critiques de thérapie
familiale et de pratiques de réseaux (Critical – to open a theoretical-technical debate on our
Reviews of Family Therapy and Network Prac- practices in family therapy,
tices) is historically the first international French- – to extend this debate to all those who, in differ-
ent ways, question existing institutions and prac-
language family therapy journal. Created in 1979
tices in the field of mental health,
in Belgium by Mony Elkaïm, who is still its direc- – to make available international documents in
tor, it was the official body of the Institute for the this field to the French-speaking public.
Study of the Family and Human Systems – Brus-
sels, Belgium. He concluded his presentation by insisting on
Organized around specific topics, the Cahiers the fact that the Cahiers critiques de thérapie
critiques de thérapie familiale et de pratiques de familiale et de pratiques de réseaux “will only
réseaux is intended for mental health practi- make sense if they solicit and allow the widest
tioners, teachers, researchers, and students alike. possible debate based on our practices, so it is
Authors are solicited or submit articles by your active participation which will be the deci-
themselves. sive element for the future of this journal”

https://doi.org/10.1007/978-3-319-49425-8
378 Camberwell Interview for Assessing Expressed Emotion in Families
Edith Goldbeter became editor in chief in

1996, following the line opened by Mony Elkaïm, Camberwell Interview for
being still involved in the journal. Assessing Expressed Emotion
in Families
Contributions
Cody G. Dodd and Ciera E. Schoonover
The first issues included articles translated into Department of Psychology, Central Michigan
French of family therapy pioneers such as Carl University, Mount Pleasant, MI, USA
Whitaker, Carlos Sluzki, Helm Stierlin, Mara
Selvini Palazzoli, Paul Watzlawick, Luigi Onnis,
Maurizio Andolfi, and others, and also texts of Name and Type of Measure
French-speaking authors such as Mony Elkaïm,
Philippe Caillé, Elisabeth Fivaz, and Danielle The Camberwell Family Interview (CFI) is a
Desmarais. There were also articles of anti- semi-structured interview measuring expressed
psychiatrists and professionals involved in insti- emotion (EE) in families.
tutional psychiatry as David Cooper, Ronald
Laing, Yvonne Bonner, etc.
The Cahiers critiques de thérapie familiale et Introduction
de pratiques de réseaux have also opened their
pages to contributors belonging to fields related to The Camberwell Family Interview (CFI; Vaughn
family therapy, to practitioners from other disci- and Leff 1976) is a semi-structured interview that is
plines or orientations, as well as to scientists such considered the gold standard measure of expressed
as Felix Guattari, Francisco Varela, Humberto emotion (EE) in families of individuals with mental
Maturana, Ilya Prigogine, Martine Gross, trying health problems. Originally designed for patients
always to keep up a constructive dialogue. with schizophrenia, the CFI is conducted with key
Here are some issue topics: “Adolescence in family members and focuses on the impact of the
context” (40, 2008), “Biology and psychotherapy” identified client’s condition on the daily life of the
(43, 2009), “Analytical therapies, systemic therapy: family. High expressed emotion in families is a sig-
what bridges?” (45, 2010), “Constrained help and nificant predictor of symptomatic relapse and other
psychotherapy” (46, 2011), “Adopting, a chal- negative outcomes for individuals across a range of
lenge?” (56, 2016), “Families, caregivers and criti- emotional, behavioral, and thought disorders.
cal illness” (57, 2016), “Co-therapy” (58, 2017). The CFI administration takes place without the
A special issue will be dedicated to the “Sin- patient present and is recorded so that it can later be
gularities of the therapist” (60, 2018) and will coded on five domains: criticism, hostility, warmth,
appear in 2018, crowning the 39 years of life of positive comments, and emotional over-
the Critical Reviews of Family Therapy and Net- involvement. An overall high or low-EE designa-
work Practices. tion is derived based on cutoffs from these
subscale scores. The typical length of the interview
is 1–2 h and coding the interview takes approxi-
Cross-References mately 2 to 3 h. Approved CFI administration
requires between 40 and 80 h of formal training
▶ Elkaïm, Mony (Van Humbeeck et al. 2002).
References Developers
https://www.cairn.info/revue-cahiers-critiques-de- The CFI was developed by Christine Vaughn and

therapie-familiale.htm. Julian Leff (1976).
Camberwell Interview for Assessing Expressed Emotion in Families 379
Description of Measure Psychometrics
The CFI has primarily been used in research Of the instruments used to measure EE in research
on the outcomes of individual diagnosed with on families of individuals with mental disorders,
schizophrenia and other chronic or severe mental the CFI is considered to be the most reliable and
illnesses. CFI scores are indicators of the emo- powerful predictor of symptomatic relapse (Van
tional climate among the patient and key relatives Humbeeck et al. 2002). Inter-rater reliability esti- C
that he or she is in close contact with. A completed mates for the five CFI scales in published research
and scored CFI produces five subscale scores and using approved CFI raters have ranged from fair
an overall EE designation of high or low. The to good. Reportedly, raters who complete the offi-
relationship between EE and relapse has often cial CFI training program are required to produce
been described as a diathesis-stress model, an intraclass correlation (ICC) coefficient of 0.80
wherein already-vulnerable patients with high- or better with an expert rater on all scales (Van
EE families accrue more negative and hostile Humbeeck et al. 2002). Estimates of the test-retest
interactions in their daily life and are thus reliability of the CFI have not been reported.
more likely to experience a relapse. The factor-analytic research on the CFI is lim-
Scores on the CFI are obtained via coding of ited, although some evidence suggests a three-factor
verbalizations made during an individual inter- model consisting of criticism, positivity, and emo-
view with a family member. A CFI manual exists tional over-involvement has the best fit (Van
that provides trained administrators with detailed Humbeeck et al. 2002). Hostility and criticism
guidelines for coding (Vaughn and Leff 1985). appear to overlap highly, and criticism is also nega-
The Critical Comments (CC) and Positive tively correlated with warmth and positive com-
Remarks (PR) scales consist of the number of ments (Vaughn and Leff 1976). The construct
negative and positive statements made about the validity of EE and its subscales is strong, as
patient throughout the interview. The three other CFI scores have been shown to correlate with phys-
scales are rated at the end of the interview on iological measures of arousal and coded interactions
Likert-type scales as overall appraisals. Emo- among patients and family members (Van
tional over-involvement (EOI) and Warmth Humbeeck et al. 2002).
(W) are rated on six-point scales (0–5) and Hos- Expressed emotion, as measured by the CFI,
tility is rated on a four-point scale (0–3). Emo- is predictive of symptom relapse, treatment
tional over-involvement is rated based on the response, and other negative outcomes in patients
interviewees’ description of their behavior in with a range of disorders including schizophrenia,
terms of protectiveness, emotional reactivity, affective and eating disorders, and substance
and devotion in response to the patient. Warmth abuse (Hooley 2007). The overall EE index
takes into account vocal aspects of the inter- appears to be the single best predictor of relapse;
viewee, and his or her expressions of interest however, the number of critical remarks contrib-
and empathy directed at the patient. Hostility utes highly to the index’s overall predictive valid-
ratings are based on severe, overly general, and ity (Vaughn and Leff 1976). Research on EE in
critical comments about the patient. Finally, rel- staff members suggests it as a potential indicator
atives are classified as high EE if they have: (a) 6 of service quality, and criticism in particular is
or more critical comments, (b) a hostility score of associated with worsened patient functioning
1 or more, or (c) an emotional over-involvement (Berry et al. 2011). In general, patients with
score of 3 or more (Van Humbeeck et al. 2002). chronic and severe conditions seemed to be
A large body of evidence indicates that individ- more vulnerable to the negative effects of high
uals with a range of mental health and other EE. Additionally, research suggests that high-EE
chronic diagnoses have worse outcomes if they relatives report higher levels of burden and are
have or live with high-EE family members also at greater risk for experiencing depression
(Hooley 2007). than low-EE relatives (Safavi et al. 2017), which
380 Camberwell Interview for Assessing Expressed Emotion in Families
also may impact their care and contribute to neg- interview conducted according to the CFI format.
ative interactions with the patient. Malcom’s psychologist, Dr. Pitts, considered
Surprisingly, meta-analytic results indicate that information obtained from the CFI alongside
the CFI may be a better predictor of poorer out- other assessment data to provide discharge recom-
comes in depression and eating disorders than it is mendations to Malcom and his family.
for schizophrenia. For example, some evidence During a feedback session with the family,
suggests that high EE is associated with engage- Dr. Pitts reviewed the results from the CFI.
ment and worse response to treatment for anxiety Mr. Waters and Malcom’s brother, James, both
disorders (Taylor et al. 2012). It is noted, however, were classified as low-EE based on their CFI scores;
that although early research showed promise for however, Mrs. Waters’s high number of critical
the CFI in terms of treatment sensitivity, reviews comments and level of emotional over-involvement
of the psycho-education and other family inter- earned her a high-EE rating. Dr. Pitts provided the
vention research have not concluded that treat- family with information about the vulnerability-
ment can reliably produce changes in EE (e.g., stress model of relapse in severe and chronic psy-
Mari and Streiner 1994; Sin et al. 2017). chiatric conditions. Then, she commented on how
Data on the cross-cultural validity of EE and all members of the family scored high on the pro-
its facets are mixed, and most of the research on tective indicators of warmth and positivity in their
the CFI has been done with US and Western interviews. To reduce the impact of criticism and
European samples. Published empirical research emotional reactivity observed in Mrs. Waters’s inter-
with the CFI in non-Western samples has produced view, Dr. Pitts recommended a brief course of family
conflicting results, with studies showing EE to be therapy and asked that the family attend an educa-
predictive of symptomatic relapse in some cultures, tional group provided by the agency for families.
but not others. Several translations of the CFI have Through these two processes, the family could
been developed, and the evidence supporting their reduce conflict and emotional reactivity in the
predictive validity has been mixed. Some studies home and learn other strategies to manage stress
have shown an association between criticism and and prevent symptom relapse.
worse outcomes in international samples; however, Based on Dr. Pitts’s recommendations, the family
this finding needs replication. Great variability in the attended several sessions of family therapy aimed at
EE profiles of families of individuals diagnosed reducing family conflict and stress. After several
with schizophrenia and other mental disorders weeks of group and family treatment, Malcom was
across cultures has been noted as a significant lim- discharged and re-enrolled in classes part-time at his
itation of the research on EE and the CFI university. The increased family cohesiveness and
(Kymalainen and Weisman 2008). use of strategies learned in the educational group
allowed the family to better support him in develop-
ing skills to manage his symptoms. This ultimately
Example of Application in Couple and helped Malcolm function more adaptively in the
Family Therapy social and academic domains.
Malcom Waters is a 26-year-old university stu-

dent who was recently admitted to an inpatient References
psychiatric treatment center after a first-episode
Berry, K., Barrowclough, C., & Haddock, G. (2011). The role
experience of psychosis. Over the past month, he of expressed emotion in relationships between psychiatric
has received medication treatment in combination staff and people with a diagnosis of psychosis: A review
with individual and group therapy. He is about to of the literature. Schizophrenia Bulletin, 37(5), 958–972.
be discharged so that he can return to living with https://doi.org/10.1093/schbul/sbp 162.
Hooley, J. M. (2007). Expressed emotion and relapse
his parents and attending school. During his pre- of psychopathology. Annual Review of Clinical Psy-
discharge evaluation, his parents and teenage chology, 3(1), 329–352. https://doi.org/10.1146/annu
brother each participated in an individual rev.clinpsy.2.022305.095236.
Caring Days in Couple and Family Therapy 381
Kymalainen, J. A., & Weisman, D. M. (2008). Expressed Introduction

emotion, communication deviance, and culture in fam-
ilies of patients with schizophrenia: A review of the
literature. Cultural Diversity and Ethnic Minority Psy- Caring Days is a strategy designed to build trust
chology, 14(2), 85–91. https://doi.org/10.1037/1099- and commitment in the couple relationship by
9809.14.2.85. increasing positive behavior exchanges. When
Mari, J. D. J., & Streiner, D. L. (1994). An overview of couples engage in more positive exchanges, they
family interventions and relapse on schizophrenia:
Meta-analysis of research findings. Psychological increase investment and trust in the relationship. C
Medicine, 24(3), 565–578. https://doi.org/10.1017/ Additionally, the procedure increases clients’
S0033291700027720. attention to caring actions exchanged and
Safavi, R., Berry, K., & Wearden, A. (2017). Expressed decreases attention on negative behaviors (Stuart
emotion in relatives of persons with dementia:
A systematic review and meta-analysis. Aging & Men- 1980).
tal Health, 21(2), 113–124. https://doi.org/10.1080/
13607863.2015.1111863.
Sin, J., Gillard, S., Spain, D., Cornelius, V., Chen, T., & Theoretical Framework
Henderson, C. (2017). Effectiveness of psychoedu-
cational interventions for family carers of people with
psychosis: A systematic review and meta-analysis. Caring Days is rooted in operant behavior,
Clinical Psychology Review, 56, 13–24. https://doi. social learning, and social exchange theories.
org/10.1016/j.cpr.2017.05.002. Operant behavior theory maintains behavior
Taylor, S., Abramowitz, J. S., & McKay, D. (2012). Non-
adherence and non-response in the treatment of anxiety increases or decreases over time as a result of
disorders. Journal of Anxiety Disorders, 26(5), 583–589. whether it is reinforced or punished, respec-
https://doi.org/10.1016/j.janxdis.2012.02.010. tively. Social learning theory maintains that
Van Humbeeck, G., Van Audenhove, C., De Hert, M., learning in social contexts can occur through
Pieters, G., & Storms, G. (2002). Expressed emotion:
A review of assessment instruments. Clinical Psychol- direct instruction and observation of others’
ogy Review, 22(3), 321–341. https://doi.org/10.1016/ behavior. Finally, social exchange theory pur-
S0272-7358(01)00098-8. ports that the relative costs and rewards
Vaughn, C. E., & Leff, J. P. (1976). The measurement exchanged in a relationship determine its rela-
of expressed emotion in the families of psychiatric
patients. British Journal of Social and Clinical Psy- tive value to partners. The Caring Days proce-
chology, 15(2), 157–165. https://doi.org/10.1111/ dure increases noncontingent positive behaviors
j.2044-8260.1976.tb00021.x. exchanged in a relationship to increase commit-
Vaughn, C. E., & Leff, J. P. (1985). Expressed emotion in ment and positive affect using direct instruction
families. New York: The Guilford Press.
provided by the partner and therapist and posi-
tive reinforcement to change partners’ interac-
tions (Stuart 1980).
Several models of relationship functioning
Caring Days in Couple and emphasize the importance of experiencing greater
Family Therapy positive relative to negative behavioral exchanges
for relationship functioning (Gottman 1993;
Jennifer M. Lorenzo1 and Robin A. Barry2 Stuart 1980). The ratio of positive to negative
1
Department of Psychology, University of behavioral exchanges may become less optimal
Maryland, Baltimore Country, Baltimore, in a relationship overtime due to reinforcement
MD, USA erosion or because negative behaviors tend to be
2
Department of Psychology, University of salient. When positive behaviors are not recipro-
Wyoming, Laramie, WY, USA cated or are not reinforced, they occur less fre-
quently. The Caring Days procedure promotes
positive behaviors, and thus should increase
Name of Strategy attraction, trust, and investment in the relationship
and a more favorable ratio of positive to negative
Caring Days behavior exchange in the relationship.
382 Caring Days in Couple and Family Therapy
Rationale for the Strategy clarifying questions to ensure accurate understand-

ing. The therapist then asks each partner to commit
The Caring Days technique is designed for imple- to performing at least one behavior from the list
mentation in the initial stages of therapy. Many daily, regardless of whether the other partner per-
couples seek treatment when experiencing a low forms the behaviors. This promotes change by
rate of caring behaviors (Stuart 1980). Couples reducing contingencies for performing positive
experiencing low rates of caring behaviors tend behaviors.
to have lower relationship commitment because Couples are also instructed to take time each
rewarding aspects of the relationship are absent or day to note whether their partner performed each
diminished. The Caring Days procedure increases behavior. This serves to increase attention to and
noncontingent positive behaviors, increasing reinforcement of partner’s positive behaviors.
reinforcing aspects of the relationship and enhanc- Posting the list in a conspicuous place (e.g., on
ing commitment. For more committed couples the refrigerator) serves as a reminder of the task
who are already engaging in caring behaviors, for the couple. Therapists should contact the cou-
implementation of the Caring Days technique ple between sessions to address concerns and
reinforces existing relationship strengths and pro- encourage adherence.
vides opportunities for the couple to practice
assertively making requests (Stuart 1980).
Case Example
Description of the Strategy or Peyton and Jamie entered therapy following the
Intervention loss of Jamie’s job. They had been married for
7 years and had a daughter aged 2. The couple
In introducing the Caring Days technique, couples described a decrease in intimacy since the birth of
are told that they may not actually experience their daughter and an increase in intense argu-
caring feelings for one another until their behavior ments since Jamie was laid off from work a few
has changed. Thus, they are asked to act “as if” months ago. During intake the couple struggled to
they care for each other. Through this explana- identify positive qualities about one another.
tion, couples are provided with a rationale to Peyton criticized Jamie’s poor housekeeping and
perform positive behaviors for their partner even not working hard enough to gain employment.
though they may not feel positively toward their Jamie complained that all Peyton did was “work,
partner (Stuart 1980). eat, and sleep.” Jame felt Peyton did not help
Each partner is asked to identify and list behav- enough with their daughter.
iors that their partner could enact that would convey The clinician explained that couples often
care to them. Behaviors must be (1) positive (i.e., it develop a pattern of focusing on negatives in the
is a behavior the partner can enact rather than a relationship until it becomes too difficult to identify
behavior the partner should refrain from), (2) spe- positives about their partner. For Peyton and Jamie
cific, (3) small (i.e., can be performed at least once to develop intimacy, they would need to change
daily), and (4) unrelated to recent intense conflict. their behaviors toward one another which would
Couples should identify several behaviors so that likely change their feelings about one another. The
each couple member will have relevant behaviors to clinician introduced the Caring Days procedure and
perform daily. They are encouraged to add behav- asked the couple to identify behaviors they would
iors to the list each week to reduce stagnation and to like their partner to do to show caring. Initially,
allow for partners’ preferences in caring behaviors Peyton identified vague behaviors such as “tidy the
to shift over time. When behaviors are listed, the house” and sources of conflict such as “get a job.”
spouse making the request should describe what, Jamie negatively framed requests such as “don’t be
when, and how the behavior should be performed. so tired in the evening.” The clinician helped the
The partner receiving the request should ask couple reframe requests to be positive, specific,
Carlson, Cindy 383
small, and not the subject of recent conflict. The Introduction

couple identified and discussed different positive
requests and agreed to perform at least one activity Dr. Cindy Carlson has contributed to the field of
daily and to record the dates they saw their partner couple and family psychology in many essential
complete the task. roles, including researcher, educator, practitioner,
The clinician called the couple 3 days later. The editor, and active professional citizen. Her schol-
couple reported inconsistently performing tasks arly and training efforts focus on family assess- C
because they did not think their partner was doing ment and intervention, particularly in the context
their tasks. The clinician reminded each partner to of the home-school partnership. She has held
complete tasks regardless of their partner’s perfor- many governance positions at her home university
mance. After about a month, the couple had added and more broadly within the American Psycho-
several additional tasks to their list. In addition to logical Association (APA). Among her many
completing caring tasks, the couple reported fewer notable achievements, Dr. Carlson is a Fellow,
arguments and more intimate moments. With Past President, and Distinguished Service Award
enhanced commitment and positive affect, the cou- winner for two APA divisions, namely, the Soci-
ple was able to successfully learn conflict resolution eties of Family Psychology and School
skills in therapy. Psychology.
Cross-References Career
▶ Behavior Exchange in Couple and Family
Dr. Carlson received a bachelor’s degree from
Therapy
DePauw University and then went on to earn
▶ Social Learning Theory
master’s and doctoral degrees in School Psy-
▶ Stuart, Richard
chology with minors in Clinical and Counseling
Psychology from Indiana University. She com-
pleted her internship training with the Memphis
References Clinical Psychology Internship Consortium in
association with the University of Tennessee
Gottman, J. M. (1993). The roles of conflict engagement,
escalation, and avoidance in marital interaction: College of Medicine. In 1982, Dr. Carlson
A longitudinal view of five types of couples. Journal accepted an academic position at the University
of Consulting and Clinical Psychology, 61(1), 6–15. of Texas at Austin (UT-Austin), where she has
https://doi.org/10.1037/0022-006X.61.1.6.
served in multiple capacities, including Director
Stuart, R. B. (1980). Helping couples change: A social
learning approach to marital therapy. New York: of the School Psychology Program, departmen-
Guilford Press. tal Graduate Advisor, and A. M. Aikin Regents
Chair in Junior and Community College Educa-
tion Leadership. Currently Dr. Carlson is the
Margie Gurley Seay Professor and Chair of the
Carlson, Cindy Department of Educational Psychology at
UT-Austin.
Shelley Riggs
Department of Psychology, University of North
Texas, Denton, TX, USA Contributions to Profession
In addition to publishing two influential books,

Name the Handbook of Family-School Intervention: A
Systems Perspective (Fine & Carlson, 1991) and
Cindy I. Carlson, Ph.D., A.B..P.P. Family Assessment: A Guide for Researchers
384 Carr, Alan
and Practitioners (Grotevant & Carlson, 1989), Council of Graduate Departments of Psychol-
Dr. Carlson has authored or coauthored approx- ogy and is now on the APA Commission of
imately 60 book chapters and journal articles. Accreditation.
She is perhaps best known for her expertise on
family assessment (Carlson, Krumholtz, &
Cross-References
Snyder, 2013; Grotevant & Carlson, 1989), the
family-school interface (Carlson, Funk, &
▶ Assessment in Couple and Family Therapy
Nguyen, 2009), and best practices for working
▶ Couple and Family Psychology (Journal)
with single-parent and stepfamily systems
▶ Single Parent Families
(Carlson, 1995). Dr. Carlson has received sub-
stantial funding for her research on the influ-
ences of family processes on children’s
References
behavior and achievement at school, school-
based interventions with parents and families, Carlson, C. I. (1995). Best practices in working with single
and intergroup relations and academic success parent and stepfamily systems. In A. Thomas &
among diverse youth (Carlson & Christenson, J. Grimes (Eds.), Best practices in school psychology
2005). (Vol. III, pp. 1097–1110). Washington, DC: National
Association of School Psychologists.
Dr. Carlson has been a dedicated educator for Carlson, C.I., & Christenson, S. (Eds.). (2005).
over 30 years and was named Outstanding Evidence-based parent and family interventions in
Graduate Advisor by UT-Austin in 2005. She school psychology [Special Issue]. School Psychol-
developed an innovative family therapy training ogy Quarterly, 20, 345–351.
Carlson, C. I., Wilson, K. D., & Hargrove, J. L. (2003). The
program at UT-Austin and has mentored numer- effect of school racial composition on Hispanic
ous graduate students, who now contribute to intergroup relations. Journal of Social and Personal
the field in academic positions, public schools, Relationships, 20, 203–220.
nonprofit agencies, community and national ser- Carlson, C. I., Funk, C., & Nguyen, K. (2009). Family-school
communication. In J. H. Bray & M. Stanton (Eds.), Wiley-
vice, and private practice settings across the Blackwell Handbook of family psychology (pp. 515–526).
country. Dr. Carlson received two Graduate New York, NY: Wiley-Blackwell Publishing.
Psychology Education Program grants for the Carlson, C. I., Krumholtz, L. S., & Snyder, D. K. (2013).
Integrated Behavioral Health Psychology Assessment in marriage and family counseling. In
K. F. Geisinger (Ed.), APA handbook of testing and
(IBHP) Program at UT-Austin, which is assessment in psychology (pp. 569–586). Washington,
designed to prepare doctoral-level students to DC: APA Publications.
provide culturally and linguistically competent, Fine, M. & Carlson, C.I. (Eds.) (1991). Handbook of fam-
evidence-based psychological services as part ily-school intervention: A systems perspective. Boston:
Allyn & Bacon.
of interprofessional health-care teams serving Grotevant, H. D., & Carlson, C. I. (1989). Family assess-
vulnerable and underserved populations within ment: A guide for researchers and practitioners. New
community health settings. York: Guilford Press.
With an extensive service record, Dr. Carlson
has made notable contributions to the specialty
of couple and family psychology. She has Carr, Alan
served on the editorial boards for five journals
and is currently Associate Editor for Couple and Peter Stratton
Family Psychology: Research and Practice. Leeds Family Therapy and Research Centre,
Dr. Carlson has held numerous leadership posi- University of Leeds, Leeds, UK
tions in APA Societies of School and Family
Psychology and represented the field as Chair
for APA’s Commission for Specialties and Pro- Name
ficiencies in Psychology. Most recently, she was
a member of the Executive Board for the Carr, Alan
Carr, Alan 385
Introduction therapy, most comprehensively articulated in

his book: Family therapy: Concepts, process
Alan Carr is best known for his research- and practice (Carr 2012). In this model, he pro-
informed, theoretically integrative clinical prac- poses that most common problems are embed-
tice models. He has been awarded many research ded in a recursive pattern of interaction
grants, and is a prolific writer having published involving the identified problem person and
over 20 books and 200 articles. He has made members of their social system. The roles C
keynote addresses and presentations to profes- adopted by those who participate in this inter-
sional associations of family therapy and clin- action pattern are driven by beliefs and narra-
ical psychology around the world. His books tives about problems, their resolution, and
have been translated into many languages. His relationships. These beliefs and narratives, in
best-selling textbooks are Family therapy: Con- turn, are underpinned by background factors.
cepts, process and practice (Wiley, 2000) and These include factors within the wider current
the Handbook of clinical child and adolescent social system, developmental experiences, and
psychology: A contextual approach (Routledge, biological vulnerabilities. In clinical practice, a
1999). Second and third editions of both have three-column formulation specifying the
been published. His research spans a range of problem-maintaining interaction pattern, under-
topics including evaluation of the effectiveness lying beliefs, and background factors may be
of systemic interventions, family assessment, developed, as well as a similar three-column
psychotraumatology, and positive psychology. formulation of exceptional episodes where the
problem was expected to occur but did not. The
process of developing these problem and excep-
Career tion formulations may be used to engage fami-
lies in therapy and motivate them to
Carr received his BA (1977) and MA (1979) cooperatively resolve the presenting problem.
in psychology from University College Dublin These formulations may also guide the develop-
(UCD). He then travelled to Queens University ment of interventions, and the order in which it
Kingston in Canada where he graduated with may be most helpful to implement these. Inter-
a PhD in clinical psychology in 1984. He was ventions that aim to disrupt behavior patterns
employed as a clinical psychologist at the may be tried before proceeding to those which
National Health Service in the UK between 1984 focus on beliefs, and these may precede those
and 1991. He returned to UCD in 1992 where that focus on background factors.
he has worked for over 25 years. At UCD, he Carr’s second main contribution has been
founded a doctoral program in clinical psychology documenting the large evidence-base that sup-
which includes systemic practice in the curricu- ports the effectiveness of systemic practice and
lum. Alongside his academic career, Carr has arguing that couple and family therapy should
practiced systemic therapy at Clanwilliam Insti- be informed by this evidence-base. Since his
tute, Dublin since 1992. Among his many acco- first review in 2000, he has supplied regular
lades, in 2011, he received an award from the updates, the most recent being Carr (2014a, b).
European Family Therapy Association for his He has shown that there is evidence for the
contribution to family therapy research. effectiveness of systemic interventions with
child-focused problems such as sleeping, feed-
ing, and attachment problems in infancy;
Contribution to Profession aspects of child abuse; childhood disruptive
behavior disorders; and adolescent eating disor-
Professor Carr has made five important contri- ders. There is also evidence for the effectiveness
butions to the field of systemic therapy. First, he of systemic interventions for adult-focused
developed an integrative model of systemic problems such as relationship distress,
386 Carter, Betty
psychosexual problems, and intimate partner

violence. Finally, for both young people and Carter, Betty
adults, there is evidence for the effectiveness
of systemic interventions with alcohol and Melinda MacDonald and M. L. Parker
drug problems, mood disorders, anxiety disor- Marriage and Family Therapy Program, University
ders, psychosis, and adjustment to illness and of Saint Joseph, West Hartford, CT, USA
disability.
Carr’s third contribution has been showing
how systemic practice may be integrated into Name
clinical psychology. This specialism arises
from his successful integration of systemics Betty Carter
into the doctoral training of over 100 clinical Elizabeth A. (Golden) “Betty” Carter
psychologists. This achievement is encapsu- (1929–2012)
lated in his book: The Handbook of child and
adolescent clinical psychology: A contextual
approach (Carr 2015). Introduction
His fourth major contribution has been in
creating a vibrant research ethos among his doc- Betty Carter, MSW, was originally trained as a
toral students and his own substantial research Bowenian Family Therapist and became well
contributions particularly of outcome measure- known for her work on the expanded family
ment in systemic therapy, and positive life cycle. In collaboration with Monica
psychology. McGoldrick, Carter integrated the concepts of
Finally, he has documented the history of fam- individual human development and the tradi-
ily therapy in Ireland, a history in which he has tional family life cycle to develop an expanded
played a dominant role (Carr 2013). perspective of family development. In addition
to the expanded family life cycle, Carter
strongly influenced the field of marriage and
Cross-References family therapy by questioning the family sys-
tems theory tenets of traditional gender roles,
▶ European Family Therapy Association power dynamics, and the narrow view of the
▶ Integration in Couple and Family Therapy female perspective. Carter was also a cofounder
▶ Research in Relational Science of the Women’s Project in Family Therapy,
▶ SCORE which aimed to amplify the female voice within
the field of family therapy.
References
Career
Carr, A. (2012). Family therapy: Concepts, process and
practice (3rd ed.). Chichester: Wiley.
Carr, A. (2013). The development of family therapy in Carter received her undergraduate degree from
Ireland. Contemporary Family Therapy, 35, 179–199. St. John’s College, NY, and went on to earn her
Carr, A. (2014a). The evidence-base for family therapy and Master of Social Work degree from Hunter Col-
systemic interventions for child-focused problems.
lege, NY. Carter then met Peggy Papp and Olga
Carr, A. (2014b). The evidence-base for couple therapy, Silverstein while attending the Ackerman Institute
family therapy and systemic interventions for adult- for the Family, NY, who worked with Marianne
focused problems. Journal of Family Therapy, 36, Walters to lead the Women’s Project in Family
158–194.
Carr, A. (2015). Handbook of child and adolescent clinical
Therapy. Carter eventually became the director
psychology: A contextual approach (3rd ed.). London: and founder of the Family Institute of Westchester
Routledge. in White Plains, NY.
Catherall, Donald 387
Contributions to Profession Lastly, Carter was the director and founder of

the Family Institute of Westchester where she was
Carter contributed to many writings and trainings a clinical supervisor and taught students about
that challenged concepts within the field of family family systems concepts while coaching clients
therapy using a feminist lens. Notably, Carter to create change within their families. Carter is
worked with McGoldrick to coauthor The Family quoted as saying:
Life Cycle: A Framework for Family Therapy I would say that, after having been in the field for
C
(1981). Carter continued to collaborate with almost 30 years, of all of the many different things
McGoldrick on works that utilized the feminist that I did, my most gratifying work was related to
critique to reevaluate traditional gender roles and gender and culture – especially when we first started
recognizing and working with gender issues. It was
power dynamics that are inherent within the mind-blowing to me that we hadn’t noticed the most
Bowenian concepts of triangles in divorce and basic of things – the organizing principle of gender.
remarriage. The pair also examined the struggle And when I did notice it, nothing was the same.
between vertical (flow of generational anxiety)
and horizontal (familial stress associated with dif- Cross-References
ferent stages of the life cycle) patterns of conver-
gence. Carter wrote Love, Honor, and Negotiate: ▶ Family Life Cycle
Building Partnerships That Last a Lifetime ▶ Feminism in Couple and Family Therapy
(1996), which focuses on the function of money ▶ Gender in Couple and Family Therapy
and power in relationships. Couples are encour- ▶ Gender Roles
aged to explore communication on cultural, ▶ Triangles in Bowen Family Therapy
social, and historical contexts associated with
gender power dynamics that influence their rela-
tionship. Carter’s body of work has brought atten- References
tion to family assessment through a multi-
contextual lens including acknowledgment of Carter, B., & McGoldrick, M. (1981). The family life cycle:
class, race, ethnicity, gender, and sexual A framework for family therapy. New York: Gardner Press.
orientation. Carter, B., & Peters, J. K. (1996). Love, honor and nego-
tiate: Building partnerships that last a lifetime. New
Carter cofounded the Women’s Project in Fam- York: Pocket Books.
ily Therapy with Marianne Walters, Peggy Papp, McGoldrick, M. (2013). The multicultural family institute
and Olga Silverstein to examine the female expe- remembers Betty Carter (May 13, 1929–September
rience within the family. The project aimed to 11, 2012). Journal of Marital and Family Therapy,
39(1), 2–4. https://doi.org/10.1111/jmft.12009.
challenge the idea that men and women share Walters, M., Carter, B., Papp, P., & Silverstein, O. (1988).
equality in a world where societal roles and rules The invisible web: Gender patterns in family relation-
are organized in favor of men at the disadvantage ships. New York: The Guilford Press.
of women. The Women’s Project hosted a series of
international meetings of female therapists to
address traditional patriarchal views of gender in
families and within the field of family therapy as a Catherall, Donald
whole. As a product of these meetings, Carter and
the other founding members of the Women’s Pro- Katelyn Steele
ject went on to coauthor The Invisible Web: Gen- Alliant International University, Los Angeles,
der Patterns in Family Relationships (1988). The CA, USA
aim of The Invisible Web was to challenge tradi-
tional gender beliefs and clinical practices in the
field of family therapy. The writings further incor- Donald Catherall is an important contributor to
porated feminist thinking to explore conflicting couple and family therapy and theory. He is well
sexist messages inherent within systems thinking. known for introducing the concept of emotional
388 Catherall, Donald
safety. Catherall has authored four books and create a healthier mindset and repair their strained
numerous papers in influential journals. relationship. The successful couple is one that can
Catherall received his Ph.D. in Clinical Psy- overcome transitory lapses in safety.
chology from Northwestern University Medical Catherall developed the therapeutic alliance
School in 1984 following his honorable dis- in couple and family therapy, akin to the well-
charge from the United States Marine Corps. established concept in individual psychother-
He began his postgraduate work at the apy. The alliance applies to two systems – not
Center for Family Studies/Family Institute of just two people. The therapist and the couple or
Chicago (1983–1987), transitioning from Team family mutually participate in, and collaborate
Leader to the Director of Clinical Services in on, the therapy. Catherall – along with William
only four years. He went on to be the Executive Pinsof, Ph.D. – developed discrete scales to
Director at the Phoenix Institute in Chicago, gauge the therapeutic alliance in individual,
Illinois (1991–2004). Catherall currently has a couple, and family therapy, adjusting for the
private clinical practice and works as a interpersonal variations in the three therapeutic
Clinical Associate Professor at Northwestern contexts. The three tiers of this system are:
University. (a) Self-Therapist; (b) Other-Therapist; and
Catherall has presented at numerous profes- (c) Group Therapist. The scales operationalize
sional conferences, including the American the therapeutic alliance in couple and family
Family Therapy Association Annual Confer- therapy, acknowledging the distinctive quality
ence (1987) and the Fourteenth Annual Family of this relationship.
Therapy Conference of the Family Institute Catherall also focuses on trauma and its
Alumni Association (1991). He also received impact on the family system. As a combat vet-
the honor of Distinguished Alumnus of the eran, Catherall was recruited to work with trau-
Year from the Family Institute Alumni Associ- matized veterans in 1981. He soon expanded
ation (1992). this interest to all trauma populations, specifi-
Catherall has contributed several important cally families. Catherall understood the impor-
theories to couple and family psychology, most tance of the family in overcoming trauma. He
notable of which is the theory of emotional safety. united his passion for trauma and the family in
The concept of emotional safety describes the role The Handbook of Stress, Trauma, and the Fam-
of shame in relationships and attachment theory, ily. Catherall culled research, theory, and prac-
and it explains the connection between adults in tice, focusing on the effect of traumatic stress on
an intimate relationship. The partner who per- intimate others and how anxiety is buffered or
ceives a threat to this attachment is bothered, augmented by the family system.
prompting criticism of their intimate other. As an Associate Professor at Northwestern
Based on the concepts of emotion and attachment, University, Catherall shares his knowledge with
emotional safety allows couple therapists to con- a new generation of therapists and theorists. As a
ceptualize client problems and to consider solu- clinician, he guides couples and families through
tions, noting the emotional subtext of their clients’ conflict and trauma.
communication. The emotionally safe relation-
ship will subsist through adversity and hardship
as it is grounded in acceptance and understanding. Cross-References
Relationship problems occur when the partners no
longer feel safe being open and unguarded with ▶ Circle of Security
each other; the partners question the sincerity of ▶ Circle of Security: “Understanding Attachment
their relationship and do not consider circum- in Couples and Families”
stances at face value. This relationship will strug- ▶ Marital Fusion in Couples
gle through innoxious remarks or situations. ▶ Therapeutic Alliance in Couple and Family
However, the emotionally unsafe couple can Therapy
Cecchin, Gianfranco 389
References High Point, Portchester. Once in Italy, in 1968,

Cecchin joined Mara Selvini Palazzoli and her
Catherall, D. R. (1984). The therapeutic alliance in indi- group – psychoanalysts interested to explore sys-
vidual, couple and family therapy. Ann Arbor: Univer-
temic ideas. The group became a foursome in
sity Microfilms International.
Catherall, D. R. (1992). Working with projective identifi- 1971 when Selvini, Boscolo, and Prata joined
cation in couples. Family Process, 31(4), 355–367. the efforts. In 1980, the foursome split and
https://doi.org/10.1111/j.1545-5300.1992.00355.x. Cecchin and Boscolo initiated a training effort to C
Catherall, D. R. (Ed.). (2004). The handbook of stress,
translate the systemic ideas in clinical practice
trauma, and the family. New York: Brunner-Routledge.
Catherall, D. R. (2007). Emotional safety: Viewing couple within institutions, hospitals, jails, enterprises,
through the lens of affect. New York: Routledge. and public wards and services. Cecchin and
Catherall, D.R. (2012). Marriage and the marital relation- Boscolo travelled the western world teaching at
ship. In C.R. Figley Encyclopedia of Trauma (pp.
seminars. The dialogue between them was gener-
363–366), Los Angeles: Sage.
ative and brought to many interesting ideas that
consolidated Milan Systemic Family Therapy.
Cecchin, Gianfranco
Contribution to Profession
Pietro Barbetta1,2 and Umberta Telfener1
1
Centro Milanese di Terapia della Famiglia, Systemic thinking was the imprint that gave
Milan, Italy meaning to everything happening around
2
University of Bergamo, Bergamo, Italy Cecchin. He would choose which road to take
by improvising and using marginal thinking and
correlating processes. He did this by following
Name his instinct and using the available stimuli. The
three key concepts that constituted his embodied
Cecchin, Gianfranco knowledge include epistemology, context, and
theory of practice, with essential links between
the three layers. From this choice he would build
Introduction each phrase and then the path, the route, and the
process, in order to deconstruct ideas and propose
Gianfranco Cecchin could listen in silence before new connections. Cecchin did not follow a script
intervening with an irreverent comment, a differ- but rather was faithful to the systemic frame,
ent point of view, something surprising, able to get which influenced the choices of the language
immediately to the core of each situation. He used, topics, timing, and the use of voice, body,
highlighted a peripheral aspect following the orig- and posture. Cecchin believed that to get dis-
inal path he was participating in co-creating, to tracted is useful in order to refrain focusing on
deconstruct usual scripts. Along with Luigi the details of the narratives. Cecchin believed that
Boscolo, Cecchin was the co-founder of the the unconscious system of the therapist has to be
Milan Center of Family Therapy, one of the responsive in order to respond naturally to what
main systemic institutions between the 1980s was happening outside of the dialogue. Levity and
and present times. He died in February 2004. improvisation are words to describe Cecchin’s
way of thinking and acting: a need of moving
from one connection to the other (Cecchin and
Career Apolloni 2003). Cecchin claimed that a large
part of psychotherapy is a speculative description
Cecchin received his degree in medicine in 1959 of the pathology and an attempt to make sense of
and completed his fellowship in child psychiatry it. Cecchin’s position differed in order to learn
at Hillside in Long Island, New York, and later at from clients taking their side, being in a
390 Challenge in Structural Family Therapy
relationship with them. He passed through irony, References

irreverence, and respect for transforming subjec-
tion in liberation. Cecchin, G. (1987). Hypothesizing, circularity, and neu-
trality revisited: An invitation to curiosity. Family Pro-
Cecchin neither criticized his clients nor
cess, 26(4), 405–413.
wished to correct them or teach how to behave Cecchin, G. F., & Apolloni, T. (2003). Idee perfette: Hybris
in a socially acceptable manner. He had the capac- delle prigioni della mente (Perfect ideas: Hybrid
ity of deconstructing discursive practices and pro- prisons of the mind). Milan: Franco Angeli.
Cecchin, L., Ray, K., Lane, G., & Ray, A. W. (1992).
posing ironic dialogues as a way of liberating new
Irreverence: A strategy for therapists’ survival
lines of flight, rhizomes. Cecchin believed that (Systemic thinking and practice series). London:
people were considered as responsible subjects Karnac Books.
who chose their own way of living their lives Cecchin, G., Lane, G., & Ray, W. (1993). From strategiz-
ing to nonintervention: Towards irreverence in sys-
and believed to be free to choose their path once
temic practice. Journal of Marital and Family
they realized they are free (Cecchin 1987; Therapy, 19(2), 125–136.
Cecchin et al. 2005). Cecchin G., Lane G., & Ray, W. (1994). The cybernetics
For Cecchin, irony was a line of flight to escape of prejudices in the practice of Psychotherapy
(Systemic thinking and practice series). London:
from the influence of power. Irony maintains a
Karnac Books.
distance between talking and doing and is the Cecchin, G., Barbetta, P., & Toffanetti, D. (2005). Who
open space in the gap between subjects. Today, was von Foerster, anyway? Kybernetes: The Interna-
the Milan School continues to bring forward tional Journal of Systems & Cybernetics, 34(3/4),
330–342.
his teachings. In the entry Hypothesizing, Circu-
larity and Neutrality Revisited: an Invitation to
Curiosity (1987), Cecchin revised what was the
big premise of the Milan group: the three main
guidelines to make therapy work. He then started
Challenge in Structural Family
proposing some key concepts for the systemic Therapy
practitioner as the one of irreverence. Irreverence
Jay Lappin
was defined by Cecchin as “the attitude that pro-
tects against dependency from something, which- Minuchin Center for the Family, Woodbury,
NJ, USA
ever this ‘something’ might be: food, other
people, perfect ideas, heroin, therapy, the need
for help, attachment” (Cecchin et al. 1992). The
irreverence toward one’s own ideas also meant Introduction
continually challenging all the possible limits
and setting the boundaries always further while In Structural Family Therapy (SFT), challenge
inhabiting a marginal positioning. Cecchin often designates the therapist’s questioning of the
told his students to flirt with their ideas and family’s individualistic certainties creating a rela-
hypothesis without ever marrying them. As such, tional understanding about the symptom and the
Cecchin often flirted with the cybernetic ideas and transformative possibilities of enhanced individ-
concepts. ual and family functioning.
Cross-References Theoretical Framework
▶ Circular Questioning in Couple and Family In Structural Family Therapy, the therapist’s goal
Therapy is to cocreate a context that expands the relational
▶ Curiosity in Couple and Family Therapy rules that bind the narrow certainty of the symp-
▶ Milan Associates tom’s location from occurring “in” the Identified
▶ Milan Systemic Family Therapy Patient (IP) to what happens between them – the
Challenge in Structural Family Therapy 391
context of the family’s relational patterns. organization, and stress, “The affective compo-
Through restructuring relationships, family mem- nent of the family members’ interactions has to
bers can experience different aspects of them- be pushed beyond the usual threshold” (Minuchin
selves and others – a liberation of possibility and et al. 1978, p. 96).
growth. It is saying, “The concept of what you
think about yourself is partial. Your certainty
about ‘this is who you are’ is wrong, but it is Description C
wrong because you are richer.” (Minuchin and
Lappin 2011, p. 29*). Challenge is inseparable from joining and
together, they are inseparable from change and
hope. To challenge effectively, “. . .you need to
Rationale find a way of validating who they are, and then
say, The way in which you think you are is partial.
Change is hard, uncertain, and stressful. It cannot It is correct, but it is partial. Join me in the trip to
be separated from its relational, developmental, expand your alternatives. Join me in the trip to
cultural, and biobehavioral contexts. For all fam- becoming richer” (Minuchin and Lappin 2011).
ilies, especially those with a symptomatic mem- Challenging the family’s homeostasis – their
ber, change presents a dilemma; face the stress of “certainty” about the problem and who is respon-
the unknown or stick with what’s known, remain sible for changing it (Minuchin et al. 2014, p. 4),
the same, but suffer the limiting consequences of however, requires the therapist’s correct assess-
stagnation. ment of the family structure – an interactional
Since the plight of the IP affects everyone, the “map” of the symptom maintaining patterns
most obvious “greater good” solution would be (Minuchin 1974). According to Minuchin, “A
simply for the IP to change. As the saying goes, family diagnosis,. . . involves the therapist’s
“Don’t ask a fish about water,” so too are the rules accommodation to the family to form a therapeu-
that govern family’s interactions “invisible” to tic system. . .” (Minuchin 1974, p. 129). It is an
them (Minuchin et al. 2014, p. 15). They are also accommodation that Minuchin has likened to a
homeostatic – that is to say that when they reach a dance – “like a tango” – in which, “. . .it is the
certain level of “affective intensity” (Minuchin response of the family, that will instruct me if
et al. 1978, p. 96) change succumbs to habit. In I should continue in that way or if I should
encountering the uncertainty and discomfort of move, and instead of being challenging, I should
accessing new feelings and behaviors, family be supportive” (Minuchin and Lappin 2011).
members may either escalate their differences, or In SFT, enactment of the family patterns is one
avoid them. The result is the same – the family of the principal tools used to elevate process from
patterns that maintain the symptom return to the the landscape of content. It is not about the “facts”
status quo. of what is said, “but rather the family rules that
Since this protective threshold constrains the organize their interactions. This process shifts
adaptive capacity of the family, it must be chal- the picture; content becomes background while
lenged respectfully. While challenge at the level family dynamics jump into the foreground”
of content or education may be necessary, neither (Minuchin et al. 2014, p. 5).
may be sufficient to take on the family’s collective Challenge is always sown with the reciprocal
symptom maintaining patterns. Transformative concept that, “Each person is the context of the
challenge must reach deeper into process, at the other” (Minuchin and Fishman 1981, p. 196). So
level of affective and physiological experience. when someone declares, “I own my depression,”
As Minuchin, Rosman, and Baker noted in their the response, “Don’t be so sure,” begins to intro-
seminal work with psychosomatic families and duce uncertainty (Minuchin and Fishman 1981,
the free fatty acid studies (Minuchin 1974, p. 196) and starts the transition from the inner-
pp. 7–8) that connected mind, body, family personal to the inter-personal.
392 Chambers, Anthony
When challenging, the family’s location of the Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psycho-
problem and expanding their world view, the ther- somatic families: Anorexia nervosa in context.
Cambridge, MA: Harvard University Press.
apist’s use of self is key. Therapists temporarily Minuchin, S., Reiter, M. D., & Borda, C. Contributions
enter the family by way of the symptom. In that from: Walker, S. A., Pascale, R., & Reynolds, T. M.
short time, the therapist must be different so that (2014). The craft of family therapy: Challenging
the family can be different. Effective change certainties. New York: Routledge.
requires the therapist’s toggling back and forth
between different aspects of self – aware, observ-
ing, accommodating, insistent, curious, funny,
somber, reflective – in order to be able to offer Chambers, Anthony
an earnest challenge to the family’s singular
vision; “Help the other to change by changing John W. Thoburn
yourself as you relate to him” (Minuchin and Department of Clinical Psychology, Seattle
Fishman (1981, p. 197). Pacific University, Seattle, WA, USA
Case Example Name
The following excerpt is from a session with Salva- Anthony L. Chambers, PhD, ABPP
dor Minuchin (Minuchin and Fishman 1981,
pp. 198–199). It is a couple in their 30s with two
small children in which the husband has left for the Introduction
last month to “find himself.” Minuchin is challeng-
ing the location of the problem from inside the Anthony Chambers Ph.D., ABPP is co-editor of
husband to between the husband and wife. the Encyclopedia of Couple and Family Therapy.
As the Chief Academic Officer at the renowned
Gregory: I don’t give her that responsibility, you
know; I don’t lay that on her. I feel depressed and
Family Institute at Northwestern University and
I felt really depressed for some time in the situation. immediate past president of the Society for
Minuchin: Hold it! You said you were depressed Couple and Family Psychology, Division 43 of
at home, you left home, and you are less depressed. the American Psychological Association,
You are saying that Pat depresses you.
Gregory: No, I really take responsibility for
Dr. Chambers is one of the rising stars in the
being depressed. I can’t put it on her. field of couple and family psychology.
Minuchin: For a moment, follow me. You are
depressed, and Pat does not help you with your
depression.
Gregory: Right. Career
Minuchin: Why doesn’t Pat help you?
Gregory: I guess I feel that a lot of my needs Dr. Chambers received his undergraduate degree
weren’t being met. I felt very frustrated. I felt very
in Psychology from Hampton University and
deprived.
completed his M.A. and Ph.D. in Clinical Psy-
chology from the University of Virginia
(Department of Psychology). He completed his
References
internship and post-doctoral clinical residency at
Minuchin, S. (1974). Families and family therapy. Harvard Medical School and Massachusetts Gen-
Cambridge, MA: Harvard University Press. eral Hospital (HMS/MGH), specializing in the
Minuchin, S., & Fishman, H. C. (1981). Family therapy treatment of couples. Dr. Chambers continued
his training through the Dr. John J.B. Morgan
Minuchin, S., & Lappin, J. (2011). Salvador Minuchin: On
family therapy. www.Psychotherapy.net, V. Yalom, Clinical Research Fellowship at The Family Insti-
Producer. A. Miller, Instructor’s manual. tute where he specialized in couple therapy and
Chambers, Anthony 393
honed an expertise in premarital counseling. in African American marriages, including the dis-
Dr. Chambers also completed specialized training proportionately low marriage rate and high
in Emotion Focused Couple Therapy (ECFT), one divorce rate among African American couples;
of the few empirically validated treatments for cultural factors responsible for change in therapy,
couple distress. Dr. Chambers is a Fellow of the especially for African American couples; intimate
American Psychological Association and a diplo- partner violence; minority father involvement in
mate with the American Board of Professional family life; and the development of empirically C
Psychology in Couple & Family Psychology. He informed couple and family supervision.
was the recipient of the Alumnus of the Year
Award by The Family Institute at Northwestern
University (2012) and the Outstanding Profes-
sional Accomplishment Award by The Family Cross-References
Institute at NU (2011).
Therapy
Contributions to Profession ▶ Culture in Couple and Family Therapy
Dr. Chambers has made numerous contributions to
the departments of marriage and family therapy and
family psychology at Northwestern University References
through his work with The Family Institute and
Chambers, A. L. (2012). A systemically infused, integra-
the Northwestern University, Center for Applied
tive model for conceptualizing couples’ problems: The
Psychological and Family Studies. He has been four session evaluation. Couple and Family Psychol-
particularly active in leadership roles in national ogy: Research and Practice, 1(1), 31–47. https://doi.
organizations including the Society for Couple and org/10.1037/a0027505. (One of the top downloaded
articles in 2012).
Family Psychology, Division 43 of APA, where he
Chambers, A. L. (in press). The four session evaluation. In
served in a plethora of leadership positions includ- J. Lebow, A. L. Chambers, & D. Breunlin (Eds.), Ency-
ing Program Chair and Secretary of the Board, clopedia of couple and family therapy. Springer
culminating in his election as President in 2016. Publishing.
Chambers, A. L., Solomon, A., & Gurman, A., (2016).
He is on the Board of Directors of the Family
Couple therapy. In J. Norcross (Ed.), Handbook on
Process Institute (2013–2019), a member of the clinical psychology. Couple therapy. APA books.
Board of Directors of the American Academy of Gooden, A. & Chambers, A. L. (in press). Black men in
Couple and Family Psychology (2013–2015), a couple therapy. In J. Lebow, A. L. Chambers, &
D. Breunlin (Eds.), Encyclopedia of couple and family
Research Consultant for Hampton University’s
therapy. Springer Publishing.
research project on African American Marriages, Lebow, J., Chambers, A. L., Christensen, A., & Johnson,
and a Consultant for the Naomi Ruth Cohen Foun- S. (2012). Research on the treatment of couple distress.
dation on Mental Health (2006–Present). Journal of Marital and Family Therapy, 38(1), 145–168.
https://doi.org/10.1111/j.17520606.2011.00249.x.
Dr. Chambers is also an Associate Editor of the
Lebow, J., Chambers, A. L., & Breunlin, D. (Eds.), online
influential APA journal Couple and Family Psy- 2016; print (2017). Encyclopedia of couple and family
chology: Research and Practice and he has been therapy. Springer Publishing.
an Associate Editor and is currently on the Edito- Pinsof, W. M., Breunlin, D., Chambers, A. L., Russell, W.,
& Solomon, A. (2015a). In D. Synder, J. Lebow, &
rial Board of the Journal of Multicultural A. Gurman’s, (Eds.), Handbook on couple therapy.
Counseling and Development. Dr. Chambers’ IPCM couple therapy. Guilford Press.
work with academic journals reflects a strong Pinsof, W., Zinbarg, R. E., Shimokawa, E., Latta, T., Gold-
history as a clinical researcher and a keen interest smith, J. Z., Knobloch-Fedders, L., Chambers, A., &
Lebow, J. L. (2015b). Confirming, validating, and
in the reciprocal interaction of research and prac-
norming the factor structure of systemic therapy inven-
tice. He maintains a thriving full time clinical tory of change initial and intersession. Family Process.
practice with a particular clinical research interest https://doi.org/10.1111/famp.12159.
394 Chasin, Richard and Laura
from Harvard University Medical School (1960).

Chasin, Richard and Laura His education included training in psychoanalysis
at the Boston Psychoanalytic Institute from
Lorna London 1966–1973 and in child psychiatry and family
Midwestern University, Downers Grove, IL, USA therapy at Family Institute of Cambridge from
1974–1978. In addition to his clinical work with
patients, he has worked as associate professor of
Name psychiatry at Harvard University and has served
as the president of the American Family Therapy
Chasin, Richard & Laura Academy (Chasin 2018).
Introduction Contributions to Profession
Richard and Laura Chasin were a couple devoted Throughout her life, Laura made significant con-
to making the world a better place through their tributions through her volunteer work and philan-
clinical interventions and civic engagements. thropic leadership. She followed in the footsteps
Their career paths, though slightly different, of her mother who served on the board of trustees
served as a platform for helping to advocate for for Spelman College. Not being one to shy away
those in need. Married in 1971, and the parents of from difficult discussions, she and her husband
three children and three step-children, Richard Richard joined forces with colleagues to moderate
and Laura Chasin spent their lives working as challenging conversations about controversial
clinicians and social advocates, dedicated to the topics (Esalen 2014). Through her work as the
service of others. founder of the Public Conversations Project, she
facilitated discussions for people of differing
ideas, identities, and values (Hess 2015). Through
Career her trainings, she was able to promote healthy
dialogue between individuals of differing beliefs
Laura Chasin was born and raised in New York. in areas such as abortion, religious tolerance, gun
As a college student at Bryn Mawr College, she safety, and sexual orientation. Her work with this
earned a bachelor’s degree in art history. Follow- nonprofit agency has been recognized by the likes
ing her undergraduate work, Laura continued her of the New York State Mediators Association, the
studies at Harvard University where she received American Association of Group Psychotherapy
a M.A. in government and a M.S.W. from and Psychodrama, and the American Family
Simmons College (Boston Globe 2015). Laura Therapy Association (Boston Globe 2015).
also completed postgraduate training in the areas Richard has published articles pertaining to the
of family therapy and psychodrama, which served treatment of patients dealing with depression
to guide much of her later work. Laura and her (Chasin and Semrad 1966), along with articles
colleagues at the Family Institute of Cambridge in highlighting the use of systemic therapy with cou-
Watertown, MA, borrowed from techniques used ples (Chasin et al. 1989). He may be best known
in strategic family therapy to help people to delve for his collaborations with his wife as a Founding
into polarizing issues and work to express their Associate of the Public Conversations Project.
ideas while also working to come to a respectful Dr. Chasin continues to maintain a private practice
understanding of one another (Staff 1992). in Cambridge, MA, where he provides psychiatric
Richard Chasin graduated Phi Beta Kappa care to individuals and couples.
from Yale University with a B.A. in psychology Laura Chasin passed away in 2015 but her
and philosophy in 1956. He was trained as a legacy for working to unite people and repair
physician and received his medical education relationships continues to live on.
Cherlin, Andrew 395
Cross-References recently he has contributed to knowledge about the

influence of socioeconomic status and welfare
▶ American Family Therapy Academy (AFTA) reform on family structure. Throughout his career
Dr. Cherlin has actively published in scholarly
journals, newspapers, and other reputable media.
References He has also written books on family structure and
the institution of marriage. C
Boston Globe. (2015). From http://www.legacy.com/obitu
aries/bostonglobe/obituary.aspx?pid=176574814
Chasin, R. (2018). Curriculum vitae. http://www.
richardchasinmd.com/ Career
Chasin, R., Herzig, M., Roth, S., Chasin, L., Becker, C., &
Stains, R. (1996). From diatribe to dialogue on divisive Andrew Cherlin is the Benjamin H. Griswold III
public issues: Approaches drawn from family therapy.
Professor of Sociology and Public Policy at Johns
Mediation Quarterly, 13(4), 323–344.
Chasin, R., Roth, S., & Bograd, M. (1989). Action methods Hopkins University. In 1976, he earned his PhD in
in systemic therapy: Dramatizing ideal futures and sociology from the University of California at
reformed pasts with couples. Family Process, 28(2), Los Angeles, and joined the Sociology Faculty of
121–136. https://doi.org/10.1111/j.1545-5300.1989.
John Hopkins University where he has been a pro-
00121.x.
Chasin, R., & Semrad, E. (1966). Interviewing the fessor ever since. His research on the sociological
depressed patient. Hospital and Community Psychiatry, characteristics of the American family has
17(10), 283–286. documented changes in family structure since the
Hess, J. (2015). Celebrating a founding mother of Ameri-
1980s, including the impact of the law and eco-
can’s dialogue renaissance. Retrieved from https://
www.huffingtonpost.com/living-room-conversations/ nomic disparities on family life and the well-being
celebrating-a-founding-mo_b_8626362.html of children.
Esalen. (2014). Retrieved from https://www.esalen.org/ Dr. Cherlin has earned many awards and distinc-
page/ctr-october-2014-participant-biographies
tions in his career. In 1993 he received a Merit
Staff. (1992). Lessons for a Stuck Society. Psychology Today,
25(5), Retrieved from https://www.psychologytoday. Award from the National Institute of Child Health
com/us/articles/199209/lessons-stuck-society and Human Development for his research on family
structure and its influence on child development. In
2001, he received the Olivia S. Nordberg Award for
Excellence in Writing in the Population Sciences. In
Cherlin, Andrew 2003, he was the recipient of the Distinguished
Career Award granted by the Family Section of the
Jeffrey Goulding and Corinne Datchi American Sociological Association, and in 2009, he
Seton Hall University, South Orange, NJ, USA received the Irene B. Taeuber Award from the Pop-
ulation Association of America, in recognition of his
outstanding contributions to demographic research.
Name
Andrew J. Cherlin, Ph.D. (1948–) Contributions to the Profession
Andrew Cherlin’s contributions to the field of family

Introduction demography and family sociology include 5 books
and more than 90 scholarly articles about family
Andrew Cherlin has been and continues to be a very structure, marriage dissolution, family demo-
influential scholar in the field of family demography. graphics, and family socioeconomic issues.
Throughout his career he has studied the changing For over three decades, Dr. Cherlin has
nature of the institution of marriage and the social researched the changing structure of the family as
effects of marriage and marriage dissolution. More well as the institution of marriage, in various
396 Chicago Center for Family Health
countries, cultures, and demographic areas. One of References

his major contributions to the field has been his
work with families that have experienced divorce Cherlin, A. (1978). Remarriage as an incomplete institu-
tion. American Journal of Sociology, 84, 634–650.
and remarriage. Dr. Cherlin has pioneered projects
https://doi.org/10.1086/226830.
to better understand how families and children are Cherlin, A. (1981). Marriage, divorce, remarriage.
impacted by the challenges associated with marriage Cambridge, MA: Harvard University Press.
dissolution and remarriage, namely, how divorce Revised and Enlarged Edition. 1992. Harvard Univer-
sity Press.
affects the behavior and achievement of children
Cherlin, A. (2004). The deinstitutionalization of American
who come from homes where the parents have marriage. Journal of Marriage and Family, 66, 848–861.
separated or divorced. Dr. Cherlin has also Cherlin, A. (2009). The marriage-go-round: The state of mar-
attempted through his research to destigmatize the riage and the family today. New York: Alfred A. Knopf.
Cherlin, A. (2014). Labor’s love lost: The rise and fall of
dissolution of marriage in an effort to promote con-
the working-class family in America. New York:
sistent support for children by both parents and Russell Sage Foundation.
extended family members throughout the dissolu- Cherlin, A., Furstenberg, F., Chase-Lansdale, P., Kiernan, K.,
tion and remarriage process. Robins, P., Morrison, D., & Teitler, J. (1991). Longitudinal
studies of effects of divorce on children in
Dr. Cherlin’s work has highlighted the changing
Great Britain and the United States. Science, 252,
role of marriage as a societal institution. 1386–1389.
Marriage used to be a necessary ingredient to achieve
maturity and success as an adult; it also was a con-
dition of stability within the family system. In today’s
society, marriage is only one option for forming a
family. Diverse family structures have developed as Chicago Center for Family
viable alternatives to traditional long-term marital Health
relationships. Dr. Cherlin’s research also showed
the evolution of marriage from a necessary rite of John S. Rolland1 and Froma Walsh2
1
passage to a symbol of social status that has become The Chicago Center for Family Health,
less essential for familial and social stability. University of Chicago, Chicago, IL, USA
2
Lastly, Dr. Cherlin was the principal investigator Chicago Center for Family Health and Firestone
of the “Three-City Study,” an interdisciplinary, lon- Professor Emerita, The University of Chicago,
gitudinal study of low-income children and their Chicago, IL, USA
caregivers in the era of post-welfare reform. The
results of this study have increased our understand-
ing of the impact of welfare reform on low-income Introduction
families and children across the life span. Specifi-
cally, low-income families were found to have The Chicago Center for Family Health (CCFH) is
higher rates of depression and heart disease, reduced an internationally renowned family therapy training
earnings, and greater food insecurity or limited institute providing resilience-oriented advanced
access to food necessary for an active and training, counseling services, and community-
healthy life. based programs.
Cross-References
Location
▶ Blended Family
▶ Divorce in Couple and Family Therapy The Chicago Center for Family Health (www.
▶ Marriage ccfhchicago.org) is located in downtown Chi-
▶ Nuclear Family cago, Illinois, with faculty offices in city and
▶ Remarriage in Couple and Family Therapy suburban areas.
Chicago Center for Family Health 397
Prominent Associated Figures strengthen families at risk, in crisis, or facing

persistent life challenges (Rolland and Walsh
John Rolland, MD, and Froma Walsh, PhD, 2005). Through the Center’s clinical services,
cofounders and codirectors, are international CCFH fellows and faculty provide counseling/
leaders in the field of family therapy (▶ “Rolland, therapy for families, couples, and individuals,
John”). Other prominent faculty members are with availability to clients in financial need.
Michele Scheinkman, LCSW, and Mona State-of-the-art postgraduate training in couple C
Fishbane, PhD, who developed and directed the and family therapy and in family systems-based
Couples Therapy training program; Gene Combs, healthcare are guided by a family resilience
MD, and Jill Freedman, LCSW; Mary Jo Barrett, framework (Walsh 2016b; ▶ ”Resilience in Cou-
MSW; Jay Lebow, PhD, LMFT; and Thomas ples and Families”). For over two decades, the
Todd, PhD. Other CCFH faculty members who Center offered a 2-year, postmasters, intensive
have been instrumental in CCFH programs certificate program, with advanced tracks in cou-
include Bessie Sultan Akuamoah, LCSW; ple therapy; child, adolescent, and family therapy;
Michele Baldwin, PhD, LCSW; Cheryl Berg, and Families, Illness, and Collaborative
LCSW; Pamela Brand, PsyD, LMFT; Ruth Fuerst, Healthcare. Currently, the Center offers the fol-
LCSW; Katherine Neill Goldberg, MA; Deane lowing training opportunities:
Graham, LMFT, LCPC; Miriam Gutmann, MD;
Lynn Carp Jacob, LCSW; Bruce Koff, LCSW; • Workshops and conferences
Ronna Lerner, LCSW; William Martin, LCSW; • Brief intensive certificate programs
Bonnie Mervis, LCSW; Michelle Adler Morrison, • Families, Illness, and Collaborative Healthcare
LCSW; David Schwartz, PhD; Nancy Segall, (FICH) Fellowship
MA, LCSW; Len Sharber, MDiv, LCSW; Robert • Distance learning and consultation
Sholtes, MD; Susan Sholtes, LCSW; Virginia • International training
Simons, LCSW; Sant Singh, MAS, MA, FIC, • Community consultation, training, services,
LCSW; Karen Skerrett, PhD, RN; Kate Sori, and research
PhD, LMFT; Lorena Valles, LCSW; Stevan
Weine, MD; and Steven Zuckerman, PhD, LMFT. Building partnerships with community-based
organizations and healthcare systems has been at
the heart of CCFH’s mission to train and support
Contributions healthcare, mental health, and human service pro-
fessionals, particularly those who work with low-
The Chicago Center for Family Health (CCFH; income and minority families, LGBT (gay, lesbian,
www.ccfhchicago.org) was cofounded in 1991 by bisexual, and transgender) clients, persons with
codirectors John Rolland, MD, and Froma Walsh, disabilities, and other vulnerable groups. CCFH
PhD, as a nonprofit advanced training institute has provided workshops and intensive certificate
affiliated with the University of Chicago. They programs and partnered with local healthcare cen-
formed a network of talented clinical faculty ters, schools, and human service agencies to pro-
members interested in advancing family systems vide specialized staff training, organizational
training and practice. The faculty, bringing varied consultation, and program development. Our sys-
couple and family therapy approaches and areas tems approach has also been usefully applied in the
of expertise, all share a strength-based, collabora- fields of pastoral counseling, family law, and fam-
tive, systems orientation to practice, responsive to ily business. Over the years, community-based
family diversity and committed to serve disadvan- programs have addressed a wide range of adverse
taged and marginalized populations and to situations (see Walsh 2016a, b), as summarized in
address social justice concerns. Table 1, with faculty coordinators noted.
CCFH is renowned for its innovative The Center is particularly noted for its innova-
resilience-oriented practice approach to tive Families, Illness, and Collaborative
398 Child Sexual Abuse in Couple and Family Therapy
Chicago Center for Family Health, Table 1 CCFH Illinois Masonic Medical Center Family Practice,
resilience-oriented, community-based program applications. has offered yearlong fellowships for postdoctoral
Chicago Center for Family Health (1991–2017): Family mental health professionals and doctoral candi-
Resilience-Oriented Training, Services, and Partnerships dates specializing in medical family therapy. Addi-
Recover from crisis, trauma, and loss tionally, CCFH has partnered with a number of
Family adaptation to complicated, traumatic loss healthcare systems and specialty care services to
(Walsh)
develop and provide family-oriented training and
Mass trauma events, major disasters (Walsh)
Relational trauma (Barrett, Center for Contextual
services, including cancer, diabetes, cystic fibrosis,
Change) genetic risk screening, multiple sclerosis, rehabili-
Refugee families (Rolland, Walsh, Weine) tation, and integrative medicine, palliative care,
War- and conflict-related recovery (Kosovar family- and hospice.
professional education collaborative) (Rolland, Weine,
Walsh)
Navigate disruptive family transitions
Divorce, single parent, and stepfamily adaptation Cross-References
(Jacob, Lebow, Graham)
Foster care (Engstrom) ▶ Families with Illness
Job loss, transition, and reemployment strains ▶ Resilience in Couples and Families
(Walsh, brand)
▶ Rolland, John
Overcome challenges of chronic multi-stress
▶ Walsh, Froma
conditions
Families, illness, and collaborative healthcare
(FICH). Serious illness, disabilities, and end-of-life
challenges (Rolland, Walsh, R. Sholtes, Zuckerman) References
Poverty, ongoing complex trauma (faculty)
LGBT issues, stigma (Koff) Rolland, J. S. (2018). Helping couples and families navi-
Overcome obstacles to success: At-risk youth gate illness and disability: An integrative practice
Child and adolescent developmental challenges approach. New York: Guilford Press.
(Lerner, Schwartz, Gutmann, Martin) Rolland, J. S., & Walsh, F. W. (2005). Systemic training for
healthcare professionals: The Chicago center for family
Family-school partnership program (Fuerst & health approach. Family Process, 44(3), 283–301.
Team) Walsh, F. (2016a). Applying a family resilience framework
Gang reduction/youth development (GRYD) in training, practice, and research: Mastering the art of
(Rolland, Walsh & Team) the possible. Special Section on Family Resilience:
Walsh, F. (2016b). Strengthening family resilience
(3rd ed.). New York: Guilford Press.
Healthcare (FICH) Program, dedicated to advanc-
ing family systems and integrated biopsychosocial
approaches in healthcare (Rolland and Walsh 2005;
John’s other entry ▶ “Families with Illness”). Child Sexual Abuse in Couple
Rolland’s Family Systems Illness Model (Rolland and Family Therapy
2018) has guided the design and implementation of
numerous projects designed to meet the training Katherine Hertlein, Brittany Donaldson and
and practice needs of health and mental healthcare Nicole Walker
professionals who work with couples and families University of Nevada – Las Vegas, Las Vegas,
facing serious illness, disability, and loss. Training NV, USA
is relevant to diverse professional disciplines, work
settings, and levels of experience and adaptable for
brief consultation, more intensive therapy, and Synonyms
multifamily group formats. Over the past
20 years, CCFH, in partnership with Advocate Incest; Molestation; Pedophilia; Sexual Assault
Child Sexual Abuse in Couple and Family Therapy 399
Introduction A child’s sense of powerlessness comes from

the process during which their desires, sense of
Child sexual abuse is a critically important prob- efficacy, continual fear, and self-identification are
lem in clinical practice. The prevalence of child violated. For example, the child may feel power-
sexual abuse ranges from study to study, from less to control their own environment and power-
0.7% to 17% for men and from 1.8% to 31% for less to control events around them. This can have
women (Laaksonen et al. 2011; Pereda significant implications for the development of C
et al. 2009), with that number being higher in self-efficacy. Further, destructive communica-
clinical populations. It is a phenomenon that tions of badness, shame, and guilt are incorpo-
occurs in all cultures and across all socioeconomic rated into the child’s experience and ultimately
statuses. A decline in the prevalence of child into their self-image.
sexual abuse in some cultures has been observed
in conjunction with a decline in the risk factors,
suggesting that the risk factors associated with Description
childhood sexual abuse have a demonstrable
impact on its prevalence. Child sexual abuse occurs when someone
attempts to engage a child in any sexually charged
interactions or behaviors, notably to the gratifica-
tion of the perpetrator (Malhotra and Biswas
Theoretical Context 2006, p. 17). This may include noncontact abuse
such as indecent exposure, contact abuse such as
Treating the trauma and physiological effects being touched, fondled, or kissed, and/or forced
experienced by children of abuse requires a activity (attempted or completed). Certain risk
long-term therapeutic framework. Because the factors such as interpersonal violence (IPV) in
treatments tend to be long-term, the theoretical families are indicative of higher levels of child
constructs behind the treatments are designed to sexual abuse. Other well-documented risk factors
address multiple areas of the child’s emotional include the age of the victim, whether the victim
well-being. Traumagenic dynamics is a theoreti- has any physical disabilities or incapacities,
cal construct to assist therapists in thinking about absence of a father in the home (which doubles
how to treat the accompanying traumatic the risk for girls but not boys), paternal impair-
sexualization, betrayal, powerlessness, and stig- ments (i.e., drug and/or alcohol abuse, poor par-
matization resultant from childhood sexual abuse. enting practices, psychopathology), social
For example, traumatic sexualization can occur isolation, and multigenerational transmission of
through a variety of ways including, but not lim- maladaptive coping and family processes.
ited to, exchanges of affection, attention, privi- Socioeconomic status also plays a role in child
leges, and gifts in return for sexual behavior. The sexual abuse. For example, boys, though not girls,
degree of traumatic sexualization can be affected who live in lower socioeconomic areas report
by factors such as the child’s age, developmental higher levels of abuse than boys in higher socio-
level, coping skills, and overall emotional and economic areas. Lacking the power, knowledge,
mental health. Betrayal refers to instances when, or necessities to receive the proper resources plays
during the course of abuse, a child may realize a major role in reporting abuse and the inability to
someone close to them whom they trusted has lied receive the proper services can be very detrimen-
or misrepresented themselves in a manipulative tal to the child being abused. Different socioeco-
way (Finkelhor and Browne 1985). Children who nomic groups may also be more reluctant to report
have trusted a family member to protect them as well, due to the lack of trust or confidence they
from these circumstances, who is then unable or have in higher authorities.
unwilling to do so, may be more susceptible to The determination as to whether one has
these dynamics of betrayal. experienced childhood sexual abuse is complex
400 Child Sexual Abuse in Couple and Family Therapy
and is often shaped by aspects of one’s life such In some cases of childhood sexual abuse, chil-
as individual history, perception of resiliency dren are removed from their homes and separated
and normalcy, and belief systems. The terms from family members. These children tend to expe-
used to describe child sexual abuse also vary rience a greater degree of separation anxiety, con-
based on cultural and ethnic contexts. Similarly, cern for the parents, and loyalty issues (Gil 1991).
the beliefs and attitudes behind what constitutes With that being said, if it is safe for the child,
sexual abuse can be culturally bound. Further- inclusion of parent(s) and/or guardian(s) as part of
more, different cultures may not have the same the therapy team can be quite helpful for the child
views of reporting child abuse that takes place. during treatment. Knowing they have a support
There may be repercussions that keep certain system can be an intervention in itself for the child.
individuals from reporting in order to avoid Issues to consider during the treatment process
embarrassment or disapproval. include attention to inappropriate attachment behav-
ior, infant regressive behavior, need for body contact
and body awareness, and need for education on
feelings. Additionally, a child’s development may
Application of Concept in Couple make it difficult to receive help and care. Without
and Family Therapy the proper tools to express how one feels or the
ability to relay their emotions, treatment can be
The way in which a therapist approaches the difficult. As the therapist, being able to address
concept of child sexual abuse in therapy is cru- and prepare for such instances can have a positive
cial to the overall treatment process and out- effect on the treatment process for everyone
come. Each family system is different from the involved.
next and, likewise, each context where child
sexual abuse takes place differs. The goal of
therapy generally focuses on helping adoles- Clinical Example
cents communicate about the abuse experience,
enhance self-esteem, learn about appropriate Jack, age 7, was brought to therapy by his mother.
family roles and boundaries, overcome isola- She reported that he had been sexually abused by
tion, and develop healthy peer relationships. a cousin 3 months ago. She stated that Jack was
There are many approaches to go about having nightmares, wetting his bed, and having
accomplishing these goals. A few examples temper tantrums that were uncharacteristic for
include abuse-focused therapy, trauma-focused him. Jack’s mother stated that when Jack revealed
CBT, play therapy, education as therapy, indi- the abuse, she responded by getting the authorities
vidual therapy, and group therapy. Psychother- involved to continue to protect Jack as well as
apy and cognitive-behavioral therapy have been other children. When the therapist brought Jack
the most utilized and studied approaches in to the play therapy room, he immediately went to
cases of child sexual abuse. These treatments hide the toy snakes and sharks in the room before
are intended to assist the sexual abuse survivor he would engage in any play. In assessment, the
in identifying and using coping skills, managing therapist evaluated Jack’s coping skills and resil-
the emotional and psychological consequences iency as well as his family structure, extant psy-
of the abuse, restructuring the family system for chopathology within his family-of-origin,
greater protection of all individuals, and reduc- circumstances surrounding the abuse, his self-
ing a family’s risk for abuse. The modality of esteem and view of self, and any other traumatic
therapy can include individual treatment, group stress symptomology.
treatment, and family therapy (Gil 1991). Ther- The therapist used play therapy techniques to
apists need to decide, based on the case before address all of these areas. This included games
them, what treatment modality would be most where Jack processed negative cognitions about
appropriate. himself and these cognitions were challenged in
Childfree Couples 401
appropriate ways. Further, the therapist used Synonyms

child-centered therapy as a way to have Jack
make his own choices in therapy, thus addressing Childfree by choice
his sense of powerlessness. The therapist also
worked with Jack’s mother to provide opportuni-
ties for Jack to have some control over areas of his Introduction
life toward developing self-efficacy. Treatment C
also centered on assisting Jack with relieving In many cultures couples have traditionally
symptoms of hypervigilance and anxiety. This followed the path of meeting, getting married,
included participation in art therapy and nondirec- and raising a family. For some, this is the right
tive play therapy, teaching relaxation skills, and choice but for others, factors such as career, pri-
instituting a new bedtime routine to address his oritizing couple closeness, disinterest in raising
nightmares. children, and financial stability become more sig-
nificant than choosing to be a parent. While
“childless” couples are unable to have children
References due to biological or psychological reasons, being
voluntarily childfree is quite different than grap-
Finkelhor, D., & Browne, A. (1985). The traumatic impact pling with infertility or deciding to become adop-
of child sexual abuse: A conceptualization. American tive parents.
Journal of Orthopsychiatry, 55(4), 530–541.
Gil, E. (1991). The treatment of abused children. In The
healing power of play (pp. 37–82). New York: Guilford.
Laaksonen, T., Sariola, H., Johansson, A., Jern, P., Description
Varjonen, M., von der Pahlen, B., . . . Santtila,
P. (2011). Changes in the prevalence of child sexual Many couples feel that family and society expect
abuse, its risk factors, and their associations as a func-
tion of age cohort in a Finnish population sample. Child
them to follow a sequence of life stages including
Abuse and Neglect, 35(7), 480–490. https://doi.org/ growing their family by adding children after they
10.1016/j.chiabu.2011.03.004. get married. The picture of a nuclear family with
Malhotra, S., & Biswas, P. (2006). Behavioral and psycho- two parents and their biological children is widely
logical assessment of child sexual abuse in clinical
portrayed in the media; couples desiring not to
practice. International Journal of Behavioral Consul-
tation and Therapy, 2(1), 17–28. https://doi.org/ have children are often underrepresented in pop-
10.1037/h0100764. ular culture. Couples who temporarily identify as
Pereda, N., Guilera, G., Forns, M., & Gómez-Benito, childfree are seen in a more positive light than
J. (2009). The prevalence of child sexual abuse in
couples who choose to remain childfree perma-
community and student samples: A meta-analysis.
Clinical Psychology Review, 29(4), 328–338. https:// nently (Koropeckyj-Cox et al. 2007). The latter
doi.org/10.1016/j.cpr.2009.02.007. often experience pressure and/or stigma from
society.
At the same time a number of demographic
changes have been noted in the USA. The num-
Childfree Couples ber of married couples is slowly decreasing with
more individuals cohabiting before marriage or
Mudita Rastogi choosing not to marry at all (McGoldrick 2011).
Illinois School of Professional Psychology, College educated individuals are more likely
Argosy University, Schaumburg, IL, USA to delay marriage, with few individuals marry-
ing before age 25 (Cherlin 2010). Furthermore,
an increasing number of couples have chosen to
Name of your Entry remain childfree. In 1990, roughly six million
childless married couples were under the age of
Childfree Couples 45 (American Demographics 1993). At present
402 Childfree Couples
couples without children make up about 6.9% of Biblical beliefs are more likely to decide to remain
the population in the United States (CDC 2015) childfree (Heaton et al. 1992).
with some estimates of voluntary childlessness Very little research exists on the topic of cou-
at 7–8% of the US population (Abma and ples’ decision-making on whether to become par-
Martinez 2006). ents or not. Cowan and Cowan’s (2000) study on
reproductive decision-making found that approx-
imately half of the couples take a thoughtful
Relevant Research About Family Life approach in deciding whether or not to have chil-
dren. Notably, 12% of the couples they observed
People report that their reasons for choosing to not were categorized as “Yes-No” couples with one
pursue parenthood includes greater sense of free- partner ready to pursue parenthood while the other
dom from responsibility in being sans children, did not. By the time the child reached 6 years of
prioritizing their couple relationship, career and eco- age, all of the “Yes-No” couples had divorced
nomic considerations, philanthropic concerns, not (Cowan and Cowan 2000; Massey-Hastings
liking children, their own early socialization experi- 2011).
ences, and concerns about the physical changes of
bearing children (Hird and Abshoff 2000).
Contemporary marriages in the developed Special Considerations for Couple and
world are less concerned with cultural and Family Therapy
family needs and instead individuals focus on
personal fulfilment and satisfying partnerships Clearly, this clinical issue has significant impact
(McGoldrick 2011). Since the 1970s women in on couples and families. One model, Choosing a
these nations have decreased childbearing vol- Childfree or Parenting Lifestyle (CCOPL), uses
untarily in order to pursue other roles and iden- a psychoeducational approach via ten modules
tities (Hird and Abshoff 2000). Feminism to help couples clarify their own and their part-
enhanced women’s rights in numerous areas ners’ attachment needs. It helps partners
including reproductive freedoms so that choos- explore, communicate, and decide whether to
ing motherhood became a choice (Boucai and remain childfree or become a parent (Massey-
Karniol 2008; Rittenour and Colaner 2012). Hastings 2011, 2016; Massey-Hastings and
Furthermore, in the USA, we saw a trend of Rastogi 2013). The CCOPL is in the process
emerging adults (individuals in their 20s) com- of being turned into an online, self-paced
pleting higher levels of education than previous psychoeducational program (Rastogi 2016;
generations (Merz and Liefbroer 2012), and Rastogi and Massey-Hastings 2015). Addition-
postponing relational decisions in order to pur- ally, couple and family therapists working with
sue career and personal goals, compared with childfree couples should consider the
individuals in earlier times who sought the sta- following:
bility much earlier in life.
While individuals who choose to be childfree 1. Women who reject motherhood may face more
come from diverse racial, cultural, and socioeco- social consequences than men (Mollen 2006).
nomic backgrounds (Mollen 2006), women hold Therapists may wish to discuss with their cli-
more favorable attitudes towards being childfree ents notions of motherhood, femininity, and
than men, reflecting the higher opportunity costs the gendered cost of nonconformity.
of motherhood versus fatherhood (Merz and 2. Childfree couples are often perceived in less
Liefbroer 2012). Individuals who display low reli- favorable light than those who are parents
giosity, have civil versus religious wedding cere- (Mollen 2006; Kemkes 2008). They may be
monies, and who tend to disagree with traditional perceived as lacking the commitment and
Childfree Couples 403
responsibility required to raise children (Hird and origin-search.proquest.com/docview/232581954?acco

Abshoff 2000). These couples may also receive untid=34899.
Kemkes, A. (2008). Is perceived childlessness a cue
unsolicited advice and pressure from friends, for stereotyping? Evolutionary aspects of a social
family, and strangers that they might regret the phenomenon. Biodemography and Social Biology,
decision later. Therapists can assist these couples 54(1), 33–46. https://doi.org/10.1080/19485565.2008.
in examining their choices in depth. 9989130.
3. Couples who value their religious traditions that
Koropeckyj-Cox, T., Romano, V., & Moras, A. (2007).
Through the lenses of gender, race, and class: Students’
C
endorse the importance of procreation may face perceptions of childless/childfree individuals and cou-
additional pressure to explain their childfree ples. Sex Roles, 56, 415–428. https://doi.org/10.1007/
stance (Merz and Liefbroer 2012). These couples s11199-006-9172-2.
Massey-Hastings, N. (2011). Choosing the parenting life-
may need support in understanding and resolving style: A manualized psycho-educational primary inter-
their conflicting values and desires. vention for couples regarding reproductive decisions.
4. Cowan and Cowan (2000) found that a majority Doctoral dissertation, American School of Professional
of couples fluctuated between wanting/not want- Psychology/Argosy University, Schaumburg.
Massey-Hastings, N. (2016). CCOPL: Choosing the childfree
ing to have children. Couple and family thera- or parenting lifestyle. Retrieved from http://CCOPL.org.
pists need to be prepared for their clients’ Massey-Hastings, N., & Rastogi, M. (2013, February).
decisions to shift. Further, it is paramount to Initial pilot study findings: Choosing the childfree or
help couples negotiate this issue honestly in the parenting lifestyle-A manualized psycho-educational
primary intervention for couples regarding reproduc-
case of “Yes-No” couples. tive decisions. Paper presented at the second
international conference on cognitive behavioral psy-
chology, Singapore.
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childlessness Adapting a psycho-educational program for couples
Cowan, C. P., & Cowan, P. A. (2000). When partners regarding reproductive decisions: In-Vivo to online
become parents: The big life change for couples. models. Paper presented at the international education
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404 Children in Couple and Family Therapy
Others parents are struggling adapting their

Children in Couple and Family parenting styles to those of their growing children.
Therapy The 5-year-old who could be picked up and
placed in time-out when cranky is now a teen
Robert Taibbi taller than his mother; when he quickly becomes
Charlottesville, VA, USA defiant when asked to take out the garbage, his
mother is at a loss at what to do instead. Often the
clinician’s role in such cases is education and skill
Introduction training, helping the parents understand their
child’s changing needs, and how to best commu-
So integral are children to couple and family nicate and behaviorally respond.
dynamics; it is no surprise that they have been But for many parents the presenting issue is the
integral part of the therapy process as well, their couple’s own differences over parenting styles,
role and focus evolving alongside the field itself. differing visions of the role of children in the
By definition children are not physically part of family and how they should be treated. Often the
the couple therapy, but that doesn’t mean that foundation for their differences is their reactions
children are not often the initial focus. Many to the parenting they received as children – the
couple therapists have had the experience of cou- neglected child who now as a parent is forever
ples presenting with child issues only to shift attentive, the child of abusive parents who now is
focus in the third session and talk about the real overly permissive and fears turning into his father.
concern, namely, issues in their intimate relation- But this can also reflect differing values – one
ship; the child’s problems were a comfortable parent believing that children and family time
initial focus, allowing the couple time to feel should be the primary everyday focus, while the
settled and safe before marching into more con- other feels that couple needs to have more time for
tentious territory. Other times the couple comes themselves. These different values may some-
into therapy seeking help with parenting skills or times reflect conflicting cultural and ethnic
reconciling differences in values and style. In foundations.
family therapy, children are, by definition, the At the most extreme forms, such parents are
primary focus, present in the room in various polarized: One parent is easy because the other is
combinations depending on the clinician’s own so strict; the other is strict because the other is so
therapeutic orientation and approach. easy. Here we can think in terms of Minuchin’s
enmeshed and disengaged parents, as well as
Bowen’s notion of triangulation, and using the
Description: Children in Couple Therapy child’s problem as focus that bypasses other cou-
ple issues. When seeing such parents together,
When children are the couple’s primary focus, the there is a feeling in the room of an ongoing
parents’ concerns can take several forms. Parents power struggle, that the couple is playing court-
of a 14-year-old may come because they fear their room and trying to have the clinician play judge to
teen may have a budding eating disorder. The teen decide who is right and who is not.
refuses to come in or even respond to the parent’s Obviously this polarization is harmful to chil-
concerns, and so the parents are seeking informa- dren in couple of ways. One is that children learn
tion about the disorder, ideas about when to seek to split the parents, playing one against the other,
medical consultation, tips about ways to initiate and know to make requests of the easy parent
this conversation with their daughter at home. when the other is not around, only intensifying
Parents of a newborn are struggling with their the parents’ conflict. The children unfortunately
own lack of sleep and irritability, but also are also get a distorted, one-dimensional view of
unsure how to help their 3-year-old who suddenly each parent – my dad is accommodating and
feels dethroned and is throwing tantrums. my mom strict – shaping their own expectations
Children in Couple and Family Therapy 405
about relationships and providing poor role of them as role models and individuals, especially
modeling for their own parenting. The biggest that she may see Jim as always punitive, rather
concern, perhaps, is that such children are living than the worried dad. She emphasized the need for
at home in a constant state of tension, spawning the couple to work together as team and said that
individual anxiety, or acting out through sibling she would help them work on a unified plan, as
rivalry. well as help them use their sessions as a safe place
Most couple and family clinicians would agree to improve their communication and resolve some C
that the parents need to get on the same page of the other underlying issues they were
around parenting, work together as a team, and struggling with.
present a unified front around expectations and The couple agreed. Utilizing a cognitive
rules, even if their own individual styles in carry- behavioral approach, the clinician helped them
ing them out may differ. And because these issues use sessions to develop a parenting plan they
are often just a tip-of-the-iceberg of other issues both could agree on, taught them develop better
that the couple cannot talk about and resolve, communication skills, and helped them address
these too need to be a focus of treatment. and resolve their other underlying couple
These differences become the starting point for issues.
treatment – to bypass the playing of courtroom and
to move the parents toward developing a unified
plan. How to do this will depend on the orientation Description: Children in Family Therapy
of the clinician. If psychodynamic or Bowenian, for
example, the clinician may explore the couple’s own Many family therapists embrace this total family
upbringing and relationship with parents. If struc- approach where family sessions include all the
tural, the clinician may focus on developing a clear children and any important extended family mem-
hierarchy; if cognitive behavioral, ask about their bers, such as grandparents. The value of such
own thoughts about parenting, ways they respond family sessions is that the clinician can fully
when problems arise, and provide behavioral home- observe all the interactional processes as they
work assignments that help the couple support, unfold in the room, can easily gather important
rather than undermine each other. assessment information, and has an opportunity to
connect with each family member, minimizing the
Case Illustration danger of a left-out member from undermining the
Sara and Jim come to therapy following an explo- treatment process.
sive argument where Sara allowed their 17-year- But conceptually family therapy is less about
old daughter to stay out later on a date than she everyone being in the room and more about thinking
normally does. Jim felt that Sara was being too in terms of family dynamics – patterns and history,
lenient, again, and resented that she made this projections, and communication – and such total
decision without his input. Sara, once again, felt family session can understandably be overwhelm-
that Jim was being too rigid. Each spent much of ing, especially for less experienced clinicians and
the first session describing their points of view and often not practical. There is not a need, for example,
frustrations. to bring a baby or toddler into a therapy session.
The clinician asked about their overall parent- They are often more a distraction that allows the
ing styles and values, and it was clear that the parents to focus upon when tension arises. Here it is
couple was polarized in their approaches. After better to meet with the parents alone if possible.
pointing this out and asking about other aspects of Often their issues around such young children are
their relationship, it was clear that they differ in around parenting skills, or reaching a balance
many areas but rarely talk about them for fear of between parenting and couple time.
having such an argument. The clinician talked School-age children can engage and benefit
about her worry about how these differences from family sessions. They are, in fact, often the
may affect their daughter, her perception of each presenting problem, the identified patient – Billy
406 Children in Couple and Family Therapy
is getting in trouble at school and Clare and Adam, The rest of the time is spent drawing Teresa
sister and brother, have been fighting all the out, building rapport, and helping her see that the
time – and your focus, depending on your orien- therapist is not just another adult who rants at her
tation, is on deconstructing the underlying prob- about her life. The goal is define with Teresa what
lem: Do the parents lack skills? Are they she would like to change at home, in her family, a
projecting their own issues on the children? Are goal for therapy. She talks about her parents get-
the parents triangulating the children to avoid ting off her back, not treating her like a child and
conflict in their own relationship? realizing that she, in fact, can make good deci-
The challenge here is incorporating the chil- sions and is not as oblivious as she seems.
dren into the session. Here the clinician needs to The clinician’s challenge now is to connect the
begin by building rapport with each child, parents’ concerns – her grades and attitude – with
matching the content and his voice tone to that what Teresa wants – her parents being less micro-
of each particular child. Those young and restless managing. This is the focus of therapy, developing
may need a table they can sit to draw or color a plan that both addresses the parents’ concerns
while you talk. Later on in therapy the clinician and those of Teresa.
may incorporate family sculptures as an assess-
ment tool or use family games to observe and
shape the family process. Relevant Research About Family Life
For teens, the clinician faces the same initial
challenges, but where school-age children are While Freud believed in the power of childhood to
often mystified by the therapy process, teens are shape lives, he had little professional contact with
often openly reluctant participants. They are children. His protégé, Alfred Adler, however,
pulled into therapy because of parents’ complaints organized child guidance clinics in Vienna and
and are likely to see the clinician as another adult developed techniques aimed at alleviating chil-
trying to get them to change. Here the clinician dren’s feelings of inferiority. His student, Rudolf
needs to control the process unfolding in the Dreikers, continued his work and brought it to the
room, making sure that the teen is not feeling United States, advancing the child guidance
ganged up on, replicating what often happens in movement in the 1920s with its focus on pre-
the home. If necessary, he wants to ask the parents venting and treating emotional disorders in child-
to leave and focus on helping the teen engage and hood (Nichols 2006).
quickly defining a goal that the teen is willing to Real strides were made in integrating children
work on. This provides a working contract for in the family dynamics in the early 1940s when
therapy that you can build upon. attention shifted from individual pathology to the
notion that family tensions could contribute to a
child’s symptoms. In these early years, however,
Case Illustration parents were viewed as the adversaries, the child
Teresa, 16 years old, comes with her parents to an the victim, culminating in one of the now infa-
initial family session. The parents start by railing mous phases of psychiatric history, namely, the
about her boyfriend and the fact that her grades are theory of Frieda Fromm-Reichmann (1948) of the
going down and that she has an “attitude” at schizophrenogenic mother – domineering
home. Teresa says nothing, stares off into space. rejecting woman married to passive men whose
After a few minutes of this, the clinician asks parenting produced schizophrenic children. Psy-
Teresa if she would mind talking with her alone. She chological treatment of children and family during
nods in agreement, and the therapist asks if the this time was divided, with a psychiatrist or psy-
parent would mind waiting in the waiting room; chologist seeing the individual child, a social
they leave. The clinician now wonders aloud, “Is worker working with the mother.
this what they always do?” Teresa rolls her eyes and In the late 1940s and early 1950s parents
nods her head. finally moved out of their villain roles, and
Children in Couple and Family Therapy 407
pathology was seen as inherent in family life. the parents to be therapists – and see if changes in
During this time researchers focused more on their behavior results in positive change in the
the intricacies of the parent–child relationship, child. If they do not or if the therapist suspects
with Bowlby (1949) investigating the attach- that there are deeper individual issues at
ment between parent and child; Melanie Klein work – attention deficit/hyperactivity disorder in
(Segal 1964) focusing on the dynamic of a young child, cutting in a teen – the clinician
mother–child separation, leading to the devel- would want to make a referral for further assess- C
opment of object relationship theory; and ment, play therapy, or a shift from family to indi-
Nathan Ackerman (Ackerman and Sobel 1950) vidual therapy.
taking the bold step of seeing the entire family at It is helpful in making such decisions for
the same time in the same room. Finally, child therapists to have their own treatment maps for
and parents were firmly interwoven, opening the specific common issues mentally in place before
door to viewing and treating the family as seeing children and families; this allows to not
one unit. have to reinvent the wheel with each family and
With his general systems theory, von allows the clinician to hit the ground running.
Bertalanffy (1968) added momentum to this per- But it is also important to realize that a large part
spective, looking at families as closed or open of good family therapy is creating a safe place
dynamic systems and heralding the power of pat- for getting issues out in the open, helping every-
terns. Bateson (1951) at Palo Alto focused on one to be more honest, and changing patterns so
homeostasis and double-bind communication, that are more functional. Ultimately it is always
helping to shape what was to become the strategic the clinician’s own orientation and therapeutic
therapy of Jay Haley (1963). Minuchin (1974) comfort zone that will ultimately shape the
studied family structure and made us sensitive to process.
boundaries, the need for hierarchy between par-
ents and children, the workings of enmeshed and
disengaged parents. Bowen (1978) looked at dif-
ferentiation, families of origin, and the important Cross-References
concept of triangulation – creating stability and
detouring conflict between parents by involving ▶ Assessment in Couple and Family Therapy
the children. Carl Whitaker (1958) focused on the ▶ Authoritarian Parenting
experiential, challenging the family to be more ▶ Authoritative Parenting
flexible. ▶ Circular Questioning in Couple and Family
These grandparents of family therapy laid Therapy
down the foundation that led to second and ▶ Cognitive Behavioral Couple Therapy
third waves of approaches – solution focused, ▶ Common Factors in Couple and Family
cognitive behavioral, multisystemic, narrative, Therapy
emotionally focused couples therapy – each fus- ▶ Conjoint Couple and Family Therapy
ing of individual therapy approaches with fam- ▶ Detriangulation in Couple and Family Therapy
ily dynamics. ▶ Disengagement in Couples and Families
▶ Family Rules
▶ Family Structure
Special Considerations for Couple ▶ Four Horsemen in Couple and Family Therapy
and Family Therapy ▶ Identified Patient in Family Systems Theory
▶ Listening in Couple and Family Therapy
There is always the question with children about ▶ Parenting in Families
at what point does the therapist move toward ▶ Problem-Solving Family Therapy
individual child therapy. Often a clinician can ▶ Separation-Individuation in Families
start with parenting issues – essentially coaching ▶ Whole Family Therapy
408 Christensen, Andrew
References Professor of Psychology at University of Califor-

nia, Los Angeles. Christensen obtained his
Ackerman, N. W., & Sobel, R. (1950). Family diagnosis: A.A. from Grand View College in Des Moines,
An approach to the preschool child. American Journal
Iowa, and his B.A. in Psychology from the Uni-
of Orthopsychiatry, 20(4), 744–753.
Bateson, G. (1951). Information and codification: versity of California, Santa Barbara. After he
A philosophical approach. In J. Ruesch & G. Bateson received his bachelor’s degree, Christensen
(Eds.), Communication: The social matrix of psychia- worked for several years, first as a social worker
try. New York: Norton.
and then as a psychology instructor at community
New York: Jason Aaronson. colleges in Iowa. Following these professional
Bowlby, J. P. (1949). The study and reduction of group positions, as well as a year traveling in the United
tension in the family. Human Relations, 2(8), 123–138. States and abroad, Christensen enrolled in the
Fromm-Reichmann, F. (1948). Notes on the development
University of Oregon, where he obtained his
of treatment of schizophrenics by psychoanalytic psy-
chotherapy. Psychiatry, 11(2), 263–274. Ph.D. in Clinical Psychology in 1976.
Haley, J. (1963). Strategies of psychotherapy. New York: Christensen’s first faculty position was as an
Gruner & Stratton. Assistant Professor of Psychology at University
Minuchin, S. (1974). Families in family therapy. Cam-
of California, Los Angeles, where he remains on
bridge, MA: Harvard University Press.
Nichols, M. (2006). Family therapy: Concepts and faculty today.
methods. Boston: Pearson.
Segal, H. (1964). Introduction to the work of Melanie
Klein. New York: Basic Books, 1963.
von Bertalanffy, L. (1968). General systems theory. New
York: Brailler.
Whitaker, C. A. (1958). Psychotherapy with couples. Although Christensen’s contributions to the field of
American Journal of Psychotherapy., 12(1), 18–23. couple and family therapy are numerous, there are
two for which he is best known. The first is his
pioneering research on the demand/withdraw inter-
Christensen, Andrew action pattern, an asymmetrical cycle of couple
behavior where one partner nags, criticizes, and
Katherine J. W. Baucom1 and pressures the other partner while the other partner
Brian R. W. Baucom2 avoids, withdraws from, or terminates discussion of
1
University of Utah, Salt Lake City, UT, USA the change being pursued. This pattern is common
2
Department of Psychology, University of Utah, in distressed treatment-seeking couples, couples
Salt Lake City, UT, USA who engage in intimate partner violence and couples
who engage in infidelity. Christensen’s most cited
and influential finding in this area, which formed the
Introduction basis of his conflict structure model of demand/
withdraw, was that the behavior an individual part-
Andrew Christensen’s contributions to couple and ner engages in is highly influenced by whether
family therapy are numerous. He is best known for she/he is seeking change or being asked to create
his research on the demand/withdraw interaction change (Christensen and Heavey 1990). When
pattern as well as the development, evaluation, and seeking change, men and women (regardless of
dissemination of Integrative Behavioral Couple whether they are in cross sex or same-sex relation-
Therapy. ships) are more likely to engage in demanding
behavior; likewise, when being asked to create
change, both men and women are more likely to
Career engage in withdrawing behavior.
Along with the late Neil Jacobson, Christensen
Andrew Christensen, Ph.D. is a Licensed Clinical also developed Integrative Behavioral Couple Ther-
Psychologist and Distinguished Research apy (IBCT; Christensen et al. 2015; Jacobson and
Chronically Ill People in Couple and Family Therapy 409
Christensen 1998) in an attempt to reach those cou- Christensen, A., Doss, B. D., & Jacobson, N. S. (2014).
ples who did not respond to Traditional Behavioral Reconcilable differences: Rebuild your relationship by
rediscovering the partner you love – Without losing
Couple Therapy (TBCT) or relapsed following yourself (2nd ed.). New York: Guilford.
treatment termination. IBCT is considered a “third Christensen, A., Dimidjan, S., & Martell, C. R. (2015). Inte-
wave” behavior therapy, in that it incorporates grative behavioral couple therapy. In A. S. Gurman,
acceptance strategies for aspects of relationships J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook
that are unlikely to change (i.e., differences between
of couple therapy (5th ed., pp. 61–96). New York:
Guilford.
C
partners, as well as partners’ emotional experi- Jacobson, N. S., & Christensen, A. (1998). Acceptance and
ences). Christensen and Jacobson conducted a change in couple therapy: A therapist’s guide to trans-
pilot trial of IBCT followed by the largest random- forming relationships. New York: Norton.
ized clinical trial (RCT) of behavioral couple ther-
apy to date, in which 134 seriously and stably
distressed couples participated in a 26-session pro-
tocol of either IBCT or TBCT. Both IBCT and Chronically Ill People in
TBCT generally produced improvements in aspects Couple and Family Therapy
of relationship functioning, although IBCT couples
displayed greater maintenance of treatment gains in Gustavo R. Medrano
some outcomes over time (Christensen et al. 2010). The Family Institute at Northwestern University,
Following his RCT, Christensen has focused his Evanston, IL, USA
professional efforts on dissemination of IBC-
T. Along with former graduate student Brian
D. Doss, he adapted IBCT principles for web deliv- Name of Family Form
ery (www.ourrelationship.com), as outlined in
Christensen et al. (2014). As part of a nationwide Chronically Ill People in Couple and Family
“rollout” of evidence-based practices in the US Therapy
Department of Veteran’s Affairs, Christensen has
also provided training in IBCT to hundreds of men-
tal health providers since 2010. Introduction
Family caregiving is an important and common role

Cross-References that may become even more common in our society
with a growing elderly population and health care
▶ Acceptance in Couple and Family Therapy trend shifting more of the patient care onto families.
▶ Acceptance Versus Behavior Change in Couple Family caregiving is a complex process that bidirec-
and Family Therapy tionally affects the caregiver and patient, with seri-
▶ Integrative Behavioral Couple Therapy ous negative consequences for the caregiver’s own
▶ Jacobson, Neil well-being if not properly managed. Given this
complexity and increased risk of depression
and psychological distress, professional help,
References including psychotherapy, should be considered for
the patient and family caregivers.
Christensen, A., & Heavy, C. L. (1990). Gender and social
structure in the demand-withdraw pattern of marital con-
flict. Journal of Personality and Social Psychology, 59,
73–81. Description
Christensen, A., Atkins, D. C., Baucom, B. R., & Yi,
J. (2010). Marital status and satisfaction five years fol-
Chronic health conditions can be defined as a
lowing a randomized clinical trial comparing traditional
versus integrative behavioral couple therapy. Journal of mental or medical health condition that persists
Consulting and Clinical Psychology, 78, 225–235. for beyond 3 months. Chronic health conditions
410 Chronically Ill People in Couple and Family Therapy
are quite common, with about half of all adults in The influence of the chronic condition also
the United States found to have at least one of the depends on the onset of the condition in relation
examined chronic health conditions and about to when and how the family was formed and how
25% of the adult population having two or more it fits with transitional times in family (i.e., family
(Ward et al. 2014). Notably, about 43% of the life cycles), such as young adult leaving child-
nearly 27 million disabled individuals in 2006 hood home, coupling, pregnancy, and raising
had mental disabilities (U.S. Census Bureau young children. For example, a daughter who is
2006), which include disorders such as schizo- in charge of caregiving for her father who was
phrenia, bipolar and chronic depression. Although paralyzed from a car accident may have more
arthritis and musculoskeletal conditions were the difficulty coping with this role if her caregiving
leading cause of activity limitations among work- began once she was married with children rather
ing age adults, mental disorders were the second than during adolescence while living at home.
leading cause of activity limitations among indi- Depending on onset of the condition in relation
viduals age 18–44 years old (National Center for to family life cycles, the chronic condition may
Health Statistics 2006). cause shifting family roles (i.e., who takes care of
Among children, the prevalence rate for what), requiring that family members manage dif-
chronic health conditions is about 30% with ferent coping styles among themselves and isola-
about 21% of children having two or more condition for patient and family.
tions (Newacheck and Taylor 1992), and about There are myriad ways in which the caregiver
7% of them having their daily functioning and family are affected by the chronic condition.
impaired by the health conditions (National Cen- The family burden of caregiving can be broken
ter for Health Statistics 2006). These common into two types: objective and subjective. Objec-
chronic conditions not only affect the patient, tive forms of family burden are practical problems
but they also affect their caregivers. With current that arise from caregiving such as financial diffi-
health care trends shifting patient care more culties due to medical bills and loss income, dis-
towards families for chronic health conditions, ruption of family relationships, limits on lifestyle
including mental disorders, the well-being of (e.g., work, social, leisure), and negative influence
caregivers is quite important, especially as the on physical health. Subjective forms of family
well-being of the patient and their close family burden are the psychological reactions family
members have been shown to be bidirectional caregivers experience, which include sadness,
(Martire et al. 2004). anxiety, embarrassment, frustration, stress of care-
A family caregiver can be the spouse, parent, taking, and grief. This grief could be connected to
adult child, or any close family member of the not only the loss of the patient’s lifestyle and
patient. The manner in which the chronic condi- identity but also the loss of the caregiver’s life-
tion affects the family caregiver depends on ill- style and identity. Such grief can then lead to
ness characteristics as well as family unintentional hostility and anger towards the
characteristics. Rolland (1994) proposes four patient, which then often results in caregiver
dimensions to better understand how an illness guilt and shame for having such emotions towards
can affect patient and family functioning. These their loved one.
four dimensions are onset (i.e., acute or gradual),
course (e.g., progressive, constant, relapsing/epi-
sodic, predictable/unpredictable), incapacitation Relevant Research About Family Life
(e.g., presence or absence and severity), and out-
come (e.g., fatal, shortened lifespan, nonfatal). Given the multiple negative ways in which a
For example, a fatal cancer that progresses pre- family caregiver can be affected, it is perhaps not
dictably and slowly has a qualitatively different surprising to see the many effects caregiving has
effect on the patient and their family than episodic on the individual. Research has shown that one
and unpredictable inflammatory bowel syndrome. third to one half of family caregivers experience
Chronically Ill People in Couple and Family Therapy 411
significant psychological distress and higher rates more often used in Black and Latino caregivers
of mental health problems than the general popu- than White caregivers, and such religious involve-
lation, with partners often having larger burdens ment is often associated with increased access to
of care as compared to other primary caregivers social support (Shah et al. 2010).
(Shah et al. 2010). In fact, depressive symptoms The value of family caregiving is not limited to
are twice as common in caregivers as non- the immediate needs that are addressed on a daily
caregivers, with some studies showing up to basis by the caregiver. Close family members can C
50% of caregivers meeting criteria for clinical have a significant influence on the patient’s psy-
depression. Additionally, researchers have found chological well-being and the management of the
that patients’ close family members may experi- illness, which includes treatment adherence and
ence poorer physical health and the diminished engagement in positive health behaviors (Martire
quality of the patient relationship (Martire et al. et al. 2004). Additionally, diverse family charac-
2004). A number of studies across conditions teristics and behaviors such as intimacy, emo-
have found that the quality of life of partners tional support, overprotective behaviors, and
tends to be lower than that of the patient (Rees criticism have been found to influence patient out-
et al. 2001). Not all effects from family caregiving comes across multiple illness groups, including
are negative as researchers have also found that chronic pain, heart disease, and rheumatic disease.
the experience can include pride in fulfilling For example, multiple studies have found that
familial responsibilities, enhanced closeness with paternal involvement in the management of pedi-
the patient, and satisfaction with one’s compe- atric chronic health conditions is positively asso-
tence. Notably, these effects are associated with ciated with not just patient outcomes but maternal
lower levels of depression and the subjective and family functioning as well. These studies and
report of caregiver burden. others show that family caregiving has value that
Beyond the severity of the chronic health con- transcends the daily needs being addressed.
dition, other factors have been found to be associ-
ated with caregiver well-being. For example,
women caregivers have been found to be at approx- Special Considerations for Couple and
imately twofold greater risk of developing clinical Family Therapy
depression than male caregivers. Differences by
caregiver ethnicity have also been found, with Given the prevalence and importance of family
White caregivers reporting greater depression caregiving with chronic health conditions, many
than Black caregivers, and Latino caregivers interventions have been developed to help
reporting greater depression than White and improve the well-being of the caregivers, and
Black caregivers. Additionally, whereas positive subsequently, the patients as well. The manner in
associations between caregiver age and caregiver which a chronic health condition is addressed in
burden (i.e., older age, more caregiver burden) couples or family therapy can vary widely includ-
have been found in White caregivers, negative ing educational, case management (i.e., matching
associations (i.e., older age, less caregiver burden) people’s needs with available programs and
have been found in Black caregivers. Of the mul- resources), and psychological interventions. Spe-
tiple factors that are associated with caregiver well- cifically for couples therapy, Baucom et al. (1998)
being, social support is possibly the most important distinguished between three types of couples-
(Shah et al. 2010). Caregiving is typically associ- based interventions: partner-assisted interventions
ated with a decrease in social support and increased (i.e., use partner as encouragement or “coach”),
withdrawal and isolation; however, strong negative disorder specific interventions (i.e., address
associations have been found between social sup- partner behaviors that contribute to individual
port and caregiver depression and burden (i.e., problem), and couples therapy (i.e., address rela-
more social support, less depression and burden). tionship distress as it influences individual’s psy-
Notably, religious coping has been found to be chopathology or medical problem).
412 Chronically Ill People in Couple and Family Therapy
There have been multiple reviews of these inter- that employ cognitive behavioral techniques to not
ventions, and commonalities arise in what makes only address the effects of the chronic condition on
an intervention most helpful for these families. the patient and family but also address relationship
Psychological interventions that address the multi- distress. This systemic approach is consistent with
ple stressors and risk factors that come with care- the known and myriad effects of chronic illness on
giving, rather than just educational interventions the patient and their families.
that aim to increase knowledge about the illness,
have been found to be more effective. In fact,
increased knowledge for a caregiver is not corre- Cross-References
lated with psychological improvement for the care-
giver. Rather, interventions that contain cognitive- ▶ Addictions in Couple and Family Therapy
behavioral strategies that address unhelpful ▶ Attention Deficit Hyperactivity Disorder
thoughts and encourage seeking social support (ADHD) in Couple and Family Therapy
have been associated with superior outcomes. Out- ▶ Alcohol Use Disorders in Couple and Family
comes for family interventions include reductions Therapy
in caregiver burden, anxiety, and depression, and ▶ Anxiety Disorders in Couple and Family
decreased depression, and in some cases, decreased Therapy
mortality for patients. The effects of the interven- ▶ Bipolar Disorder in Couple and Family
tions are generally greater for family caregivers, Therapy
with the effects being greater when these interven- ▶ Borderline Personality Disorder in Couple and
tions directly address relationship issues as well Family Therapy
(Martire et al. 2004). ▶ Cognitive Behavioral Couple Therapy
As with family interventions, couples-based ▶ Cognitive-Behavioral Family Therapy
interventions that use cognitive-behavioral tech- ▶ Depression in Couple and Family Therapy
niques have also been found to be effective for a ▶ Family Focused Therapy for Bipolar Disorder
variety of chronic psychological and medical con- ▶ Family Psychoeducational Treatments for
ditions. Specifically for couples, Fischer et al. Schizophrenia in Family Therapy
(2016) reported that multiple studies have found ▶ Medical Model in Couple and Family Therapy
that couple-based interventions using cognitive ▶ Obsessive Compulsive Disorder (OCD) in
behavioral techniques to be as effective, if not Couple and Family Therapy
more effective, than individual interventions for a ▶ Posttraumatic Stress Disorder (PTSD) in Cou-
variety of chronic psychological and medical con- ple and Family Therapy
ditions. Couple-based interventions have generally ▶ Schizophrenia in Couple and Family Therapy
been found to not only significantly improve out-
comes related to the psychological and/or medical
condition, but unlike individual interventions, References
simultaneously also address relationship distress.
Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D.,
These conditions include depression, alcohol & Stickle, T. R. (1998). Empirically supported couple
abuse, obsessive-compulsive disorder, post- and family interventions for marital distress and adult
traumatic stress disorder, and cancer. Other chronic mental health problems. Journal of Consulting and
medical conditions (e.g., arthritis, chronic pain, Clinical Psychology, 66(1), 53–88.
Fischer, M. S., Baucom, D. H., & Cohen, M. J. (2016).
cardiovascular diseases, HIV) have been studied Cognitive-behavioral couple therapies: Review of the
but not as extensively as cancer in this interper- evidence for the treatment of relationship distress, psy-
sonal context to make definitive statements regard- chopathology, and chronic health conditions. Family
ing couple-based interventions efficacy relative to Process, 55(3), 423–442.
Martire, L. M., Lustig, A. P., Schulz, R., Miller, G. E., &
individual therapy (Fischer et al. 2016). Helgeson, V. S. (2004). Is it beneficial to involve a family
In sum, patients and their families appear to be member? A meta-analysis of psychosocial interventions
well served when seen in couples or family therapy for chronic illness. Health Psychology, 23(6), 599–611.
Circle of Security 413
National Center for Health Statistics. (2006). Health for relationship-focused prevention with families
United States with chartbook on trends in the health of young children in contexts of risk and/or early
of Americans. Hyattsville: Author.
Newacheck, P. W., & Taylor, W. R. (1992). Childhood intervention with families showing caregiver-
chronic illness: Prevalence, severity, and impact. Amer- child relationship problems.
ican Journal of Public Health, 82(3), 364–371. The COS* graphic (see COS Original Circle at
Rees, J., O’Boyle, C., & MacDonagh, R. (2001). Quality of http://circleofsecurityinternational.com/handouts)
life: Impact of chronic illness on the partner. Journal of
the Royal Society of Medicine, 94, 563–566. distils essential concepts of attachment theory and C
Rolland, J. (1994). Illness, families & disabilities. research, making them easily accessible to parents
New York: Basic Books. and practitioners. Of several COS* intervention
Shah, A. J., Wadoo, O., & Latoo, J. (2010). Psychological variants, the two most widely disseminated are
distress in carers of people with mental disorders. British
Journal of Medical Practitioners, 3(3), 327–334. Circle of Security Intensive* (COS-I) and Circle
U.S. Census Bureau. (2006). http://factfinder.census.gov/ of Security Parenting* (COS-P).
servlet/STTable?_bm=y&-geo_id=01000US&-qr_na COS-I* is a psycho-educational and psycho-
me=ACS_2006_EST_G00_S1801&-ds_name=ACS therapeutic early intervention using individual-
_2006_EST_G00_&-_lang=en&-_caller=geoselect
&-redoLog=false&-format= ized video-based assessment and treatment to
Ward, B. W., Schiller, J. S., & Goodman, R. A. (2014). improve attachment relationships. Originally
Multiple chronic conditions among US adults: A 2012 developed as a 20-week group-based approach,
update. Preventing Chronic Disease, 11, E62. https:// COS-I* has also been used individually and in
doi.org/10.5888/pcd11.130389.
home and more restrictive settings (i.e., prison).
COS-P* is a preventative intervention for care-
givers of young children using a manual and
DVD-based protocol with groups or individuals,
Circle of Security in center- or home-based delivery.
Anna Huber1, Erinn Hawkins2 and Glen Cooper3
1
Macquarie University, Sydney, NSW, Australia
2 Prominent Associated Figures
Griffith University, Gold Coast, QLD, Australia
3
Circle of Security International, Spokane,
Originally developed by Glen Cooper, Kent
WA, USA
Hoffman, and Bert Powell, COS* was further
enhanced and tested over time with research part-
ners, Robert Marvin and Jude Cassidy.
Name of Model
Circle of Security
Synonyms Grounded in attachment theory and research,

COS* interventions also draw heavily on family
COS; Circle of Security Intensive (COS-I); Circle therapy, object relations, and psychodynamic the-
of Security Parenting (COS-P) ories. Supporting research shows that (1) secure
attachment is a protective factor for health,
social, and emotional development, (2) insecure
Introduction attachment can increase the risk of problematic
developmental outcomes in the context of other
The Circle of Security (COS*) is both a frame- risks, (3) disorganized attachment increases the
work (represented graphically) for understanding risk of later psychopathology, and (4) attachment
attachment relationships, as well as a strengths- can change if the child’s experience of caregiving
based intervention approach (Powell et al. 2014). changes. The model’s core concepts are as
It provides concrete guidelines and clinical tools follows:
414 Circle of Security
Child Exploration and Attachment Are need to provide a balance between warmth and
Connected to Adult Caregiving support and appropriate structure, limit setting,
The Circle graphic represents three dynamically and guidance; and (3) they should mostly follow
interlinked behavioral systems (exploration, the child’s signals but at times be able to actively
attachment, and caregiving). It shows that a pre- intervene (take charge, e.g., to ensure the child’s
dictably available and protective caregiver (hands safety, solve problems, and/or provide behavioral
on the circle) is needed for the child to become and emotional containment).
secure. The caregiver’s job is to serve both as a
secure base when the child has exploration (“top Behavior as Communication and
of the circle”) needs and a safe haven when the Co-regulation of Affect
child has attachment (“bottom of the circle”) Children’s behavior is understood as a form
needs. of communication regarding attachment, explora-
When a child’s exploration system is activated, tion, or caretaking needs. A child may openly
the caregiver needs to signal when and if it is safe signal (cue) what they need from the caregiver
for the child to follow their innate curiosity and or hide their real need (miscue). By framing
explore (support my exploration); monitor the child behavior as communication about legitimate
child (watch over me); provide scaffolding for developmental needs, caregivers can shift their
learning and the acquisition of new skills (help focus from trying to eliminate a particular behav-
me); give joint attention to, encourage, and enjoy ior to understanding what the behavior is signal-
the child’s endeavors (enjoy with me); and share ing (see below for miscuing).
their delight in the child as a person (delight in Children develop emotional regulation capaci-
me). Providing a secure base enables the child to ties through caregiver co-regulation by “being
best meet their learning potential, develop skills, with” their child. This involves a caregiver
and build a sense of their own autonomy. connecting with the child, communicating (non-
When the child feels fearful, distressed, verbally and/or verbally) their understanding of
or emotionally dysregulated, or their interest in the child’s internal emotional experience and
exploration wanes, they need caregivers to be remaining available to the child while the feeling
open to meet these emotional needs (welcome passes.
my coming to you); provide comfort (comfort
me), protection (protect me), and co-regulation Intergenerational Influences, Defensive
(organize my feelings); and communicate the fun- Processes, and Caregiving
damental message of the child’s inherent self- COS* teaches caregivers that the way they think
worth (delight in me). Providing a safe haven and feel about their child can be influenced (both
when the child has these “bottom of the circle” positively and negatively) by their own childhood
needs deactivates the attachment behavioral sys- experiences of being cared for. Caregivers’ defen-
tem, contributing to a smooth balance between the sive states of mind (known as “shark music”)
child going out on the top of the circle may be activated if their child’s need coincides
(exploration) and coming in (attachment) on the with their own unmet childhood need, limiting
bottom, thus supporting healthy social and emo- perception of and responsiveness to the child’s
tional development. real needs in the relationship.
The COS* message is that, as hands on the If caregivers react defensively, over time the
child’s circle, the caregiver’s role is “Always child also defensively limits their expression of
be bigger, stronger, wiser, and kind. Whenever these needs (miscuing). This is framed as the child
possible follow my child’s need. Whenever nec- adapting to the caregiver’s needs (limited circles,
essary, take charge.” This encompasses several limited hands). Caregivers learn that some of
crucial messages for caregivers: (1) caregiving these inadequate caregiving responses regularly
requires predictable emotional availability; (2) as evoke fear in children, with negative developmen-
the more capable partner in the relationship, they tal consequences.
Each caregiver-child dyad referred for COS- Populations in Focus

I* typically has a core dyadic relational diffi-
culty (linchpin issue), resulting from caregiver COS-I* targets the caregiving-attachment rela-
defensive responses, which promotes insecurity tionship in moderate- to high-risk caregiver-child
for that child. The linchpin issue becomes the dyads showing established relationship difficul-
focus of the intervention for that dyad, taking ties. This version has been adapted for use with
into account the caregiver’s defensive style or pregnant women, caregivers of infants, and care- C
core sensitivity. givers of children up to 8 years of age.
COS-P* was developed as a universal preven-
tion model introducing and promoting attachment
Increasing Security, Reducing
security for all families. It may also be appropriate
Disorganization, and Relationship Repair
as a preliminary intervention with moderate- to
Relational ruptures caused by instances of
high-risk families, prior to engaging in the more
insensitive or frightening caregiving become
intensive COS-I*.
problematic for child development if they are
not repaired. COS* provides caregivers with a
framework for interactive repair of these break- Strategies and Techniques Used in the
downs, through “time-in.” Time-in is a three- Model
step process. The first step is a time-out for the
parent if needed. This allows the parent to reg- Strategy/technique COS-P COS-I
ulate their affect enough to be able focus on the Facilitator training 4-day Qualified
training; no therapists
needs of the child. The next step is for the parent specific undergo
to support co-regulation of emotion to help the prerequisite 10-day
child calm. This is done through a repair routine qualification training, must
that includes the parent taking charge to help the or post- pass the exam,
training and be
child feel safe, helping the child put language to supervision supervised for
their emotional experience, and providing a requirements a minimum
sense of connection until the child is calm period and
enough to take the next step. When the parent until
competent
is calm enough and the child is calm enough,
Use relational Central Crucial
each person takes responsibility for his or her processes between the aspect of the therapeutic
part in the rupture, makes amends, and talks therapist and parent as curriculum requirement
about new ways of dealing with the problem in a vehicle for
influencing parallel
the future.
change in the parent-
child relationship:
facilitator creates
Theory of Change holding environment
COS* interventions promote more secure and less and serves as a secure
disorganized child attachment by focusing on the base and safe haven
parent-child relationship and targeting caregiver for parent/s
capacities within the attachment relationship. Group process: over If group If group
time the group can delivered delivered
COS* aims to increase caregivers’ capacity to serve as a secure base
meet their children’s needs by providing a and safe haven for
map of a secure relationship and then video- parents, support
based practice with relationship-focused observa- vicarious learning,
normalize struggles,
tion, reflection, and empathy. By also providing and create a group
caregivers with a “secure base” and “safe haven,” momentum for
facilitators enable caregivers to experience what change
they need to do for their children. (continued)
416 Circle of Security
Strategy/technique COS-P COS-I Strategy/technique COS-P COS-I

Assessment of Caregivers Linchpin issue desired) relational
relationship-based identify own for each patterns once aware of
difficulty areas of caregiver-child these behaviors,
relational AND thoughts, and feelings
difficulty caregiver 4. Build empathy for
defensive style the child
(core Parents invited/ ✓ ✓
sensitivity) challenged to take
identified action (choosing
through security) to change
videotaped problematic relational
observation of dynamics they
caregiver-child become aware of
interaction and
Delivery mode – Group/ Group/
narrative
adaptations/options individual individual
interview with
available Center based/ Center based/
caregiver
home home
Psycho-education: Presented and Presented and
theory and research reflected on reflected on
• Attachment, using circle using circle
exploration, and graphic, graphic,
caregiving; animations, animations, Research About the Model
importance of handouts, handouts,
caregiving video clips, video clips, The majority of research on COS* to date has
relationship stock video caregivers’
• Child examples own video
focused on COS-I* and its adaptations. Several
development and examples studies of COS-I* found significant reductions
foundations of in attachment disorganization and increases in
healthy/adverse attachment security after intervention, compared
trajectories
• Emotional
to either pre-intervention levels or comparison
regulation groups. These promising findings were robust
• Defensive across child age groups, including early infancy
processes (Cassidy et al. 2010) and preschool-age children
• Intergenerational
transmission of
(Hoffman et al. 2006; Huber et al. 2015a),
caregiving relational as well as different risk groups, including famil-
dynamics ies attending a US Early Head Start Program
• Necessity/ (Hoffman et al. 2006), families presenting to
opportunities for
relational repair
a community mental health service in Australia
Guided use of video Stock footage Individualized (Huber et al. 2015a, b, 2016), and mothers in a
to: of secure and clips and tape US jail-diversion program for pregnant, nonviolent
1. Develop skills in insecure reviews offenders with substance abuse histories (Cassidy
behavioral dyads and tailored to et al. 2010). Caregivers of children aged 1–7 years
observation of actors linchpin issue
caregiver-child of dyad and in the Australian study also showed improvements
relationship dynamics caregiver’s in their own emotional well-being following COS-
2. Help caregivers core sensitivity I* (Huber et al. 2016) and in relationship capacities
become aware of (perceptions of self, child, and the caregiving rela-
caregiver and child
representations and tionship and reflective stance) important in the
how these are promotion of attachment security (Huber et al.
connected with 2015a). The study also found improvements in
behavior child behavioral and emotional functioning after
3. Promote reflection
on current (and COS-I*. The largest improvements were shown
(continued)
by caregivers and children with the least optimal
capacities and functioning before COS-I* (Huber child protection involvement, but custody had
et al. 2015a, b, 2016). Mothers who completed the been restored once Lucia was established in the
jail-diversion program also showed benefits in rela- residential program. As a child, Lucia had an
tional capacities that promote attachment security, alcoholic mother for whom she frequently had
with levels of maternal sensitivity at the post- to care and been sexually abused by one of her
intervention assessment being comparable to mother’s partners, leading to a brief period in
mothers in a community comparison group care after disclosing the abuse. C
(Cassidy et al. 2010). While these studies are lim- Lucia reported that Amy was hard to manage
ited by their small sample sizes and their lack of and became bossy, having tantrums if she could not
randomized control groups, together their findings get her own way. Lucia presented as depressed and,
show promising preliminary evidence that COS-I* though she wanted to look after Amy, reported
improves attachment outcomes for children feeling overwhelmed by parenting challenges.
11–58 months of age from high-risk families and Assessment revealed the linchpin issue for the
it appears to benefit caregivers and children who dyad was Amy needing to be sure her mother’s
need it the most. hands were fully on the circle as the bigger, stron-
Two randomized controlled trials of COS* ger, wiser, and kind adult in the relationship. Lucia
interventions have also shown promising inter- felt overwhelmed and incapable (shark music)
vention effects. A randomized controlled trial of and collapsed when the child needed her to take
a four-session home-visiting version of COS-I* charge. Lucia’s core sensitivity (separation sensi-
for first-time mothers of irritable infants, aged tivity) suggested she feared rejection if she self-
6–9 months, found that dyads were differentially activated as the parent. As a result Amy was left to
susceptible to the intervention depending on manage situations without adequate adult emo-
infant irritability and maternal attachment style tional support. Amy responded by becoming con-
(Cassidy et al. 2011). Specifically, the interven- trolling and punitive (indicating disorganized
tion was efficacious for more secure and attachment). Amy miscued her need for Lucia to
dismissing mothers with highly irritable infants, be the hands by acting like she was the adult, but
and more preoccupied mothers with moderately when her mother was not there, her anxiety and
irritable infants, with these infants more likely to insecurity were apparent.
be secure at 12 months of age compared to con- Lucia participated in a 20-week group
trols. A randomized controlled trial of COS-P* COS-I* intervention, while Amy attended
found that while there was no change in child childcare. Through observing her own and
attachment following the group intervention, other caregivers’ tape reviews, Lucia realized
mothers who participated in COS-P* reported that the past was being repeated, became more
greater improvements in relationship capacities empathic toward Amy, and recognized that,
that promote attachment security compared with contrary to her fears, Amy needed her and was
control group mothers (Cassidy et al. 2017). not able to manage without adult support. Lucia
These studies, while promising, require replica- also acknowledged she had to let go of excuses
tion to better understand what version of COS* is and step up to be the parent Amy needed. Lucia
best suited to specific populations. began taking charge and providing emotional
support even when Amy acted like she did not
need it (miscued).
Case Example By the time they completed the intervention,
Lucia was enjoying being with her child and feel-
Lucia, a 29-year-old sole parent of 3-year-old ing more capable as a parent; Amy appeared less
Amy, was referred to participate in COS-I* after bossy and self-reliant and was using Lucia more
a year in a residential drug rehabilitation pro- for support. Post-intervention assessment showed
gram. Amy had spent a year out of her mother’s Amy’s attachment had become secure and prior
care consequent to the substance abuse and clinical level behavioral and emotional problems
418 Circle of Security Parenting Enrichment Program
were now reported in the normal range. Lucia’s

reflective capacities and representations of the Circle of Security Parenting
caregiving relationship, self, and child had all Enrichment Program
significantly improved, and parenting stress was
also significantly reduced. Julie A. Peterson1, Christie Ledbetter2 and
Jermaine Thomas3
1
The Family Institute, Northwestern University,
Evanston, IL, USA
Cross-References 2
Alabama Psychological Services Center,
Madison, AL, USA
▶ Attachment Theory 3
Cornerstone Counseling Center of Chicago,
▶ Bowlby, John
Chicago, IL, USA
Name of Model
References
Circle of Security Parenting Enrichment Program.
Cassidy, J., Ziv, Y., Stupica, B., Sherman, L., Butler, H.,
Karfgin, A., et al. (2010). Enhancing attachment
security in the infants of women in a jail-diversion Introduction
program. Attachment & Human Development, 12(4),
333–353.
Cassidy, J., Woodhouse, S., Sherman, L., Stupica, B.,
The impact of the family system – especially
& Lejuez, C. (2011). Enhancing infant attachment parenting – is understood to leave long lasting
security: An examination of treatment efficacy impressions on children. From being a child’s
and differential susceptibility. Development and teacher, mentor, and protector, parents serve in
Psychopathology, 23(1), 131–148.
Cassidy, J., Brett, B. E., Gross, J. T., Stern, J. A.,
many roles for their children. To optimally pre-
Martin, D. R., Mohr, J. J., et al. (2017). Circle of pare for success, parents look for strategies and
Security-Parenting: A randomized controlled trial in interventions to assist them in promoting individ-
Head Start. Development and Psychopathology, 29, ual and family resiliency. Various studies have
651–673. https://doi.org/10.1017/S0954579417000244.
Hoffman, K., Marvin, R., Cooper, G., & Powell, B. (2006).
found that parent-training courses often aid in
Changing toddlers’ and preschoolers’ attachment clas- decreasing parent stress and increasing perceived
sifications: The Circle of Security intervention. Journal competency in ability (Neece et al., 2012;
of Consulting and Clinical Psychology, 74(6), Meirsschaut et al., 2010). Others have described
1017–1026.
Huber, A., McMahon, C., & Sweller, N. (2015a). Efficacy
how parents feel more capable in handing difficult
of the 20-week Circle of Security Intervention: parenting challenges when exposed to workshops
Changes in caregiver reflective functioning, represen- or direct interventions rather than personal
tations, and child attachment in an Australian clinic research (Keen et al., 2010). One well-known,
sample. Infant Mental Health Journal, 36(6), 556–574.
Huber, A., McMahon, C., & Sweller, N. (2015b).
evidence-based parenting intervention is called
Improved child behavioural and emotional functioning Circle of Security.
after Circle of Security 20-week intervention. Circle of Security Parenting Enrichment Pro-
Attachment and Human Development, 17(6), 547–569. gram is an evidence-based parenting intervention
Huber, A., McMahon, C., & Sweller, N. (2016). Improved
parental emotional functioning after Circle of
used to address concerns around attachment and
Security 20-week parent–child relationship interven- security. Over the course of the last decade, Circle
tion. Journal of Child and Family Studies, 25(8), of Security (COS) has grown in research and
2526–2540. developed into a widely used model that is avail-
Powell, B., Cooper, G., Hoffman, K., & Marvin, R. (2014).
The Circle of Security Intervention: Enhancing attach-
able in at least ten languages with ongoing
ment in early parent-child relationships. New York: research to continue improving the program.
Guilford. Lindquist and Watkins (2014) reviewed seven
Circle of Security Parenting Enrichment Program 419
different parenting training programs to determine attachment caregiver will be available to their
common core concepts that impact effectiveness. needs (Ainsworth et al., 1978). The second is
They found that a majority of parenting programs insecure avoidant attachment. This attachment
aim to do the same task by “promoting a better style is characterized by a child’s physical and
understanding of the basic needs and motivations emotional independence from the caregiver, as
that underlie a child’s behavior while also improv- the child does not seek out the caregiver when
ing communication and fostering mutual respect” distressed (Ainsworth et al., 1978). The next is C
(Lindquist and Watkins, 2014, p. 161). Where insecure ambivalent or resistant attachment. This
programs differ are with respect to their theoreti- style is characterized by a child’s duel dependence
cal roots. and rejection of the caregiver (Ainsworth et al.,
1978). The final attachment style is disorganized,
which is characterized by fearful, anxious, or
Prominent Associated Figures inconsistent responses towards the caregiver
(Ainsworth et al., 1978). This style is often asso-
Developed by Glen Cooper, Kent Hoffman, and ciated with neglect, abuse, or other adverse rela-
Bert Powell, Circle of Security is embedded in tionship with the caregiver.
family systems, object relations, and attachment Each attachment style found in children is cor-
theory. Hoffman, Cooper, and Powell have run a related with parenting response styles that pro-
clinical practice in Spokane, WA, for more than mote the child’s attachment to the caregiver.
30 years working with families and adult clients. Using the Circle of Security model, the primary
They have worked together for the last few belief around therapeutic change is that once the
decades converting research around attachment attachment style has been identified, parents are
styles in early parent-child relationships to provided with necessary skills and tools to assist
develop a treatment model meant to promote them in breaking adverse patterns that perpetuate
healthy attachment. insecure attachment styles in order to promote
more secure attachments with their children. Hoff-
man, Marvin, Cooper, and Powell (2006) created
Theoretical Framework their own video-based examples similar to
Ainsworth’s Strange Situation intervention.
As previously noted, Circle of Security is These videos are used for the education of parents
grounded within object relations and attachment on attachment styles to assist with identifying
theory. Originated by Bowlby and Ainsworth, their own interactions with their young children.
object relations and attachment theory reflect on Circle of Security aims to educate parents through
the development of one’s personality by exploring use of video education, individual consultation
the complex relationship between oneself and with clinicians, and group work to not only under-
others, particularly, how one becomes indepen- stand the principles of attachment theory, but also
dent from others while also having a profound to develop behavioral management strategies to
attachment to them (Bowlby, 1969). Ainsworth enhance a more secure attachment style. Much of
is known for her exploration and identification of this work is also done through the use of self-
attachment styles through her laboratory-based reflection steps that allow parents to explore the
observations of an infants’ response to the brief material and connect their parent-child interac-
separation and reunion with a parent called the tions with attachment styles.
Strange Situation (Ainsworth et al., 1978). Ains-
worth identified four basic attachment styles that
have been later linked to the development of Populations in Focus
adverse mental health issues later in life.
The first is a secure attachment, which is char- Previous research indicates that the Circle of
acterized by a child’s confidence in that their Security method mainly focuses on child
development concerning attachment within the distressed or seeking reconnection. As such, the
parent or caregiver-child relationship. Majority therapist helps increase the caregiver’s level of
of studies have focused on examining caregiver- sensitivity and responsiveness to the child’s sig-
child dyads including children who are at risk nals of need for soothing. An additional goal is to
for attachment issues because they are inse- increase caregiver empathy and ability to reflect
curely attached to their caregiver (Hoffman upon one’s own, as well as the child’s, behavior,
et al., 2006; Marvin et al., 2002; Fardoulys and thoughts, and feelings concerning attachment-
Coyne, 2016; Huber et al., 2016). Psychosocial related interactions. Lastly, the therapist helps to
factors related to insecure attachment have increase caregiver reflection regarding personal
included parent mental health problems, paren- developmental history that may be affecting pre-
tal divorce or separation, substance abuse by a sent caregiving behavior (Marvin et al., 2002;
family member, family violence or abuse, and Hoffman et al., 2006).
abuse or neglect of the children (Huber et al., The COS program typically lasts 20 weeks,
2016; Horton and Murray, 2015). Since attach- although a shortened 10-week version is avail-
ments develop early in life between children and able. As outlined by Marvin et al., (2002), and
caregivers, studies were mainly concerned with Fardoulys and Coyne (2016), the program
toddlers – or preschool-aged children. However, begins with a pre-intervention assessment
the age range for child participants across the using the Circle of Security Interview (COSI),
research spanned from as early as 11 months to which is semi-structured interview designed to
10 years of age. Parent and caregiver ages assess the caregiver’s internal working models
ranged from 16 to 55 years of age (Hoffman of self and child, developmental attachment his-
et al., 2006; Marvin et al., 2002; Fardoulys and tory, and to identify individual treatment goals
Coyne 2016; Horton and Murray 2015). The for each dyad. Based on Ainsworth’s infant sys-
Circle of Security-Parenting (COS-P) serves as tem (Ainsworth et al., 1978) and the adult clas-
the only group-based attachment program avail- sification, each dyad is coded as Secure/
able in a manualized, multilingual format Autonomous, Avoidant/Dismissing, Preoccu-
(Horton and Murray 2015). This program has pied/Ambivalent, Disorganized/Abdicating, or
been implemented in many countries such as the Insecure-Other/Unclassifiable. During the inter-
United States, Italy, New Zealand, and Ger- vention phase, the therapist meets with a group
many, which increases the model’s applicability of caregivers, once per week, to review edited
across cultures (Horton and Murray 2015; video-vignettes of caregiver-child interactions.
Pazzagli et al., 2014; Ramsauer et al., 2014; The meetings focus on caregiver education
Fardoulys, and Coyne 2016). regarding becoming the safe haven, increasing
caregiver sensitivity to meet their child’s attach-
ment needs, and the caregiver’s vulnerabilities
Strategies and Techniques Used in within the caregiver-child interactions. Con-
Model cepts unique to COS include “limited circles of
security,” or insecure interactions between the
The Circle of Security model utilizes a group caregiver and child, and “shark music,” or a
treatment modality, parent education, and psycho- caregiver’s vulnerabilities. Each week, one
therapy intervention to promote a healthy attach- dyad’s video interaction becomes the focus of
ment development process (Marvin et al., 2002; the group to allow for reflective dialogue. Four
Hoffman et al., 2006; Fardoulys, and Coyne vignettes are implemented to highlight the par-
2016). To achieve this goal, the protocol has sev- ent’s caregiving system, areas of struggle, suc-
eral main tenets. First, it is imperative to establish cessful moments with the child, as well as
the caregiver as a safe and secure base so that the celebrations of the parent-child relationship. At
child can feel comfortable exploring their envi- the conclusive sessions, the group reviews
ronment as well as returning to the caregiver when changes that have occurred within each
Circle of Security Parenting Enrichment Program 421
caregiver-child dyad. A post-intervention identified as securely attached; following the

assessment, consisting of caregiver rating scales intervention, 54% were classified as securely
and child and caregiver questionnaire data, is attached. In sum, such results are encouraging
implemented to demonstrate each dyad’s about the value of COS to improve attachment
changes from insecure patterns of attachment between caregiver and child. Limitations of this
to secure ones. study and several others examining the effective-
ness of the COS program are that there was no C
control group and the sample size was small (e.g.,
Research about the Model Marvin et al., 2002; Hoffman et al., 2006; Huber
et al., 2016; Fardoulys and Coyne 2016). More
Mercer (2015) conducted a literature review of studies are needed to demonstrate COS’s effec-
outcome studies and other reports which have tiveness compared to other parenting education
examined the effectiveness of the COS program. programs in improving the caregiver-child
The researcher reviewed 116 texts, which relationship.
included books, journal articles, and dissertations.
Following the review, Mercer concluded that the
COS program is an emerging treatment with much Case Example
promise. It was reported that the intervention is
theoretically sound given that it stands on well- Karen is a 34-year-old divorced, single mother
established principles of attachment theory, but with an 18-month-old daughter named Jessica.
that it cannot yet be considered an evidence- Karen entered into individual therapy due to her
based intervention, as more empirical studies struggle with recurrent bouts of depression. She
involving randomized controlled trials need to reported that she grew up in a volatile environ-
be conducted, particularly by independent ment in which her mother also struggled with
researchers without an allegiance to the develop- depression, and she characterized the relationship
ment of the model (Mercer 2015). between her and her mother as very distant. Fur-
In one study, Hoffman et al., (2006) examined thermore, she expressed that her mother was emo-
the effectiveness of the COS program with chil- tionally unavailable. Throughout treatment,
dren living within disadvantaged environments Karen vowed to be a much better parent than her
that put them at risk for mental health issues mother, but she was worried that her daughter
later in development. The study consisted of presented as withdrawn and shut down, which
65 parent-child dyads pooled from Head Start reminded her of how she presented when she
and Early Head Start programs, set in an average was a young girl. As a result, Karen’s therapist
sized city in the state of Washington. Approxi- recommended that she and her daughter enter into
mately 6–8 weeks before the intervention, the the COS program being held at a local community
participants underwent a pre-assessment phase, center. Karen agreed to participate.
in which the participants’ attachment patterns At the beginning of the COS program, Karen’s
were assessed using the Strange Situation Proce- psychosocial history, as well as her internal work-
dure and the Circle of Security Interview (COSI). ing model for herself and her child were gathered
The full 20-week COS intervention was using the Circle of Security Interview (COSI)
implemented with groups of five to six parents. (Hoffman et al., 2006). In addition, the interac-
The researchers found that prior to the interventions between Karen and Jessica were video
tion, 60% of the children fell into one of two of the recorded and assessed using the Strange Situation
high risk attachment classification groups: Procedure (Hoffman et al., 2006). During this
Disorganized-controlling or Insecure-other. How- procedure, the clinician noticed that Jessica
ever, after the intervention, only 25% of the chil- played with the toys in the room while Karen
dren fell into these two groups. Additionally, prior was present in the playroom. Karen was looking
to the intervention, 20% of the children were through her phone for much of the procedure, and
Jessica never cued her mother to become involved References

in her play. A stranger then entered the room, and
Karen was asked to leave. When this occurred, Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S.
(1978). Patterns of attachment: Psychological study of
Jessica stopped playing and she sobbed silently by
the Strange Situation. Hillsdale: Erlbaum.
the door. Karen then entered back into the room, Bowlby, J. (1969) 1982. Attachment and loss, Vol. 1:
and Jessica did not seek closeness with her Attachment. New York: Basic Books.
mother, rather she went back to playing, as if Fardoulys, C., & Coyne, J. (2016). Circle of security inter-
vention for parents of children with autism spectrum
using her explorative system to defend against
disorder. Australian and New Zealand Journal of Fam-
the excitation of her attachment system. Based ily Therapy, 37, 572–584. https://doi.org/10.1002/
upon this dynamic, it was determined that Jessica anzf.1193.
exhibited an Insecure-Avoidant attachment style. Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B.
(2006). Changing toddlers’ and preschoolers’ attach-
To follow, Karen was shown the video record-
ment classifications: The circle of security intervention.
ing, and she was provided psychoeducation on Journal of Consulting and Clinical Psychology, 74(6),
attachment theory. In addition, she was informed 1017–1026. https://doi.org/10.1037/0022-006X.74.6.
that Jessica exhibited Insecure-Avoidant attach- 1017.
Horton, E., & Murray, C. (2015). A quantitative explor-
ment characteristics. The clinician explained to
atory evaluation of the circle of security-parenting pro-
Karen that it is important that she show an inter- gram with mothers in residential substance-abuse
est in Jessica’s play activity and praise the crea- treatment. Infant Mental Health Journal, 320–336.
tivity exhibited within her play. In addition, https://doi.org/10.1002/imhj.21514.
Huber, A., McMahon, C., & Sweller, N. (2016). Improved
Karen was informed that Jessica may often mis-
parental emotional functioning after circle of security
cue that she does not need her mother by playing 20-week parent-child relationship intervention. Jour-
or exploring independently when the mother nal of Child and Family Studies, 25, 2526–2540.
returns to the room following a separation, but https://doi.org/10.1007/s10826-016-0426-5.
Keen, D., Couzens, D., Muspratt, S., & Rodger, S. (2010).
that this is often a self-protective behavior due to
The effects of parent-focused intervention for children
a concern that she may not receive the emotional with a recent diagnosis of autism spectrum disorder on
responsiveness that she seeks. This explanation parenting stress and competence. Research in Autism
resonated with Karen, as she reported often feel- spectrum disorders, 4, 229–241. https://doi.org/
10.1016/j.rasd.2009.09.009.
ing this way with her own mother. By the end of
Lindquist, T. G., & Watkins, K. L. (2014). Modern
the program, Jessica appeared a lot less with- approaches to modern challenges: A review of widely
drawn, evidenced by her tendency to smile used parenting programs. The Journal of Individual
more and reach for her mother when there was Psychology, 70(2), 148–165. https://doi.org/10.1353/
jip.2014.0013.
a separation of some kind. Jessica appeared more
Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002).
securely attached, and Karen exhibited fewer The circle of security project: Attachment-based inter-
depressive symptoms, as she felt like a more vention with caregiver-pre-school child dyads. Attach-
competent parent. ment and Human Development, 4(1), 107–124. https://
doi.org/10.1080/14616730210131635.
Meirsschaut, M., Roeyers, H., & Warreyn, P. (2010). Par-
enting in families with a child with autism spectrum
disorder and a typically developing child: Mother’s
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▶ Attachment Theory research and theory. Research on Social Work Practice,
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▶ Bowlby, John Neece, C. L., Green, S. A., & Baker, B. L. (2012). Parent-
ing stress and child behavior problems: A transactional
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▶ Object Relations Family Therapy tual and Developmental Disabilities, 117(1), 48–66.
▶ Object Relations Couple Therapy https://doi.org/10.1352/1944-7558-117.1.48.
Circle of Security: “Understanding Attachment in Couples and Families” 423
Pazzagli, C., Laghezza, L., Manaresi, F., Mazzeschi, C., & Attachment relationships develop from birth, and
Powell, B. (2014). The circle of security parenting and these early care experiences with primary care-
parental conflict: A single case study. Frontiers in
Psychology, 1–9. https://doi.org/10.3389/fpsyg.2014. givers shape one’s responses to important rela-
00887. tionships throughout the lifespan. As attachment
Ramsauer, B., Lotzin, A., Muhlhan, C., Romer, G., theorist and clinician John Bowlby (1953)
Nolte, T., Fonagy, P., & Powell, B. (2014). envisioned more than 50 years ago, children cre-
A randomized controlled trial comparing circle of secu-
rity intervention and treatment as usual as interventions ate internal working models of themselves and of C
to increase attachment security in infants of mentally ill the people in their closest relationships. Bowlby
others: study protocol. BMC Psychiatry, 1–11. http:// argued that patterns of attachment in childhood
www.biomedcentral.com/1471-244X/14/24. profoundly impacted the psychological develop-
ment and capacity for intimate relationships from
the cradle to the grave.
The Circle of Security provides a way to under-
Circle of Security: stand the complexity of the attachment system
“Understanding Attachment (Powell et al. 2014). The Circle of Security is
in Couples and Families” designed to enhance one’s ability to promote
safety and well-being in relationships. This entry
Deidre Quinlan1, Mary Ann Marchel2, Glen
describes an approach to understanding and
Cooper3, Kent Hoffman3 and Bert Powell3
1 applying attachment theory in couple and family
Circle of Security International, Duluth,
relationships by using the conceptual framework
MN, USA
2 of the Circle of Security including the Circle of
College of St. Scholastica, Duluth, MN, USA
3 Security graphic to understand the attachment
Circle of Security International, Spokane,
system, “being with” as a way to conceptualize
WA, USA
co-regulation, and “shark music” to bring into
awareness the adult state of mind.
No variables have more far reaching effects on

personality development than a child’s experiences Theoretical Context for Concept
within the family. Starting during his first months in
his relations to both parents, he builds up internal Attachment theory combined with research on brain
working models of how attachment figures are
likely to behave towards him in any of a variety of development (Schore and Schore 2008) and trauma
situations, and on all those models are based all his (van der Kolk 2005) is now the dominant theory of
expectations, and therefore, all his plans, for the rest child development (Schaffer 2004). Through this
of his life. lens comes understanding about what it means to be
John Bowlby (1973), Attachment and Loss
a person in relationship. Attachment theory sug-
gests development is linear, directional, and cumu-
lative, that there are sensitive periods in human
Name of Concept development, that change becomes increasingly
difficult the longer the pathway is followed
Attachment and Circle of Security (Sroufe 2005), and that what comes first builds the
foundation for all that comes later.
According to Bowlby (1969), attachment is a
Introduction motivational behavioral system with the pur-
pose of regulating proximity to an attachment
Attachment plays a powerful role in shaping fam- figure. The attachment system includes both
ilies and intimate relationships and in determining exploration, where the function is for learning,
the emotional health of the developing child. and protection, where the function is for safety.
424 Circle of Security: “Understanding Attachment in Couples and Families”
The third part of the attachment system is the for proximity and follows the child’s need for
parent system. protection, comfort, and delight and/or helps
Specifically, the Circle of Security graphic organizing feelings.
depicts the three main pillars of attachment theory The components of the Circle of Security
as follows: (a) the hands, which represent the care- graphic are rooted in early attachment-based
giving system (attachment figure); (b) the top of the research (Bowlby 1969) and include the research
Circle, which represents the exploratory system; of Mary Ainsworth. In the 1960s, Ainsworth
and (c) the bottom of the Circle, which represents developed a technique called the strange situation
the care seeking system (Powell et al. 2014). (Ainsworth et al. 1978). The strange situation is
In Circle of Security, the hands on the graphic used to systematically measure the quality of
represent the parent’s role in providing a secure attachment relationships. This added to the
base from which the child can explore and a safe mounting evidence of the importance of the
haven to which the child can return. In other attachment system in understanding child devel-
words, the parent is an attachment figure. To be opment. While Ainsworth et al.’s (1978) classifi-
effective as an attachment figure, parents must cation system captured secure and insecure
demonstrate that they possess the strength, attachment strategies in dyads, there remained an
wisdom, and care to protect children from the unclassified group whose behaviors could not be
fear of real or imagined dangers. categorized. Main and Solomon (1986) later clas-
With the hands of the parent providing a secure sified these outlying cases, further adding to the
base, children have a sense that their parent is field of attachment with their work on disorga-
supporting their exploration and allowing curios- nized attachment and later the Adult Attachment
ity. This is an important role because parents act as Interview (Main et al. 1985). Main and Solomon
a model for what is safe or dangerous. Children (1986) introduced a fourth classification: disorga-
depend on their parents to protect them while they nized. What follows is a description of secure,
explore; they also watch to see if their parent is insecure, and disorganized attachment.
paying attention to them for that needed protec-
tion. Parents are sometimes surprised to learn that Secure Attachment
their children need them just as much when they Secure attachment relationships help to carry chil-
are out exploring as they do when they are in their dren along a healthy developmental path and into
parent’s lap. As children get older, they can travel adulthood (Bowlby 1969). Security is achieved
farther and stay away longer. when the parent repeatedly assists the infant in
The top half of the Circle of Security graphic coping constructively with negative emotions,
represents children’s needs when their exploratory remains engaged during times of need, provides
system is activated. These needs are met if the the necessary co-regulation, and transforms the
parent supports the child’s bid for exploration and infant’s dysregulated feelings into tolerable emo-
watches over, delights, helps, and enjoys the tions (Sroufe 1977). Key caregiver behaviors
child. Over time, children remember what parents include sensitivity to the infant’s cues, responsive-
have indicated is safe and what is dangerous. ness, as well as physical and psychological avail-
When children have explored long enough and ability (Ainsworth et al. 1978). In Ainsworth’s
become tired, frightened, or uncomfortable, they strange situation, about 60% of dyads are secure.
have a new set of needs that require a response Over time, the attachment strengthens between
from the parent. The bottom half of the Circle of parent and infant, creating a connection that is so
Security graphic represents children’s needs when enduring it can never be circumvented. With this
their attachment system is activated. Unless they security, the developing child thrives and, using
are very frightened, the first thing children need this internal working model, goes on to form
after this system is triggered is a sign that they are secure bonds in other primary relationships later
welcome to come back to the parent. These needs in life. With confidence, secure individuals move
are met if the parent both welcomes the child’s bid through life’s experiences believing that when
they struggle there is that special someone they for comfort. Based on a history of unresponsive
can turn to for support. There is a direct and clear care, anxious-avoidant children struggle to find or
path toward resolution of the struggle. seek comfort from relationships when distressed,
are unsure about parent availability, and feel
Insecure Attachment unworthy of love or comfort (Ainsworth
According to attachment theory, children are et al. 1978).
likely to develop maladaptive social behaviors C
when the environment they are raised in deviates Disorganized Attachment
from what is considered evolutionarily adaptive, Infants form attachments when there is a consis-
or “normal” (Bowlby 1969). Since infants cannot tent parent to interact with repeatedly over time,
control the relationship capacities of the parent, regardless of the quality of the interaction. For
they must learn to adapt in order to survive. To both secure and insecure attachment, repeated
that end, human beings either feel secure because daily interactions provide memories that organize
they are able to experience secure attachment into an internal working model of predictable
relationships or insecure/disorganized because of relationship strategies to attempt in times of
the specific ways needed security in relationship need. These strategies make sense and, for better
goes unmet. or for worse, get the job done.
With insecure attachment, there is a direct and For the disorganized child, there is no clear
clear path toward resolution of the struggle, but it path, and relationships are not predictable. Disor-
comes at a cost. Children learn to attend to both ganized attachment is the irresolvable paradox
their need for security and their parent’s tendency that occurs when the parent is both the source of
to respond to that need (Powell et al. 2014). Chil- the child’s fear and the haven for the child’s safety
dren become exquisitely sensitive to which (Main and Solomon 1986). When the disorga-
behaviors they can display to their parent and nized child’s attachment system is activated, the
which behaviors they need to limit or avoid brain signals the attachment system to seek prox-
showing. imity, but if the parent is the source of the fear
Ainsworth et al.’s (1978) classification system where does the infant turn? Disorganized infants
contains two categories of insecure attachment: anx- fear the parent that they rely on for protection and
ious resistant and anxious avoidant. Children with thus face fear without a solution (Cassidy and
an anxious-resistant attachment style struggle with Mohr 2001). Because infants are biologically
relationships because they seek separation from the wired to seek proximity, fear leaves the attach-
parent when their exploratory system is activated; ment system unresolved. Fear short circuits the
however, the exploration is distressing to the parent brain, and the parts of the brain that evaluate
who, in an effort to stay in the relationship, pulls the situations in a logical way tend to shut down
child too close. Based on a history of inconsistent (Perry and Szalavitz 2009).
care, anxious-resistant children show signs of frus- Children with disorganized attachment are
tration regarding contact when distressed, have dif- chronically afraid, always on the verge of losing
ficulty separating, and cannot be reassured by the emotional and/or behavioral control, and have
presence of a parent. difficulty using another as a trustworthy resource.
When the anxious-avoidant child’s attachment Children who experience maltreatment, abuse, or
system is activated and the child seeks proximity neglect, who are left alone without adequate
to the parent, the attachment need in the child supervision, whose parents are involved in sub-
signals distress in the parent, and the parent stance abuse and the criminal justice system, who
pushes the child away in order to stay in relation- are mentally ill, or those whose parent faces
ship. If the parent’s early experience of needing unresolved loss or trauma are at risk of disorgani-
comfort was rejection, then the parent’s response zation (van Ijzendoorn 1999). In addition, parents
will be influenced by his/her unconscious proce- who experience their infant’s distress as a threat
dure for avoiding rejection by denying the need are vulnerable to create disorganized attachments.
Adult Attachment and State of Mind include intellectualization or idealization of their

Bowlby’s attachment work was primarily concen- early relationships, maintenance of a dismissing
trated on understanding the essence of the infant- stance, and avoidance of closeness when under
caregiver relationship. However, he believed stress. In a clinical relationship, a dismissive client
tenets of attachment theory were applicable to may “feel” difficult to connect with, evoking little
the human experience from the cradle to the emotional response.
grave. A central hypothesis of adult attachment Anxious-preoccupied attachment styles are
theory is that the caregiver’s mental representa- characterized by an intense neediness with a
tions (or state of mind) are an important predictor strong orientation toward relationship. Anxious-
of infant’s quality of attachment (Main et al. preoccupied attachment styles are often marked
1985). That is, patterns of responsiveness in care- by strong emotions, but because there is an inef-
giving are transmitted across generations. ficiency to their use of the relationship experience,
The adult measures of attachment focus on they are often misunderstood. Anxious and imma-
state of mind, as examined through structured ture features serve as barriers to full access of the
interviews (the Adult Attachment Interview, “other” as a relational partner. As stated,
George et al. (1984, 1985, 1986); Q-sorts dismissive-avoidant and anxious-preoccupied
(Kobak 1989); and questionnaires (Hazan and adult attachment styles are considered organized
Shaver 1987; Collins and Reed 1990). Study of approaches to negotiating relationships with part-
adult attachment has identified four styles: secure ners. There is observed predictability, though less
autonomous, dismissive avoidant, anxious preoc- than optimal, in relational behaviors.
cupied, and unresolved. These roughly corre- This is not the case in the unresolved/disorga-
spond to infant classifications: secure, anxious nized attachment style, an observed orientation
resistant, anxious avoidant, and disorganized. emerging from Adult Attachment Interview
Similar to Ainsworth’s (1978) infant classifi- (AAI; George et al. 1984, 1985, 1986) when a
cation system, adult attachment styles are rooted subset of transcripts include narratives that are
in the idea that fear is the driving, organizational deemed “unclassifiable” (Hesse 1999). Features
force behind the search for safety and security. of the disorganized attachment style include the
Separation is inherently threatening; hence, in speaker’s inability to make sense of their experi-
the ideal course of events, threats lead to reunion ences or establish coherence across the interview.
and a return to normal functioning. Stories are fragmented, and there is difficulty in
In concordance with adult attachment styles clarity of expression.
schema, there are individual differences with As partners or caregivers, those experiencing
regard to how adults “make meaning” of and an unresolved/disorganized attachment style may
navigate relationship. For example, in those rela- demonstrate unpredictable, confusing, or erratic
tionships considered secure autonomous, there is behaviors surrounding relationship. State of mind
a held expectation that their partners will be there rests on being frightened, constantly operating out
in times of need. Further, there is an openness to a fight, flight, or freeze response in the face of
depending upon “the other” and reciprocation of perceived stress. Difficulty in trusting the “other”
support for their partner. results in struggles in successful intimate
In contrast to secure relationships, some adults relationships.
appear insecure in their relationships, demonstrat-
ing dismissive-avoidant or anxious-preoccupied
attachment styles. While both dismissive- Description
avoidant and anxious-preoccupied attachment
styles are considered to include “organized” strat- Attachment in Adult Romantic Relationships
egies of maintaining the relationship, the inherent The notion of attachment as a lifelong process was
efficiency and effectiveness are less than optimal. extended to adult romantic relationships in the late
Hallmarks of the dismissive-avoidant style 1980s. Parallel to infant and caregiver attachment
relationships, Hazan and Shaver (1987) propose successful close relationships that comes with
that adults in romantic relationships (a) feel safety reflection. Can you think of someone who will
when in close proximity to their partner; only rely on themselves to solve problems or
(b) experience feelings of insecurity when the always relies on someone else? Or someone that
other is inaccessible; (c) enjoy shared exploration must always manage feelings on their own or that
and discovery with one another; (d) seek close, cannot manage their own feelings and must
intimate, physical contact; and (e) engage in always look for someone else to take care of C
“baby talk.” their problems? Adults with a history of relation-
When using the Circle of Security graphic to ship needs on the Circle that went unmet need
look at adult intimate relationships, the couple supportive hands (like a therapist or partner)
shifts roles between being the hands for the other who can be with them and provide a secure base/
to being on the Circle needing hands, depending safe haven. Access to supportive hands promotes
on who has the need and who is able to provide the exploration and reflection on these childhood
needed support in the moment. Secure adult rela- struggles that interfere with their current capacity
tionships require both to participate in fulfilling to be in relationship and to parent their children.
each other’s needs for exploration and for Couples also need a coherent roadmap to begin
connection. to understand relationship struggles. For many
At the heart of secure attachment in couples is adults, knowing that they do not want to replicate
the knowledge that partners are emotionally avail- their experiences as a child is positive but only
able to each other and will remain emotionally tells them what not to do. When someone only
present during times of need. Daniel Stern knows what they do not want to do, the pendulum
(1985) calls this “being with” which is a key tends to swing too far in the other direction. The
concept used in Circle of Security. During Circle of Security graphic illustrates children’s
infancy, people learn how to self-regulate through needs in primary relationships. Understanding
repeated predictable and consistent experiences of relationship needs helps couples use the graphic
“being with,” or co-regulation, with a parent. to see where they were struggling as children and
Within these repeated secure experiences, infants to reflect on how those struggles manifest in cur-
are learning what it means to be a person in rent relationships. With reflection comes choice.
relationship – that they are valued, that they are In the attachment literature, a secure state of
worthy, and that there is at least one person in the mind is measured by the capacity of the person to
world who understands them and what they need. hold the good and bad of the story without getting
A partner’s capacity for “being with” is developed lost in the telling of the story and without getting
in these early foundational experiences of dismissive of the importance of the impact of the
co-regulation. details of the story (Main and Solomon 1986). The
Circle of Security is designed to help individuals
derive clarity on their state of mind struggles that
Application of Concept in Couple and evoke uncomfortable feelings and are met with a
Family Therapy need to self-protect. These struggles are referred
to as “shark music” (Powell et al. 2014). Shark
In family therapy, helping parents learn to track music occurs when one’s partner’s need (or your
their own process by enhancing their power of child’s) on the Circle requires a response that is
reflection is at the heart of the Circle of Security safe but feels uncomfortable (even dangerous).
(Powell et al. 2014). Much of the success in the One suddenly feels uncomfortable – lonely,
relationship depends on the individual’s capacity unsafe, rejected, helpless, abandoned, angry, and
to reflect on self-held strengths and struggles, to controlled (Hoffman et al. 2017).
recognize when there is a rupture, and to make Using the Circle of Security graphic, under-
repair. Knowing when to support yourself and standing where shark music shows up on the
when to accept help is an essential skill of Circle and then having someone “be with” you
to help reflect on your strengths and struggles can dangerous, their support for exploration is limited.
be organized and provide a way to bring clarity to There are a number of responses depending on
an experience that before had no access to words their partner’s own relational history, including
to describe (Powell et al. 2014). Attachment hiding their need to explore by acting like they
research shows that as coherence increases, secu- need closeness, comfort, or protection; acting pas-
rity increases (Main and Solomon 1986). The sive/aggressive, angry, and hostile; and/or
Circle of Security helps build coherence, as it appearing helpless, needy, and clingy.
provides opportunity for the telling of the story Like support for exploration, a partner’s sense
in an organized way and brings to the conscious that they are “welcome to come back in” on the
awareness patterns of behavior that before went bottom of the Circle is a combination of a partner’s
unknown. own comfort level with closeness as well as what
When using the Circle of Security, the goal is not is happening in the moment. If a person expresses
to find problems. Rather, it is to discover those a basic need for comfort, and their partner’s early
places on the Circle where one finds themselves experience of needing comfort was rejection, then
feeling anxious (shark music) or on the way to the partner’s response will be influenced by their
anxious (Hoffman et al. 2017). Adults with histories unconscious procedure for avoiding rejection by
of insecure attachment often grow up to struggle as denying the need for comfort. In these relation-
partners and/or parents with the same relationship ships, partners learn that emotional or physical
needs on the Circle that went unmet as a child. closeness, or needing comfort, is unacceptable,
Children need to know that adults are in charge and they may hide their need to seek closeness
and appreciate the sense of safety that comes from by acting like they want to explore or be distant;
knowing this. With partners, however, there is they may distract from their partner’s need for
turn-taking being bigger, stronger, wiser, and closeness.
kind on the Circle which means that whoever is
the most able to respond to the needs in the
moment must be the hands. But many people Clinical Example: Shondra and Aidan
struggle here for a variety of reasons. They over-
emphasize one aspect of being bigger, stronger, The Circle of Security can be used specifically for
wiser, and kind while at the same time underem- couple therapy, while other times therapists can
phasize another aspect. If someone is perceived as use the Circle to focus on families. The Circle of
mean rather than kind, or weak rather than strong, Security also helps to see the parallel process of
they become frightening to the partner. Everyone attachment relationships. In this case example, the
has an innate wisdom to run away from what is overlap of working with the parent/child relation-
frightening and to run to their attachment figure ship and partner relationship is apparent.
for security. For children, if a parent is the source
of both the fear and protection, there is no solution Family (Parent and Child) Therapy
(Cassidy and Mohr 2001). This is true for adults as Shondra first came for family therapy because of
well and may leave them with a diminished capac- concerns about the escalating behavior of her
ity to see their partner as a resource. Not surpris- 3-year-old daughter. She was biting, refusing to
ingly, young children who learn that relationships go to bed, having excessive tantrums, and running
are not trustworthy grow up to struggle with adult away from her caregivers at every opportunity.
relationships. Shondra was afraid to take her anywhere and
On the top of the Circle, “support for explora- instead just stayed home. The parents were
tion” is often a combination of the partner’s own disagreeing over how to handle the situation. Con-
comfort level with separation, as well as what is flict in the marriage was escalating, and Shondra
happening in the moment. If a partner is inconsis- and the child’s father, Aidan, had recently sepa-
tently available, uncomfortable with separation, rated. Aidan is unwilling at this time to participate
needs to be needed, or sees the world as too in the family therapy.
During the family history intake, Shondra The next week Shondra begins the session by
described her own mother as mean and gave an sharing she has decided that she needs to make
example of how, as a child, every day when she changes on her own and quit waiting around for
left for school her mom would be angry with her and her husband. She has been thinking more about
make her feel awful. The therapist asked Shondra bigger and stronger and being the hands. Her
what it would be like for her now if her mom had reflection has led her to realize that her fear of
been more kind to her, if her mom would have been being alone has kept her with her husband. She C
able to “be with” her when she was a little girl. decided to take charge and told Aidan that she
Shondra then began to cry and spoke about how wants him to either participate with her in therapy
she has always had to hold in her tears, how she or leave the marriage. She states that she is not
always feels like crying, but never acts on it because acting like “the parent” when she keeps looking
(as a child) when she cried her mom would get for someone else to be in charge. She concludes
mean. “Mean” meant that her mom would make that she has to be the hands and take charge. She
her get a mirror and look at herself. As she looked talks more about how she has been scared of her
into the mirror, her mother would tell her to stop daughter, scared she is “not gonna like me.” She
crying and to control her feelings. As she shared this tearfully shares her realization that they are afraid
memory, Shondra had a moment of reflection where of each other.
she realized she is doing this to her own child. She is Shondra returns the next week excited to
afraid of any intense feelings that her daughter share another story about taking charge. She
shows, such as anger, and is afraid her daughter had been to the doctor and was told the pacifier
will not love her. In response, she consistently had to go because her daughter’s teeth were
pushes her daughter to show her a “happy face” bucking out. She said, “I knew her having the
and to push away other feelings. nook was a me thing, and not a her thing. I was
In the next weekly session, the hands on the letting her stuff her feelings by offering her a
Circle are more deeply explored. Shondra is asked nook when she was stressed or upset, I used it to
to think about bigger and stronger and, when she shut her up so I didn’t have to comfort her and
gets weak, to reflect on what stops her from being organize her feelings. I would just put the nook
bigger and stronger. She returns the following in her mouth, but what she really needs is for me
week excited to share that she figured out where to be with her and help her figure it out
she hears shark music around her own fear of together.” She shares how she made a plan
being alone. She believes that this gets in her with her daughter to give the nook to a younger
way of being the parent. She shares that this also infant at the child care center. After that, her
serves as a barrier to greater intimacy in her rela- daughter asked a few times to go in and see the
tionship with her husband. She describes a fight baby, but otherwise she is doing okay with the
they once had, which included yelling and calling change. The therapist shares that children really
each other names. It started in the car with their want adults to take charge and how her daughter
daughter in the back in a car seat. Her husband feels safe to know that her mom is in charge.
dragged Shondra out of the car and across the During the next session, Shondra talks about
lawn. A neighbor witnessed the incident and going to a playgroup and problems with her daugh-
called the police. When the police came, Shondra ter running all around the room acting out of con-
denied it happened to protect her husband. She trol. When it is time to leave, her daughter takes off
wonders out loud about why she protected him. and runs around. The therapist talks about her
She reflects that at the time she was more daughter’s emotional cup being empty and her
concerned at that moment that Aidan might hyperactivity being less about exploration on the
leave her. She did not think about her daughter top and more about the bottom of the circle and her
and what it was like for her. She sees how this left need to reconnect with her mom. The next week
her daughter with no hands when she was fright- Shondra shares how she has started to enter the
ened. She lowers her head and cries silently. playgroup space and sit for a few minutes with her
daughter before she takes her out to find her shoes. cost to the relationship with his wife. As a hus-
She makes a point to connect with eye contact, a band, he sees how he responds to his wife with
smile, and a hug. She says this has made a huge anger – by sometimes criticizing, sometimes
difference. Her daughter is more calm and cooper- blaming, sometimes threatening, but always
ative. She reports it takes longer up front, but it is pushing her away from her need for connection.
faster than later chasing her all over. In turn, he also pushed away his own possibility
for connection. They leave the session with
Couples (Wife and Husband) Therapy newfound empathy for each other and hopeful
The following week both Shondra and Aidan for change.
arrive for family therapy. Shondra starts
discussing her fear of abandonment, her worry
that he might actually leave her, and how she has Cross-References
struggled for closeness in their relationship. She
shares more about her childhood relationships, ▶ Adult Attachment Interview
and how when she was distressed, her mother ▶ Attachment Disorders in Couple and Family
would embarrass her and try to talk her out of Therapy
her feelings. She recounts how her mother would ▶ Attachment-Based Family Therapy
tell her that if she could not manage these small ▶ Circle of Security
struggles, she would never be able to manage the ▶ Object Relations Couple Therapy
big things that life brings. Shondra reflects further
and shares that it really was because her mother
could not handle her own feelings and, as a result, References
neither can she. She learned that struggles had to
be really big before her mother would be with her Ainsworth, M. D., Blehar, M., Waters, E., & Wall,
on the bottom of the circle. Shondra starts to see S. (1978). Patterns of attachment: A psychological
study of the strange situation. Hillsdale: Lawrence
how she is doing the same now in her relationship Erlbaum Associates.
with her husband. Bowlby, J. (1953). Child care and the growth of love.
Aidan listens and softens his tone. He realizes London: Penguin Books.
how mad he has been at his wife and talks about Bowlby, J. (1969). Attachment and loss. Vol. 1. Attachment.
London: Hogarth.
how Shondra reminds him of his mother, who he Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation.
experienced as yelling and blaming him for every- New York: Basic Books.
thing. He remembers how he was embarrassed by Cassidy, J., & Mohr, J. (2001). Unsolvable fear, trauma,
his mother every time something went wrong. and psychopathology: theory, research, and clinical
considerations related to disorganized attachment
Hence, he learned that he must never make mistakes across the life span. Clinical Psychology: Science and
to avoid feeling ridiculed. No matter how hard he Practice, 8, 275–298.
tried, she was never satisfied and always Collins, N., & Read, S. (1990). Adult attachment relation-
complained. Shondra hears his story and recognizes ships, working models and relationship quality in dat-
ing couples. Journal of Personality and Social
the familiar pattern they are in together – she gets Psychology, 58, 644–683.
needy, he takes over, she blames, he ignores, she George, C., Kaplan, N., & Main, M. (1984, 1985, 1996).
protests more, he withdraws, she yells louder, he Adult attachment interview protocol. Unpublished
explodes. manuscript, University of California at Berkeley.
Hazan, C., & Shaver, P. R. (1987). Romantic love concep-
The therapist asks Aidan how his life might tualized as an attachment process. Journal of Person-
be different today had he been able to turn to his ality and Social Psychology, 52(3), 511–524.
mom when he struggled. He begins to see how Hesse, E. (1999). The adult attachment interview: Histor-
his behavior is a form of self-protection as he ical and current perspectives. In J. Cassidy & P. R.
Shaver (Eds.), Handbook of attachment
works to stay away from the painful memories (pp. 395–433). New York: Guilford Press.
of feeling alone in his pain, away from the Hoffman, K., Cooper, G., & Powell, B. (2017). Raising a
bottom of the circle, even if it comes at a high secure child: How circle of security parenting can help
Circular Causality in Family Systems Theory 431
you nurture your child’s attachment, emotional resil- Synonyms

ience, and freedom to explore. New York: Guilford
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Kobak, R. (1989). The attachment interview q-sort. Uni- Circularity; Mutual causality; Pseudo-feedback;
versity of Delaware: Unpublished manuscript. Reciprocal causality; Reciprocity; Recursive
Main, M., & Solomon, J. (1986). Discovery of an insecure relationship
disoriented attachment pattern: Procedures, findings
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opment in infancy. Norwood: Ablex. Introduction
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in
infancy, childhood, and adulthood: A move to the level Circular causality is a concept that creates a shift in
of representation. Monographs of the Society for
Research in Child Development, 50(1–2., Serial how we understand interactions. Traditionally, a
No. 209), 66–104. linear continuum consisted of a definitive start and
Perry, B., & Szalavitz, M. (2009). Born for Love: Why end point where family issues were thought to be
empathy is Essential – and Endangered. New York: rooted to a singular cause. The concept of circular
Harper Collins.
Powell, B., Cooper, G., Hoffman, K., & Marvin, B. (2014). causality helps to move away from the traditional
Circle of security intervention: Enhancing attachments way of viewing interactions to a more relational
in early parent child relationships. New York: Guilford context focusing on the interactions between two
Press. events.
Schaffer, H. R. (2004). Introducing child psychology.
Oxford: Blackwell. Circular causality focuses on the reciprocal rela-
Schore, J. R., & Schore, A. N. (2008). Modern attachment tionship between two events. The perspective of
theory: The central role of affect regulation in develop- reciprocal relationships stems from the foundations
ment and treatment. Clinical Social Work Journal, 36, of cybernetics, which refers to the regulatory action
9–20.
Sroufe, L. A. (1977). Attachment as an organizational where one part of the system impacts another.
construct. Child Development, 48, 1184–1199. A reciprocal perspective moves away from the
Sroufe, L. A. (2005). Attachment and development: A mechanical way of viewing systems
prospective, longitudinal study from birth to adulthood. (individualistic) toward a relational viewpoint with
Attachment and Human Development, 7, 349–367.
Stern, D. N. (1985). Interpersonal world of the infant: a focus on interactional patterns between contextual
A view from psychoanalysis and developmental psy- factors that exist within families. The shift in con-
chology. New York: Basic Books. ceptualization creates a circular process in which
van der Kolk, B. (2005). Developmental trauma disorder: one part of the system influences other parts.
Toward a rational diagnosis for children with complex
trauma histories. Psychiatric Annals, 35(5), 401–408. The purpose of circular thinking is to understand
van Ijzendoorn, M. (1999). Disorganized attachment in the impact that the internal and external factors have
early childhood: Meta-analysis of precursors, concom- on the family system. The expansion of thinking
itants, and sequelae. Development and Psychopathol- results in a shift that dramatically influences the
ogy, 11(2), 225–249.
conceptualization of presenting problems. The
shift from linear to circular thinking resulted in no
longer focusing solely on past events to discover
root causes. Rather, in conceptualizing through the
Circular Causality in Family expanded perspective, it is evident that the regula-
Systems Theory tory systems are continually evolving, while being
impacted by other factors within the family system.
Lisa Kelledy and Brandon Lyons
Northcentral University, San Diego, CA, USA
Name of Theory The prominent figures associated with circular

causality include Gregory Bateson and Norbert
Circular Causality Wiener. Wiener was the creator of cybernetics
432 Circular Causality in Family Systems Theory
from which circular causality was born. Bateson rather attention was given to the processes that
built upon Wiener’s work by introducing the gave meaning to the presented events.
concepts of first- and second-order cybernetics. By altering the conceptualization of how a
system interacts (individualistic to systemic), the
focus shifts toward the role of each part of the
Description system. Each person shares in the responsibility
for the construction of the relationship, forming a
Circular causality is a central tenet of family recursive process where each person equally
systems theory. Family systems thinking has impacts the interactions with the other. Viewing
shifted issues within the family system from the system alteration in this way, the distinction
a distinctive cause-and-effect outcome to one between cause and effect and mutual influence
of mutual influence creating an interactional becomes visible. The distinction assists in helping
pattern. Circular causality is known as a holistic one understand that patterns are shared and con-
type of thinking that involves patterns, rules, and stantly evolving. The evolution of these interac-
interconnections within a system (Sholevar and tional patterns highlights the distinct differences
Schwoeri 2003). Holistic thinking extends and eliminates the notion that there is a primary
beyond a linear cause-and-effect relationship by root cause for the relationship disturbance.
taking a more in-depth look into the interactional Instead, relationships become a shared process
patterns that emerge and how they influence the influenced by both individuals as well as mutually
functioning of the family system. influencing factors.
Looking at the functioning of a family system
from a systemic point of view, we start with
the origin of the theory. The term systems theory Relevance to Couple and Family Therapy
is found in the underpinnings of cybernetics, orig-
inating from the work of Norbert Wiener and Circular causality provides a foundation and a
Gregory Bateson. Wiener and Bateson challenged framework in couple and family therapy. As a
the epistemological view that there is a definitive systems therapist adopts the circular causality
root cause to any problem. Their objection to the framework, the underpinnings of relationships
cause-and-effect viewpoint led to what is known and patterns that are simultaneously influenced
today as systems theory or general systems theory. by one another begin to emerge. For the field
The development of cybernetics challenged the of couple and family therapy, the framework of
notion of an absolute truth (i.e., A leads to B, these patterns provides a structure of thinking
which leads to C) and provided an alternative about clients in a manner that encourages a holis-
view where conceptualizing the family system is tic assessment of the presenting problems. The
both recursive and reciprocal (Bateson and structure removes the pathology of linear causal-
Donaldson 1991). The recursive action generated ity and creates space for a relational assessment
the family systems theory that the relationship that considers the entire couple/family system.
between two things have mutual influence upon The notion of circular causation is a recursive
each other rather than a cause-and-effect relation- formation. No single event is independent of
ship between two things (Bateson and Donaldson another. When one part of the system is impacted,
1991). The systems theory/cybernetics perspec- the influence on another event, or series of events,
tive shifted away from thinking about why some- creates a recursive interaction in which neither
thing happens toward what is happening within event is mutually exclusive. Understanding rela-
the family system (Becvar and Becvar 1982). The tionship systems in this manner allows the client’s
shift in epistemology led to the development of a concerns to be seen as having a relational impact
systemic framework known as circular causality. in which all parts of the system are influencing the
The focus was no longer on the linear causality, other.
Circular Causality in Family Systems Theory 433
Clinical Example of Application of by Sara as dismissive of her feelings as evidenced

Theory in Couples and Families by the way in which John constantly reminds
Sara that she is wrong to feel the way that she
Circular causality is an important consideration has expressed. As the interactional pattern
for working with couples and families. The con- emerges, Sara indicates finding it easier to not
tent of what the clients may bring to therapy will engage with John by remaining silent. The couple
not be linear. Consider the two descriptions below has maintained the same interactive pattern C
to gain an understanding of how linear and circu- of “demanding” and “dismissiveness” for the
lar causality differ from one another. majority of their 20-year marriage. However, as
Using an example of a linear perspective, a their daughter is preparing to transition into col-
husband and wife present in therapy with what lege, Sara realizes that she does not want to con-
they identified as “communication issues.” The tinue in their relationship in the same manner.
therapist begins to ask questions that focus on Sara’s goal for therapy is to find her voice in
the why the communication pattern persists. the marital relationship. John’s goal is to discover
These why questions create the structure that the reasons for Sara’s disconnect from the
points to the cause-and-effect perspective that relationship.
concern A leads to concern B. Taking the position From a linear perspective, it would appear that
of why, the therapist is functioning from a linear as John uses his authoritative voice, Sara chooses
perspective. In doing so, the structure does not to withdraw and remain silent, demonstrating a
provide a framework for how the couple’s inter- cause-and-effect relational pattern. The linear per-
actions are influencing one another, and therefore spective assumes that Sara is not engaging with
the communication patterns have a limited focus. John because of his authoritative tone. The linear
From a circular causality perspective, a hus- viewpoint does not provide alternative explana-
band and wife present in therapy with same tions of the impact that other potential factors may
concern regarding communication issues. The be having on the relationship.
therapist begins to ask questions that focus on From a circular causality perspective, John’s
what is happening in the system that makes the actions of using an authoritative voice (event A)
communication pattern persist. When changing are influencing Sara’s actions of withdrawing
the focus from why to what, the therapist is func- (event B). In turn, Sara’s actions of withdrawing
tioning from a relational perspective that under- influence John’s actions by increasing the author-
stands that the events are not mutually exclusive itative tone (event A), and the pattern continues.
from one another. This position maintains that the When viewing interactional patterns from the
functioning of the systems is reliant to under- circular causality framework, a dialogue emerges
standing the role that each person plays. In addi- centering around the interactive cycle.
tion, the therapist aims to understand both the The circular display would be event A leading
internal and external factors influencing the func- to even B which then leads back to event A,
tioning of the relationship. From this vantage leading back to event B. The cycle continues to
point, the therapist is able to engage in the system repeat until the cycle is disrupted. As described,
by identifying other factors contributing to the the interactional pattern displays a systems per-
communication pattern. spective that demonstrates the impact each partic-
The following example demonstrates an ipant’s actions has on the other participant’s
interactional pattern from a circular causality actions. From this perspective, the more John is
perspective. John and Sara have been married authoritative and outspoken, the more Sara with-
for 20 years and have an 18-year-old daughter. draws. The more she withdraws, the more outspo-
They are coming to therapy to discuss concerns ken John becomes. In other words, John’s
about communication issues. Sara describes John elevated tone influences Sara’s silence and Sara’s
as authoritative and demanding. John is also seen silence influences John’s elevated tone. Viewing
434 Circular Questioning in Couple and Family Therapy
the couple’s interactions from a circular causality

perspective enables the dialogue to shift away Circular Questioning in
from cause-and-effect and toward the interac- Couple and Family Therapy
tional dynamics within the relationship.
As the interactional shift occurs, the cycle will Chris J. Gonzalez
be interrupted and the parts of the system (i.e., the Department of Psychology, Counseling, and
clients’ belief systems) are altered. The altered Family Science, Lipscomb University, Nashville,
system and the members of that system begin to TN, USA
form a relationship through new communication
patterns that encourages systems-oriented think-
ing. The systems-oriented framework provides Name of the Strategy or Intervention
clients the opportunity to see how their interac-
tions and experiences with others can influence Circular questioning
communication patterns. Adopting a systems
perspective of circular causality creates an
epistemological shift that involves patterns, Introduction
rules, and interconnections of the system. The
shift often results in the reduction of blame and Circular questioning is a systemic method of clin-
expands the clients’ insight regarding the pres- ical inquiry initially developed by the Milan Asso-
ence of numerous different variables within the ciates (Palazzoli Selvini et al. 1980) and later
relationship. adapted widely within the field of couple and
family therapy (Fleuridas et al. 1986). The inno-
vative work of the Milan Associates applied sys-
tems theory and cybernetic epistemology to
Cross-References
clinical work with family systems which, in part,
resulted in an approach to therapy which directed
questions toward a relational system rather than
▶ First Order Cybernetics
an individual (Palazzoli Selvini et al. 1980). Cir-
▶ Linear Causality in Family Systems Theory
cular questioning is a practical methodology that
▶ Reciprocity in Couples and Families
makes the clinical shift from individual and linear
▶ Second-Order Cybernetics in Family Systems
to relational and circular (Fleuridas et al. 1986).
Theory
▶ Systems Theory
▶ Wiener, Norbert
Circular questioning emerged amidst the rise of

References the systemic revolution in mental health treatment
Bateson, G., & Donaldson, R. (1991). A sacred unity:
in the twentieth century. The emerging systemic
Further steps to an ecology of mind (1st ed.). theories of Bateson (1972) and Watzlawick et al.
New York: HarperCollins. (Watzlawick et al. 1967) were so innovative that it
Becvar, R., & Becvar, D. S. (1982). Systems theory and amounted to a paradigm shift in thinking and
family therapy: A primer. Lanham: University Press of
America.
conceptualizing mental health by expanding the
Sholevar, G. P., & Schwoeri, L. D. (2003). Textbook of way in which mental health disorders were under-
family and couples therapy: Clinical applications stood. The impact of this emerging theory was so
(1st ed.). Arlington: American Psychiatric Association revolutionary that it gave birth to a new way to
Publishing.
Wiener, N. (1948). Cybernetics or control and communi-
intervene in mental health problems. This revolu-
cation in the animal and the machine. Cambridge, MA: tionary theorizing expanded upon current individ-
MIT Press. ualistic thinking of the day and began to include
Circular Questioning in Couple and Family Therapy 435
relational contexts, such as families, as the cause of of the individuals separately. In short, one of the
mental disorders, the maintenance function of men- desired outcomes of circular questioning is to
tal disorders, or a context changed by the mental develop a meta-level relationship with the family
disorder – and often all three. In short, from this (Palazzoli Selvini et al. 1980).
emerging systemic theory came a collection of Circular questioning can also serve as a way to
systemic hypotheses about mental health disorders, assess and diagnose a client system by exploring
primarily that disorders manifest in an individual the accuracy of systemic hypotheses developed by C
were also bound within a relational context laden the therapist (Fleuridas et al. 1986). Asking circu-
with rules, roles, and transactions (Palazzoli et al. lar questions can help to reveal the roles people
1990). These systemic hypotheses carried with take in the client system, what overt and covert
them implications for assessment, diagnosis, and rules govern the client and how transactions func-
treatment. From these hypotheses, circular tion in the client system. In short, circular ques-
questioning was developed to serve as a technique tions are designed to move the client system to
whereby these rules, roles, and transactions might become aware of its patterns or even to perform
be highlighted, explored, and activated in a therapy their patterns of interaction in therapy.
session – a desired outcome linear and individual- Circular questioning can also function to help
istic questioning methodologies were not equipped family members understand each other in the con-
to perform. text of the roles, rules, and transactions of the sys-
tem. Circular questioning serves as a sort of forced
empathy for individuals as the therapist seeks to
Rationale for the Strategy or discover the extent to which a system is self-aware
Intervention of its own functioning while assisting the family in
viewing itself systemically (Fleuridas et al. 1986).
Being rooted in systemic theory and systemic Finally, circular questioning can serve as an
hypothesizing, circular questioning moves the intervention that invites the family to change its
long-standing intervention of the question itself functioning. Circular questioning invites the fam-
from linear to systemic by asking questions of a ily to break the unwritten rule found in many
system about the system as opposed to asking families which is to avoid commenting on rela-
questions of an individual about themselves. Cir- tionships between family members while in their
cular questioning is versatile in that it can be used presence (Brown 1997). In commenting about
whenever the therapist addresses any relational relationships in the system while in the presence
system and is therefore not limited to any model of the people being commented on, the rules of
of systemic therapy. silence about who can talk about whom are at least
More specifically, the rationale for using circu- challenged, are certainly exposed, and could pos-
lar questioning emerges when the therapist seeks sibly be amended.
to build rapport with a client system, when a
therapist diagnoses systemic functioning, when a
therapist seeks to build empathy in relationships, Description of the Strategy or
and as an intervention to invite change in the Intervention
patterns maintained by the homeostatic function
of the system. The variations and innovations within the practice
Building rapport and a therapeutic alliance with of circular questioning are limited only to the
a client system requires a nonlinear approach. Cir- creativity of a therapist or client system (e.g.,
cular questioning is a nonlinear approach that reflecting team, co-therapists) and how they
allows for rapport and alliance building with client devise ways to ask these circular questions of a
system. Circular questioning enables the therapist couple, family, or other client system (Tomm
to establish rapport with the family itself rather than 1984). There is therefore no singular description
simply one or more of the individuals or with each of the circular question. In an effort to help
436 Circular Questioning in Couple and Family Therapy
students and clinicians grasp the concept and Case Example

practice of circular questioning as differentiated
from linear questioning, Fleuridas et al. (1986) The Groves family presented for therapy with
developed a circular questioning taxonomy the parents reporting the presenting problem of
which serves as a framework for the use of circu- their daughter’s depression. Darryl (44) is the
lar questions. In this taxonomy, circular father/husband who is an Executive Vice Presi-
questioning is parsed into four overarching cate- dent at a finance company. Sheron (43) is the
gories across the span of a client case including: mother/wife and she works as a CEO of the skin
definition of the problem, sequence of interac- care company which she founded 5 years ago.
tions, comparison and classification, and Telly (14), their daughter, is a sophomore in
intervention. high school and has recently begun wearing all
Problem definition questions are asked of each black clothes (the same outfit every day), wear-
member in order to highlight how each member of ing thick and black eyeliner as well as painting
the family perceives, describes, and explains fam- her fingernails black. She spends hours in her
ily functioning in present tense. Sequences of bedroom listening to music with dark lyrics and
interaction questions are asked of each member snapchatting with her friends.
of the family to highlight who does what and When the family enters the therapy room and
when they do it. Comparison and classification the therapist welcomes them, Telly never looks up
questions are asked of each member of the family from her phone. Sheron orders her to get off her
about other members of the family. Intervention phone in a sharp tone of voice and then turns to the
questions are asked of each member of the family therapist and apologizes with a conciliatory, “I’m
with an aim for challenging the family system so sorry,” and then shakes her head and says, “teens
while also examining the systemic response to these days.” Telly rolls her eyes and shoves the
the challenge. phone into a her black and white skull purse. Darryl
From the four overarching categories of circular looks for a place to sit trying to appear to be doing
questions, Fleuridas et al. (1986) further built out the something constructive as he avoids conflict.
framework for circular questions using time: past, In the first session, the therapist hypothesized
present, and future / hypothetical. Using circular that the daughter’s depression reported by the
questions to help the family situate their problem parents as the reason for therapy is a symptom
in time can help to provide context that the problem and means by which the daughter could get the
may not have always been present and may not family some help for the larger problem they
always have to be. There is a present functioning were having. In order to test the hypothesis as
of the system, but there is also an historical aspect to well as build rapport with the client system, the
how the system has functioned in the past. Finally, therapist asks each individual a problem defini-
there is a sense of anticipated or hypothetical function question, “What is happening in this family
tioning of the system in the future. that makes therapy a good choice?” beginning
Further still, Fleuridas et al. (1986) built out the with Sheron, followed by Darryl, and then Telly.
framework with three different kinds of circular Each of the members of the family agreed that
questions: questions of difference, questions of there was a problem in the family. However,
agreement/disagreement, and questions of expla- each of their descriptions of the problem was
nation/meaning. different. Sheron and Darryl were surprised that
Penn (1982) offers an example of a circular they partially disagreed on the nature of prob-
question by asking, “How are relationships differ- lem as Sheron said the problem was Telly’s
ent comparing before and after the problem depression while Darryl said the problem was
began?” This question asked of each person in Telly’s depression, overall family tension, and
the system fits within the taxonomy as a sequence his own insomnia. The insomnia was a surprise
of interaction question, a past, and present ques- to Sheron and Telly. Telly insisted she was not
tion, as well as a difference question. depressed, but that her, “faker parents haven’t
Circular Questioning in Milan Systemic Therapy 437
given a crap for the whole past year.” Her Cross-references

answer and her anger surprised both of her par-
ents and they tried to deflect her answer. The ▶ Bateson, Gregory
therapist respectfully listened to the parents and ▶ Milan Associates
then persisted with Telly inviting more from the ▶ Milan Systemic Family Therapy
daughter and she gave more. ▶ Penn, Peggy
The therapist followed up asking each family ▶ Reflecting Team in Couple and Family Therapy C
member, “When were things different from how ▶ Selvini-Palazzoli, Mara
they are now?” Here the therapist uses neutral ▶ Tomm, Karl
language in order to maintain rapport and not ▶ Watzlawick, Paul
commit any of the family members to anyone’s
definition of the problem. In doing so, the thera-
pist takes the side of the family without privileg- References
ing or marginalizing anyone’s perspective. This
circular question also continues with the defini- Bateson, G. (1972). Steps to an ecology of mind.
Northvale: Aronson.
tion of the problem category of question but
Brown, J. (1997). Circular questioning: An introductory
moves it into the past using the difference angle guide. Australian and New Zealand Journal of Family
on the question. Therapy, 18(2), 109–114.
In a subsequent session, the family had consol- Fleuridas, C., Nelson, T. S., & Rosenthal, D. M. (1986).
The evolution of circular questions: Training family
idated their ideas about the presenting problem to
therapists. Journal of Marital and Family Therapy,
how the members of the family interact with each 12(2), 113–127.
other and how they communicate. The parents Palazzoli Selvini, M., Boscolo, L., Cecchin, G., & Prata,
were still concerned about Telly’s behaviors, but G. (1980). Hypothesizing – Circularity – Neutrality:
Three guidelines for the conductor of the session.
had not mentioned depression for a few weeks.
Then the therapist asked this circular question of Penn, P. (1982). Circular questioning. Family Process,
Telly: “How do you think your mom would 21(3), 267–280.
respond if I told her that the family is not yet Tomm, K. (1984). One perspective on the Milan systemic
approach: Part II. Description of session format,
ready for you to change?” This interventive circu-
interviewing style and interventions. Journal of
lar question invokes a paradox implying a redis- Marital and Family Therapy, 10, 253–271.
tribution of power in the family system. This Watzlawick, P., Bavelas, J. B., & Jackson, D. (1967). Prag-
question invites the family to observe itself differ- matics of human communication: A study in interac-
tional patterns, pathologies, and paradoxes.
ently than it had to this point. Further, it is a
New York: Norton.
question intended to perturb the homeostasis of
the system with an invitation to reorganize itself in
a healthier manner. The question assigns respon-
sibility for change to the whole family by
highlighting mom’s power through the eyes of Circular Questioning in Milan
the daughter but also opening the door for the Systemic Therapy
daughter to change as the change assumption is
embedded within the implied, “You are eager to Kelly Kennedy, Amanda Szarzynski and
change if the family would ever let you.” Irene Bautista
Literally, dozens or even hundreds of circular Converse College, Spartanburg, SC, USA
questions could be asked in this case were it be
carried over the course of full treatment from
intake to termination. Circular questions are a Synonyms
versatile tool of therapy that can be used at any
point in therapy and within any model of Circular interviewing; Nonlinear questions;
therapy. Systemic reframing
438 Circular Questioning in Milan Systemic Therapy
Introduction for the therapist in determining a healthier pattern

of behavior for the family. Circular questioning is
Initially developed specifically for Milan Sys- also used in other systemic therapies such as stra-
temic Therapy, circular questioning appears in tegic and MRI models. All of these models are
several systemic therapies to identify patterns informed by systems theory, in which the therapist
and changes in behavior. An overall understand- and system move from a more linear processing of
ing of the problem emerges through these types of systems to a circular one where each member’s
nonlinear questions, which allow the family to behavior is affected by others in a reciprocal man-
reframe their issues by shifting the blame and ner (Becvar and Becvar 2013).
making beliefs explicit. Circular questioning Some therapists suggest that more
enables therapy to progress by eliciting new infor- “interventive” circular questions that are future
mation through process questioning and creating oriented and hypothetical may steer away from
a stronger therapeutic alliance when compared Milan’s neutrality stance. In a study by Scheel and
to strategic or lineal questioning. Neutral questio- Conoley (1998), they found through observation
ning of the relational conceptualization of issues of interventive versus more descriptive circular
from each member of the system allows a com- questions that clients did not always feel the ther-
prehensive view of circular behavioral mainte- apist stayed neutral in interventive questioning.
nance. Different types of circular questions Therefore, therapists adhering to the Milan
gather information about cyclical patterns, shift model must take caution when using circular
or remove blame, find changes in patterns, and questioning to stay neutral in their stance.
assess clients by posing hypothetical scenarios.
Circular questions can also be used in conjunction
with lineal questions to help gain more informa- Rationale
tion about the system; however, the therapist
should be aware of remaining neutral to avoid a Circular questions are helpful to assess and track
defensive response from the clients. Overall, dou- the overall pattern in systems. Many systems
ble description questions, such as circular ques- come to therapy with an identified patient as
tions, are a useful therapeutic assessment and the “problem” behavior. Circular questions are
intervention technique (Selvini et al. 1980). used to help family members understand their
part in the process as well as reduce blame for
the identified patient. In using circular
Theoretical Framework questioning, the therapist and system work
together to make otherwise implicit beliefs
Circular questioning is most commonly associ- explicit in the therapy room (Feinberg 1990).
ated with Milan Systemic Therapy. Therapists They also may help to indirectly reframe the
who developed Milan Systemic Therapy believe issue or problem in therapy by dissecting the
that therapists should focus on behavioral overall process of the system (Becvar and
exchanges between members of a system and Becvar 2013).
help them to develop a deeper understanding of By helping the system point out assumptions,
how each member’s behavior influences and is the therapist elicits new information for the family
influenced by other members (Brown 1997). members to use to move toward second-order
Leading developers of Milan Systemic Therapy change. In addition, by asking more general pro-
cite Gregory Bateson as influential in the devel- cess questions from each member of the system,
opment of circular questioning and draw from his the therapist helps to avoid getting stuck in con-
idea of the double description where causality tent, which may produce a more defensive
is reciprocal and circular (Diorinou and Tseliou response from family members (Feinberg 1990).
2014). An element of time when the pattern Finally, therapeutic alliance is an important
changes or the problem develops can be helpful determining factor for change in therapy. Ryan
Circular Questioning in Milan Systemic Therapy 439
and Carr (2001) studied the effects of questioning circular questions assess clients in a less threaten-
styles on therapeutic alliance in 28 families with ing way since the event has not happened (e.g., “If
84 participants. In comparison to strategic and your son were to persuade you to let him spend the
lineal questioning, circular and reflexive questio- night with a friend, who would cave in first?”).
nings were related to higher ratings of therapeutic Any differences noted over time, between percep-
alliance. tions of the family members, between parts of a
person, or between situations, should be noted and C
highlighted by the therapist. In addition, the ther-
Description of the Strategy or apist should pay close attention to draw out rela-
Intervention tionships between behaviors, thoughts, feelings,
and meanings among members (Brown 1997).
Circular questioning is a type of questioning If members become defensive when asking
designed to expose the overall interactional pat- questions, the therapist may consider reversing
tern of a system. Nelson et al. (1986) offer specific the question to ask about the issue from the oppo-
guidelines for a circular interview and emphasize site direction (e.g., “Who decided your family
the role of the therapist as remaining neutral. They should come to therapy?” to “Who does not
indicate that therapists should first begin concep- believe the family should be in therapy?”). In
tualizing the case in terms of relationships, instead addition, the therapist may find linear questions
of as individuals. Therapists should ask questions are helpful in some cases but should only be used
of all family members, with special care not to in leading to information that helps form circular
spend too much time with one individual’s con- questions (Nelson et al. 1986).
ceptualization. During the interview, the therapist
should concentrate on issues related to the pre-
senting problem or circular hypothesis and note Case Example
any similarities or differences in keywords or
phrases to describe the issue. A comprehensive Jack is the father of four daughters and has
view of the system’s issue should involve a full recently been widowed. Jack (42), Danielle (16),
cycle of behaviors or patterns that maintain the Stephanie (13), Sarah (9), and Beth (4) have been
issue. dealing with their grief the best they can, but after
Forms of circular questions include behavioral months of distress at home, the family presents in
sequence, behavioral difference, ranking, before- therapy due to Stephanie’s cutting, aggression
and-after, and hypothetical circular questions toward her sisters, and disobedience to her father
(Selvini et al. 1980). Behavioral sequence ques- and older sister. The therapist begins the therapeu-
tions track an initial cycle or pattern of behavioral, tic process by building rapport and joining with
and the therapists prompt the system until a feed- each member of the family system. Stephanie’s
back loop is formed (e.g., “When X brings up an safety is assessed by the therapist, and plans for
issue to you, what happens next?”). When behav- keeping her safe in the future are discussed col-
ioral difference and ranking questions are used, laboratively with Jack. However, this case exam-
the therapist typically seeks to take the blame off ple will focus on other aspects of family treatment.
of the identified patient and will sometimes use In an effort to begin shifting the problem and
others as an example (e.g., “What does your part- blame from Stephanie, the identified patient, the
ner do that is avoidant?” or “How does your therapist assesses the family interactional pattern
family of origin typically handle that issue?,” and opens up conversations to a more cyclical
followed by “Whose response is the most help- process level. The therapist utilizes circular
ful?”). Before-and-after questions assess for how questioning as much as possible from the very
patterns change before and after an issue (e.g., beginning of therapy with the family. Some gen-
“How did your communication with your mother eral types of questions might include “Jack, how
change after the divorce?”), and hypothetical have you seen the girls cope with the loss of their
440 Circular Questioning in Milan Systemic Therapy
mother?”, “Danielle, what changes have you therapist can utilize hypothetical circular ques-
noticed in the family without your mom around?”, tions to ease the family into envisioning poten-
and “Sarah, how have you seen your family come tial positive changes. These questions might
together through this difficult time?” Each of consist of “Stephanie, what would your sisters
these examples can be asked to each family mem- do if you were nice to them?”, “Sarah and Beth,
ber in order to get each person’s perspective, build what do you think would happen if Stephanie
rapport, and elicit engagement in the therapeutic and Danielle got along?”, and “Jack, what
process. Some questions may need to be adapted would you be able to do as a family if the girls
to more appropriate developmental levels for the were no longer fighting with one another?” Ide-
younger children. Additionally, using puppets ally, the therapist’s use of circular questioning
and/or a family talking stick to conduct circular with this family will lead to a more holistic view
questioning may assist in making the conversation of the problem and systemically oriented solu-
more fun and engaging for all ages in the family tions. Stephanie will no longer be perceived as
system. the problem child, but instead, the family will be
More specifically, the therapist can utilize able to work together to change the interactional
different types of circular questions. Behavior patterns that may have contributed to and/or
sequence questions might include “Jack, what maintained the problem.
happens first that leads up to an anger outburst
from Stephanie?”, “Stephanie, how does your
dad usually react when you get angry?”, and
Cross-References
“Danielle, what does your dad do if you and
Stephanie get into an argument?” Once an inter-
actional pattern is identified, the therapist can
▶ Cecchin, Gianfranco
then follow up with behavioral difference ques-
▶ Milan Associates
tions such as “Sarah, how do you respond when
▶ Milan Systemic Family Therapy
your dad asks you to do your chores?”, “Beth,
▶ Prata, Giuliana
what about you?”, and so forth to see how each
▶ Reflecting Team in Couple and Family Therapy
child responds differently when their dad asks
▶ Selvini-Palazzoli, Mara
them to do their chores. These questions begin
▶ Tomm, Karl
with understanding one of the presenting prob-
lems but quickly shift the blame to a more sys-
temic interactional process level, rather than
References
staying focused on the identified patient. Some
ranking questions can be utilized as well, such Becvar, D. S., & Becvar, R. J. (2013). Milan systemic/
as “Who usually wins the arguments at your strategic therapy. In Family therapy: A systemic inte-
house?”, “Who gets the most upset when the gration (pp. 224–229). Upper Saddle River: Pearson
chores don’t get done?”, and “Who gets in the Education.
Brown, J. (1997). Circular questioning: An introductory
least amount of trouble at home?” These ques- guide. A.N.Z.J. Family Therapy, 18(2), 109–114.
tions can help the therapist learn more about the Diorinou, M., & Tseliou, E. (2014). Studying circular
power dynamics and relational patterns in the questioning “in situ” discourse analysis of first sys-
family. Some before-and-after change questions temic family therapy session. Journal of Marital and
Family Therapy, 40(1), 106–121.
might include “What were arguments between Feinberg, P. H. (1990). Circular questioning: Establishing the
siblings like before your mom died compared to relational context. Family Systems Medicine, 8, 273–277.
now?”, “How have you seen your dad’s role Nelson, T. S., Fleuridas, C., & Rosenthal, D. M. (1986). The
change now that he is the only parent in the evolution of circular questions: Training family therapists.
Journal of Marital and Family Therapy, 12(2), 113–127.
house?”, and “Danielle, what is different about Ryan, D., & Carr, A. (2001). A study of the differential
your responsibilities as the big sister now versus effects of Tomm’s questioning styles on therapeutic
when your mom was around?” Lastly, the alliance. Family Process, 40(1), 67–77.
Circumplex Model of Marital and Family Systems, The 441
Scheel, M. J., & Conoley, C. W. (1998). Circular questioning circumplex model in Family Systems Theory and
and neutrality: An investigation of the process relation- organized it around the orthogonal dimensions of
ship. Contemporary Family Therapy, 20(2), 221–235.
Selvini, M. P., Boscolo, L., Cecchin, G., & Prata, family Adaptability (i.e., the family’s systemic
G. (1980). Hypothesizing-circularity, neutrality: Three ability to change when facing situational or devel-
guidelines for the conductor of the session. Family opmental stress) and family Cohesion (i.e., the
Process, 19(1), 3–12. intra-familial system emotional bonding). Further,
Olson and colleagues conceptualized Communica- C
tion as a third key dimension that allows families to
move along the axes of Adaptability and Cohesion
Circumplex Model of Marital
(Olson et al. 1989).
and Family Systems, The
Jason L. Wilde
Description
Dixie State University, St. George, UT, USA
The Circumplex Model of Marital and Family Sys-
tems (Circumplex Model) plots the two dimensions
Name of Concept
of Adaptability and Cohesion orthogonal to each
other, each on a continuous scale from low to high.
The Circumplex Model of Marital and Family
Healthy family functioning is posited to be more
Systems
likely for families that are balanced on each dimen-
sion; that is, for families that function in the central
Synonyms levels of each dimension and avoid the extremes of
high or low (Olson et al. 1989). For simplicity in
Couple and Family Map (Olson et al. 2014). mapping these dimensions, four levels of each are
used. The four levels of Adaptability are, from low
to high: rigid, structured, flexible, and chaotic. The
Introduction
four levels of Cohesion are, from low to high:
disengaged, connected, cohesive, and enmeshed.
The Circumplex Model of Marital and Family
These two sets of four levels create a grid of sixteen
Systems was originally developed by David
family types (see Fig. 1). The four central family
Olson, Douglas Sprenkle, and Candyce Russell
types (neither low nor high on either Adaptability or
with the goal of bridging the gap they saw
Cohesion) are considered “balanced” and include
existing between theory, research, and practice
Structurally Connected, Structurally Cohesive,
in family therapy (Olson 1989). The model
Flexibly Connected, and Flexibly Cohesive.
brings together three important theoretical con-
The four extreme family types (either high or low
cepts: Adaptability, Cohesion, and Communica-
on both Adaptability and Cohesion) are considered
tion, in a manner useful to both researchers
“unbalanced” and include Chaotically Disengaged,
trying to understand family dynamics and inter-
Rigidly Disengaged, Chaotically Enmeshed, and
ventionists (therapists, educators) trying to help
Rigidly Enmeshed. Unbalanced families are posited
families functionally improve.
to be more likely to experience dysfunction, yet
clinicians need to be careful to make assessment
Theoretical Context for Concept with cultural expectations and the context of the
family in mind. The remaining eight family types
The term “circumplex” was coined by Louis are “midrange” (neither unbalanced nor balanced).
Guttman to describe a circular relation of The family types are also depicted in Fig. 1.
correlated variables organized around two Adaptability and Cohesion are assessed for
orthogonal dimensions (see Strauss 1964, and the Circumplex Model using two validated and
Schaefer 1959). Olson and colleagues based their reliable assessment devices, the Family
442 Circumplex Model of Marital and Family Systems, The
Circumplex Model of
Low -------------------- COHESION --------------------- High
Marital and Family
Systems, The, Fig. 1 The Disengaged Connected Cohesive Enmeshed
Circumplex Model of
Low ------- ADAPTABILITY ------ High

Marital and Family Systems
Chaotic Chaotically Chaotically Chaotically Chaotically
Disengaged Connected Cohesive Enmeshed
Flexible Flexibly Flexibly Flexibly Flexibly

Structured Structurally Structurally Structurally Structurally

Rigid Rigidly Rigidly Rigidly Rigidly

Adaptability and Cohesion Evaluation Scales, functioning, allowing them to (a) see if such func-
fourth edition (FACES IV) and the Clinical Rating tioning is normative for their current stressors and
Scale (CRS) (Olson 2011). Family Adaptability (b) plan how to alter processes to improve func-
consists of processes surrounding leadership, tioning. Further, it can be used to chart progress as
discipline, negotiation, roles, rules, and family a family changes (Olson et al. 2014).
change. Family Cohesion consists of proces-
ses surrounding separateness vs. togetherness, “I
vs. We” orientation, emotional closeness, loyalty,
Clinical Example
shared/non-shared activities, and dependence
Maryssa and Tyrone have been together for 5 years,
vs. independence (Olson et al. 2014).
married for just over 2 years, and they have a 1-year
Family Communication processes are used,
old daughter. They present with issues surrounding
according to the Circumplex Model, for working
emotional drifting and control. Maryssa says,
out issues on any of the subscales for Adaptability
“We’re just not as tight as we used to be, ya’ know,
or Cohesion, such as leadership (part of family
there is this distance, this emotional wall building
Adaptability) and amount of shared activities (part
that’s hard to break through.” Tyrone states, “I love
of family Cohesion). Family Communication is
her and our daughter and I want to work out this
assessed by looking at listening skills, speaking
relationship, but I don’t seem to be able to do
skills, amount of self-disclosure, clarity of mes-
enough., It’s got to be her way and she doesn’t
sages, frequency of staying on topic, and amount
want me hanging with my friends no more—I’m
of respect and regard family members give each
getting stir crazy, I need some freedom.”
other in conversation (Olson et al. 2014).
Using the Circumplex Model, their counselor
helps Maryssa and Tyrone each plot out three
Application of Concept in Couple and locations on the grid: one for where they saw
Family Therapy/Education their respective family of origin operating, one
for where they see themselves operating, and
The Circumplex model is the basis for the popular one for where they ideally would like to be as
marital intervention program, PREPARE/ a family. Looking at the family of origin plots,
ENRICH, run by Life Innovations, Inc. The Tyrone notes that they both grew up in the same
Circumplex Model graphically depicts a family’s rough, impoverished neighborhood, just a few
current functioning in terms of core family pro- streets apart. He plotted his family as operating
cesses of Adaptability and Cohesion. It gives a in a Chaotically Disengaged style and Maryssa
common language for families to discuss their plotted her family as operating in a Structurally
Clarifying the Negative Cycle in Emotionally Focused Therapy 443
Enmeshed style. With some guidance, Tyrone Cross-References

hypothesizes about the difference, “My dad was
never around and my mom had alcohol prob- ▶ FACES IV
lems and a hard time keeping a job. We never ▶ Olson, David
knew what to count on so everyone just had to ▶ PREPARE/ENRICH
take care of themselves. Maryssa’s family pulled ▶ Sprenkle, Douglas
everyone together to deal with the neighbor- C
hood chaos, they had a lot of rules and her
parents enforced them strictly. I remember vis- References
iting the first time and thinking, ‘Man, this place
feels secure,’ and I wanted something like that.” Olson, D. H. (1989). Circumplex model of family systems
VIII: Family assessment and intervention. In
The counselor helps Maryssa add to the insight,
D. H. Olson, C. S. Russell, & D. H. Sprenkle (Eds.),
“Yeah, and I remember thinking, ‘It would be nice to Circumplex model: Systemic assessment and treatment
do what I wanted once in a while, like this free-spirit of families (pp. 7–50). New York: Routledge.
man I’d met.’ He opened up my world. That’s one Olson, D. H. (2011). FACES IV and the circumplex model:
Validation study. Journal of Marital & Family Therapy,
reason I put my ideal as Flexibly Cohesive—I mean,
37, 64–80.
I want the family closeness kinda like my family had, Olson, D. H., McCubbin, H. I., Barnes, H. L.,
just with some greater adaptability. But when he Larsen, A. S., Muxen, M., & Wilson, M. A. (1989).
pulls away and acts all independent, like he doesn’t Families, what makes them work. Newbury Park, CA:
Sage Publications. (updated edition).
really need me—I mean, I see him sometimes
Olson, D. H., DeFrain, J., & Skogrand, L. (2014). Mar-
looking like he’s going for a Chaotically Disen- riages and families: Intimacy, diversity, and strengths
gaged family, that’s where I really think we are (8th ed.). New York: McGraw-Hill Education.
sometimes right now—and I, I get real controlling, Schaefer, E. S. (1959). A circumplex model for maternal
behavior. The Journal of Abnormal and Social Psy-
like I’m trying to make us be Rigidly Enmeshed. It’s
chology, 59, 226–235.
like an emotional tug-of-war with us in separate Strauss, M. A. (1964). Power and support structure of the
corners of the map.” family in relation to socialization. Journal of Marriage
“Um-hmm,” Tyrone agrees. “But our ideals and the Family, 26, 318–326.
aren’t really too far apart. Having greater structure
became real important to me. I had some great
teachers who took me in and helped me see that
I could set goals and use education to get out of the Clarifying the Negative Cycle
neighborhood and make something of my life. So in Emotionally Focused
that’s why I put my ideal at Structurally Connected, Therapy
I know I need structure in my life, but I never saw
how to do it in a family so when she tries to get too Lorrie Brubacher1 and Sue M. Johnson2
1
close and gets controlling, I just retreat to what University of North Carolina, Greensboro,
I know from growing up. But I really don’t want to NC, USA
2
be there.” The International Centre for Excellence in
With coaching and some other work to heal Emotionally Focused Therapy, The University of
past hurts, Maryssa and Tyrone begin changing Ottawa, Ottawa, ON, Canada
communication processes to achieve their goals of
a family with balanced Adaptability and balanced
Cohesion. They work diligently, finding making Introduction
the change difficult but rewarding. Their new
communication processes help them negotiate The model of emotionally focused therapy can be
without becoming extreme and help them pull seen to draw on two overall basic techniques:
together as a couple with a shared vision as to (1) Clarifying the negative cycle is necessary for
where they want their family to be. the first change event of de-escalation, and
444 Clarifying the Negative Cycle in Emotionally Focused Therapy
(2) deepening emotional experience – especially The view of attachment theory (Bowlby 1982;
of attachment fears and longings – is needed for Johnson 2013; Mikulincer and Shaver 2016) is
the two transformative change events of the sec- that distressed partners become stuck in mis-
ond stage of EFT. Clarifying the negative cycle attempts at regulating attachment insecurities
involves assembling the process of emotion as it is and seeking secure connection (using strategies
triggered between two partners caught in negative of anxious hyperactivating or avoidant suppres-
cycles of separation distress (Johnson 2004; John- sion) that paradoxically heighten insecurity.
son and Brubacher 2016). It is a collaborative Clarifying the repetitive negative interaction
process of clarifying what each partner does that cycle as the problem creates a safe base from
unwittingly pulls the other partner into the cycle which to attend to the attachment fears and
and identifying each partner’s unacknowledged unmet needs driving the cycle (Johnson 2004) so
attachment emotions that are pulling him/her as to reprocess the attachment emotions into sig-
repeatedly into this reactive pattern. nals of mutual reaching and responding to one
another.
Theoretical Framework Typical Negative Cycles

Variations of the basic demand-pursue/withdraw-
Clarifying the negative cycle, a process used in the defend negative cycles of interaction are seen in
first stage of emotionally focused therapy (EFT), several typical cycles described below. The
is based on the view that it is neither lack of descriptions identify the insecure attachment
insight nor conflict that leads to relationship dis- strategies (Mikulincer and Shaver 2016) that
solution. Rather, it is attachment partners’ failure make up these cycles.
to repair and reconnect following relationship Pursue/withdraw. Critical, demanding pur-
ruptures that erodes a relationship (Huston et al. suits of a more anxious pursuer trigger avoidance
2001). Since negative self-reinforcing feedback and distancing in the other and vice versa.
loops block repair and reconnection, clarifying Attack/attack. One partner is likely using a
this negative cycle is the first change event on more anxious attachment strategy, hyper-
the path toward reshaping a distressed activating his/her attachment needs and relent-
relationship. lessly pursuing connection. The more avoidant
partner may be fighting back in self-defense, con-
tinuing to minimize his/her own and others’
A Systemic, Experiential, Attachment-
attachment needs.
Oriented Process
Withdraw/withdraw. Withdraw/withdraw
The technique of clarifying a distressed couples’
couples seldom argue, and seldom get close.
negative cycle is rooted in the tripartite systemic,
Some have occasional blow-ups when an emo-
experiential, and attachment orientations of EFT.
tionally raw spot is touched. Both default to
The systemic view is that self-reinforcing repeti-
avoidant positions of not counting on or trusting
tive patterns of demand-pursue/withdraw-defend
the other.
characterize distressed couple relationships and
perpetuate the distress (Gottman 1994;
Bertalanffy 1968). The experiential view is that Rationale for Clarifying the Negative
therapeutic change occurs when therapist and cli- Cycle
ents engage with present-moment emotional
experience, to access awareness of the unfolding Clarifying the negative cycle as the basic problem
process of emotion. Emotion clarifies needs, in relational distress is one of the depathologizing
primes action responses, organizes social interac- aspects of EFT. Partners in distress are encour-
tion, and creates meaning (Arnold 1960; Ekman aged to discover that their problem is not a
2003/2007). deficit in oneself or in the other partner, but is
the repetitive cycle that they are inadvertently automatic action tendencies (e.g., defend/with-
triggering when either partner senses rejection or draw) and reactive secondary emotional expres-
abandonment. sions (e.g., anger and numbness).
Increasingly Informed by Attachment

Description of Clarifying the Negative
Clarifying the negative cycle is primarily a sys-
Cycle C
temic process that has been part of EFT since its
inception (1985). It is, however, inseparably
Clarifying the negative cycle includes identifying
integrated with attachment-oriented experiential
the following aspects:
techniques (empathic reflection, validation, evoc-
ative responses and questions, and empathic con-
1. Action tendencies: Identifying the steps in the
jectures). As EFT was increasingly shaped by
dance of distress: Outlining the behaviors in a
attachment theory, it evolved from the first inte-
couple’s negative cycle from the story they tell
gration of systemic and experiential approaches
and from observing and capturing the cycle as
(Johnson and Greenberg 1985), to an approach in
it happens in session. Their typical responses
which each of the systemic and experiential inter-
are linked together in a self-perpetuating loop,
ventions are reflective of attachment themes and
such as “the more s/he _____, the more
reactions to a threat to the attachment bond
s/he_______.” The typical positions of anx-
(Johnson 1996, 2004).
ious attachment pursuit or avoidant suppres-
sion and withdrawal are identified.
Process of Emotion 2. Danger cues: Naming the specific danger cues
The view that emotion and interaction patterns are to which each partner reacts. Clarifying what it
both systemic processes (Johnson and Greenberg is that one partner does (a behavior, a voice
1985; Johnson 2004) is an explicit part of EFT. tone, a gesture) that is typically perceived by
Clarifying the negative cycle essentially consists the other partner as a danger cue or a threat to
of ordering the interactive process of emotion as it the attachment bond of secure connection.
is triggered between attachment partners and, in 3. Linking action tendencies to perceived threats:
doing so, accessing the specific underlying attach- Helping partners acknowledge and express
ment fear of each partner that is propelling the their steps in the dance (“I do shut down,
reactive cycle. when I hear a harsh tone.” “I do lash out
The EFT therapist helps partners to assemble when I see you shrug.”) and validating how
elements of emotion – cue, cognitive appraisal, normal and natural these moves are, in the
bodily arousal, and action tendency – to gain context of perceived threat.
access to the core attachment emotions that are 4. Attachment meanings: Helping partners
driving the process but are not yet in conscious acknowledge and express the meanings they
awareness or formulated in words. For example, make of the other partner’s self-protective
to assemble and order a more withdrawn partner’s behaviors by evoking and reflecting attach-
emotion and access a core primary fear of rejec- ment meanings that trigger or get triggered in
tion, an EFT therapist will evoke and validate the the cycle (“What did it say to you Andie, that
different elements of emotion, metaphorically she was late?” “What does his loud outburst
opening doorways of: (1) the cue which is per- followed by his silence say to you, Bella?”)
ceived as threatening (such as a partner’s harsh 5. Secondary emotions: Attuning to, and validat-
tone of voice); (2) the cognitive appraisal made of ing the reactive, secondary emotions of each
that cue (“I’m letting him/her down again.”); partner (When pulled into emotional imbal-
(3) the bodily sensation experienced when that ance Bella is angered by Andie’s distance;
cue is perceived (tension in the stomach, as the Andie is briefly frustrated, followed by
body prepares for fight or flight); and (4) the numbness.)
446 Clarifying the Negative Cycle in Emotionally Focused Therapy
6. Safety: Maintaining emotional safety by “catch- Case Example

ing bullets” when necessary. Reframing aggres-
sion with a validating attachment reframe; e.g., Bella and Andie sit in sullen silence, for a few
“When you don’t know how to tell her how minutes before Andie mumbles a complaint about
unwanted you feel, it is so easy to slip into how Bella can never be ready on time. A plethora
frustration and attempts to shut her down.” of criticisms tumble forth from Bella,
7. Primary emotion: Validating the attachment while Andie’s eyes turn down and his arms
meanings and evoking the underlying attach- fold across his chest. He disappears into stony
ment emotional music that drives the dance of silence.
disconnection and fuels distress. Both partners
typically feel lonely. Withdrawers commonly
fear rejection and nonacceptance, while pur- Therapist: This is a very difficult moment –
suers commonly fear abandonment. both of you feeling the other one
Withdrawers typically view their partner as upset with you! (reflection and
unpredictable and feel safer staying distant, validation). Right now, Bella you
whereas pursuers are likely to view self as looked at Andie fold his arms and go
unlovable and the other as unavailable for silent, and you became very agitated.
closeness. Your voice sped up as you recounted
8. Summarizing the negative cycle, the fears that many struggles of the past few days.
trigger it and the attachment consequences of You sound very frustrated!” What
this cycle for both partners: “Bella, the more happened for you Bella as you heard
you complain about his distance and try to pull Andie’s complaints over your being
him close, Andie the more hear you’re letting late?”
her down and the more you angrily shut her Bella: I heard, “Here we go again!” – I’ve
out. When he shuts down, Bella, you become tried for years to tell him he is
frantic and aggressive. Underneath, Bella you good enough, that I am so proud of
are lonely and afraid you’ll lose him at any him, that I just want him to open up
moment and Andie, you’re afraid she doesn’t to me, but he is always on guard,
really love and accept you. This cycle takes ready to defend himself and put the
over, leaving you both feeling alone and blame on me – then he won’t talk to
unwanted.” me for days.
9. Framing the dance of distress as the common Therapist: So you hear Andie’s complaint and
enemy and helping couples to step out of it in you hear that you are being shut out,
session. It then becomes something they can that he is pulling away from you and
contain and move beyond. Simple attachment you become desperately frustrated,
frames can be offered for different cycles and trying to tell him he has no reason to
attachment positions of pursuit or withdrawal. shut you out – yes?
An attachment frame for a pursue/withdraw Bella: Exactly!
couple could be: “The more Bella turns up Therapist: And Andie, just before Bella
the volume, the more Andie steps farther exploded with her frustration at you,
away.” Both are trapped in pain and isolation.” you were saying how angry you
A withdraw/withdraw couple’s cycle could be are that she was late to come to
reframed as, “The more Cy walks away, this appointment. (Andie nods
looking unhappy (with me, Jess assumes), the definitively.) Can you tell me what
more Jess walks away and gets busy (to numb it means to you when she is late?
the pain of isolation), and both are trapped in Andie: “That I’m not enough for her to
pain and loneliness.” care about getting ready on time!”
Therapist: Ah, so is this how many of your Andie is not available when she needs him – that he
unhappy times play out? Andie, could disappear at any time; Andie dreads signals
what you hear that is that Bella is from Bella that he is unimportant to her – fearing he
dissatisfied with you (cue). You are is not measuring up in her eyes.
on guard for little signs (limbic After both partners engage in the process of
appraisal) that she cares clarifying the negative cycle, and acknowledge
(attachment meaning), and when she and disclose to each other the underlying attach- C
forgets something or is late, your ment fears propelling their reactive moves, the
massive concern that you are not first change event of EFT is complete. Partners
measuring up in her eyes (more have named the basic negative cycle.
attachment meaning), rips through Through the de-escalation process of clarifying
your heart (bodily arousal) and the negative cycle, partners discover new views of
before you know it, you fire back in one another. Pursuing partners who previously
defense (action tendency) and step seemed randomly hostile are now recognized as
far, far away from the trigger of your desperately seeking connection and protesting the
pain (action tendency). And Bella, other partner’s emotional distance. Withdrawn
you live on the edge of fear (limbic partners who previously appeared nonchalant
appraisal) that he is going to turn and uncaring are now understood to be distancing
away from you, looking for ways to to protect themselves from criticism and rejection.
pull him close and grasping for This first event of de-escalation establishes suffi-
messages that you are precious to cient emotional safety and awareness to begin the
him (action tendencies/meaning transformative change events of Stage 2.
making), getting annoyed each time
you sense even a hint (limbic
appraisal) that he is stepping back or Cross-References
going silent – is that it?”
▶ Attachment Injury Resolution Model in
Emotionally Focused Therapy
The cycle continues to get triggered in the ses- ▶ Attachment Theory
sion. Each time it does, the therapist tracks what is ▶ Circle of Security: “Understanding Attachment
happening, validating their reactions, and reflecting in Couples and Families”
any hints of their underlying fears and attachment ▶ Deepening Emotional Experience and
distress. By the end of Stage 1, Andie and Bella Restructuring the Bond in Emotionally
have clarified their dominant negative cycle and Focused Couple Therapy
begun to understand how they trigger this cycle in ▶ Emotion in Couple and Family Therapy
each other. Bella is beginning to grasp, “You shut ▶ Emotionally Focused Couple Therapy
me out (action tendency/position of withdrawal) ▶ Emotionally Focused Couple Therapy and
because you think I don’t care (attachment mean- Physical Health in Couples and Families
ing). You are looking for signs that I care about ▶ Emotionally Focused Couple Therapy and
you.” Andie is absorbing a new sense of Bella: Trauma
“You get angry with me (action tendency/position ▶ Emotionally Focused Family Therapy
of demand-pursue) because you are afraid I’ll turn ▶ Hold Me Tight Enrichment Program
away from you and shut you out” (primary fear of ▶ Hold Me Tight/Let Me Go Enrichment
abandonment). Clarifying this automatic self- Program for Families and Teens
protective cycle, each partner also touches the ▶ Johnson, Susan
underlying attachment fears that leave them each ▶ Training Emotionally Focused Couples
so vulnerable to this negative pattern: Bella fears Therapists
448 Classification in Couples and Families
References 1994; Smith et al. 2012; Gouin et al. 2010;

Whisman 2007). Early research documented
Arnold, M. B. (1960). Emotion and personality. New York: the effects of emotional neglect and attachment
Columbia Press.
processes on children’s development (e.g.,
Bertalanffy, L. (1968). General system theory: Founda-
tions, development, applications. New York: George Beckett et al. 2006; Manly et al. 2001) and
Braziller. the link between intimate partner relationship
Bowlby, J. (1982). Attachment and loss: Vol. 1, attachment distress and mental health (e.g., Hammen
(2nd ed.). New York: Basic Books.
1991; Whisman 2001). More recent studies have
Ekman, P. (2003/2007). Emotions revealed: Recognizing
faces and feelings to improve communication and emo- documented some of the biological and behav-
tional life. New York: St Martin’s Griffin. ioral mechanisms through which family
Gottman, J. (1994). What predicts divorce? Hillsdale: relationships and maltreatment can impact life-
Erlbaum.
long health (e.g., Boeck et al. 2017; Kiecolt-
Huston, T. L., Caughlin, J. P., Houts, R. M., Smith, S. E., &
George, L. J. (2001). The connubial crucible: Newlywed Glaser and Wilson 2017; Thomas et al. 2008).
years as predictors of delight, distress, and divorce. Jour- Based on this accumulated literature and the prev-
nal of Personality and Social Psychology, 80, 237–252. alence of these problems, family problems and
Johnson, S. M. (2004). Creating connection: The practice
family maltreatment are considered important
of emotionally focused couple therapy (2nd ed.).
New York: Brunner/Routledge. public health problems.
Johnson, S. M. (2013). Love sense: The revolutionary new An important first step in addressing public
science of romantic relationships. New York: Little health problems is proper detection and assessment
Brown.
of the problems in the international classification
Johnson, S. M., & Brubacher, L. L. (2016). Clarifying the
negative cycle in emotionally focused couple therapy systems – the International Classification of Dis-
(EFT). In G. Weeks, S. Fife, & C. Peterson (Eds.), eases (ICD) and the Diagnostic and Statistical Man-
Techniques for the couple therapist: Essential interven- ual for Mental Disorders (DSM). Family problems
tions (pp. 92–96). New York: Routledge.
and maltreatment have not been fully included with
Mikulincer, M., & Shaver, P. R. (2016). Attachment in
adulthood: Structure, dynamics, and change reliable definitions in these classifications systems in
(2nd ed.). New York: Guilford Press. the past (DSM-IV, ICD-10). However, some pro-
gress has been made in the DSM-5 and revisions are
underway for the ICD-11.
Four main types of relational problems have
Classification in Couples and been the focus of the DSM-5 and ICD-11 revi-
Families sions and will be reviewed here: intimate partner
violence, caregiver-child relational problems, inti-
Heather Foran and Laura Restle mate partner relationship distress, and child mal-
Alpen-Adria-University Klagenfurt, treatment. These four types of relationship
Klagenfurt, Austria problems are prevalent, are associated with nega-
tive public health impacts, and have definitions
with operationalized criteria and assessment tools
Synonyms to support their inclusion in the DSM-5 and ICD-
11. Further, identification of these four types of
Assessment in Couples and Families; Diagnosis relational problems has clear implications for
improving communication between health care
providers and in improving treatment planning.
Introduction
History of Classification Systems for
The relevance of intimate partner and family rela- Relationship Problems
tionships for overall well-being, mental health, Efforts to improve the classification of relational
and physical health has been established with problems can be dated back to the 1970s but
numerous studies (e.g., Lissau and Sorensen change has been slow. During the DSM-IV and
Classification in Couples and Families 449
ICD-10 revisions, relational problems were listed “affect the diagnosis, course, prognosis, or
as psychosocial processes of clinical relevance in treatment of a patient’s mental disorder”. The
the “V codes” and “Z codes,” respectively. The ICD-11 proposed definitions, also described
DSM-IValso included relational problems in Axis below, are more consistent with the field trial
IV and as part of the Global Assessment of Rela- tested criteria than those included in the DSM-5.
tionship Functioning (GARF), which could be Also, notably, the ICD is more widely used
coded on Axis V. The ICD-10 included family globally and includes not only mental disorders C
maltreatment in other chapters. Family maltreat- but all causes of disease and disability. The ICD
ment could be coded as a “T code” in the Injury, is especially relevant for the integration of rela-
Poisoning and Certain Other Consequences of tional problems into health care systems and
External Causes chapter and as a “Y code” in surveillance systems.
the External Causes of Morbidity and Mortality
chapter.
Unfortunately, the numerous codes and lack of Description: Current Criteria for
definitional criteria has led to unreliable coding. Relational Assessment in the DSM and
Moreover, important types of relational problems ICD Intimate Partner Violence
were left out completely (e.g., child psychological
abuse). Overall, the ICD-10 and DSM-IV codes Intimate partner violence includes Partner Physi-
have been underutilized and are used unreliably, cal Abuse, Partner Psychological Abuse, Partner
which has resulted in limited public health utility. Sexual Abuse, and Partner Neglect. The empirical
Based on the problems with DSM-IV and ICD- foundation for the criteria is described in depth
10, there was a clear need to work toward more elsewhere (Foran et al. 2013). The DSM-5 defines
reliable and valid assessments. A Relationship Partner Physical Abuse as “nonaccidental acts of
Processes Working Group was established and physical force that result, or have reasonable
three meetings with support from the Fetzer Insti- potential to result, in physical harm to an intimate
tute took place. The first meeting in May 2005 partner or that evoke significant fear in the partner
focused on evaluating the empirical foundation have occurred.” The following criteria are catego-
for relational processes in the DSM (Beach et al. rized into Acts (e.g. shoving, biting, burning),
2006). The second meeting in May 2007 focused Impacts (physical harm, significant fear, reason-
on the content of proposed criteria. The third able potential to result in physical harm), and
meeting in October of 2010 took place in Swit- Exclusion (excluding acts for self-protection or
zerland in collaboration with experts from the protection of other’s from harm). The DSM-5
World Health Organization. It focused on the incorporates field-tested criteria, but did not
revisions for the ICD-11 with particular attention include the complete criteria set (Heyman
to cross-cultural relevance and implementation in et al. 2015).
high and low-resources regions (Foran The ICD-11 proposed definition is similar to
et al. 2013). the DSM-5, but does not list as many examples of
The proposal for the ICD-11 revisions were nonaccidental physical acts and includes the fur-
formally submitted in 2011. Field trials for par- ther operationalization that there must be at least
ticular categories in the DSM-5 and ICD-11 one act of physical force during the past year. The
were conducted. A modified version of the ICD changes to these criteria and other criteria
field-tested criteria for relational problems described below were based on the feedback pro-
were accepted in the DSM-5, but some operatio- vided by an international working group with
nalizations of the criteria were not included. All expertise in family problems from diverse cul-
DSM-5 relationship processes are included as tures, disciplines, and countries. Further, criteria
Z codes in the section, Other Conditions That were sometimes simplified to make them more
May be a Focus of Clinical Attention. A Z code, usable in low resource settings across HICs and
may be the “focus of clinical attention” or LMICs.
In the DSM-5 and proposed ICD-11 defini- populations (e.g., elderly populations) is needed
tions, Partner Psychological Abuse is defined as to evaluate these definitions of Partner Neglect
nonaccidental verbal or symbolic acts by one and determine the inter-rater reliability.
partner that result in significant harm to the
other partner. Ten examples of acts such as Intimate Partner Relationship Distress
berating or humiliating the victim and stalking Relationship distress with spouse or intimate part-
the victim are provided. The major difference ner in the DSM-5 is defined as: “[Problematic]
between the DSM-5 and ICD-11 proposed def- quality of the intimate (spouse or partner) rela-
initions for Partner Psychological Abuse is that tionship or [problematic] relationship quality is
the ICD-11 version includes a more detailed affecting the course, prognosis, or treatment of a
specification of the Impacts criterion (“acts mental or other medical disorder.” Further, it
causing or exacerbating at least one of the fol- defines criteria as “impaired functioning in behav-
lowing impacts: significant fear, significant psy- ioral, cognitive, or affective domains” and lists
chological distress, somatic symptoms that examples under the following categories: behav-
interfere with normal functioning and fear of ioral problems, cognitive problems, and affective
the recurrence of emotionally abusive act problems. Specific examples were excluded since
(s) that cause victim to significantly limit any they can be culturally specific.
of these five major life activities – work, educa- The ICD-11 proposed definition differs in
tion, religion, medical or mental health services, that it includes text to indicate that the relation-
and contact with family/friends”). ship distress is severe and long-lasting, which is
The definitions for Partner Sexual Abuse in the absent from the DSM-5 definition. It is also
DSM-5 and ICD-11 overlap in that they both more detailed in describing the areas of func-
include “forced or coerced sexual acts” or “with tioning that can be disturbed and includes the
an intimate partner who is unable to consent” and additional areas of physical health, interper-
“whether or not the act is completed.” In the sonal interaction, and major life-role activities.
DSM-5, one of the field trial tested criterion has The changes made to the DSM-5 and the ICD-11
been removed: “physical contact of a sexual proposed definitions are more closely in line
nature (e.g., kissing, fondling) is against the with definitions of relationship researchers and
expressed wishes of the partner and that causes enables better correspondence with assessment
considerable distress to the partner”. This raises tools which differentiate clinically significant
concerns that the DSM-5 definition may leave out levels of relationship distress from normative
certain forms of sexual assault. levels (Foran et al. 2015).
In contrast to Partner Physical, Sexual, and
Psychological Abuse, the definitions for Partner Child Maltreatment
Neglect have not yet been extensively tested in Mirroring partner maltreatment, child maltreat-
field trials. The DSM-5 describes Partner ment includes four categories in the DSM-5 and
Neglect as “egregious act or omission by one ICD-11 proposal: Child Physical Abuse, Child
partner that deprives a dependent partner of Psychological Abuse, Child Sexual Abuse, and
basic needs” and the context is given, including Child Neglect (Slep et al. 2015). Child Physical
examples. “Basic needs” and other terms are not Abuse and Psychological Abuse follow the same
operationalized, which may impact inter-rater structure as Partner Physical Abuse and Partner
reliability. The ICD-11 definition is “egregious Psychological Abuse in which Acts and Impacts
acts or omissions that result in physical harm to are required to be coded as present. The wording
a spouse or intimate partner who is incapable of of the criteria and the definition of Impacts differ
self-care.” It differs from the DSM-5 in that the for the DSM-5 and ICD-11 proposed criteria. In
Impacts criterion only includes physical injury the DSM-5 definition, a case in which a caregiver
or reasonable potential for injury, but not psy- throws a knife at their child’s head, but misses,
chological harm. Further work with vulnerable would not be coded as Child Physical Abuse since
it did not cause injuries or death. In the ICD-11 child.” The ICD-11 proposal defines Child
proposed criteria, this would be coded as Child Neglect as “confirmed or suspected egregious act
Physical Abuse because the additional Impact (s) or omission(s) by a child’s parent/caregiver
criterion of “reasonable potential for significant that deprive the child of needed age-appropriate
injury.” care and that result, or have reasonable potential to
The definition for Child Psychological Abuse result, in physical or psychological harm.”
in the DSM-5 reads: “nonaccidental verbal or Although both the DSM-5 and ICD-11 proposed C
symbolic acts by a child’s parent or caregiver definitions include Acts with Impacts, Impacts are
that result, or have reasonable potential to result, only operationalized in the ICD-11 proposed
in significant psychological harm to the child.” definition.
The ICD-11 definition is “confirmed or suspected
verbal or symbolic acts with the potential to cause Caregiver-Child Relational Problem
psychological harm to the child.” Examples of There is a rich history of research and theory on
Acts are similar across the DSM-5 and ICD-11 parent/caregiver-child relational problems using a
proposed definitions, but the ICD-11 examples are plethora of measurement approaches at different
more specific and the additional example of “pur- ages. A problem with the existing validated sys-
poseful indoctrinating the child to consider a par- tems is that they are quite complex and costly,
ent evil, dangerous or not worthy of affection” is making implementation in low and middle income
included. The DSM-5 Impact criterion includes countries (LMICs) unrealistic. To address this gap,
only “psychological harm,” whereas the ICD-11 the Relational Processes Working Group set out to
proposed criteria is more detailed and also develop and test a concise definition of caregiver-
includes “reasonable potential for significant psy- child relational problems that could be used as an
chological harm” (followed by examples), and assessment in epidemiological research and used in
“stress-related somatic symptoms that interfere both low- and high-resource clinical settings (see
with normal functioning.” Wamboldt et al. 2015). The definition was devel-
The Child Sexual Abuse definitions for the oped and revised based on feedback from interna-
DSM-5 and ICD-11 differ in defining the perpe- tional experts, tested in the DSM-5 field trials and
trator. Child Sexual Abuse in the DSM-5 is is currently being tested in ICD-11 field trials. As
defined as “any sexual act involving a child that reviewed in Wamboldt et al. (2015), this is a work
is intended to provide sexual gratification to: in progress and will continue to need further test-
A parent, caregiver, or other individual who has ing. Similar to the other relational problems, the
responsibility for the child; OR Others (without code of a caregiver-child relational problem
direct physical contact between child and [other requires evidence of an Act and Impacts. Acts
but involving exploitation by the caregiver])”. include “pervasive sense of unhappiness with the
The ICD-11 defines Child Sexual Abuse as “sex- relationship, parent or child and thoughts” or “run-
ual acts involving a child that are intended to ning away that are more than transitory.” Impacts
provide sexual gratification to an adult”. An include behavioral, cognitive, and affective symp-
Impact is not required because the Act is consid- toms similar to the structure of Intimate Partner
ered sufficient to identify Child Sexual Abuse. Relational Distress. The DSM-5 field
Acts are divided into physical contact and non- trial supported the reliability and clinical utility of
contact exploitation, which are defined through the definition (Wamboldt et al. 2015). The version
examples. ultimately included in the DSM-5 does not match
Child Neglect is defined in the DSM-5 as the DSM-5 field trial tested definition, but was
“confirmed or suspected egregious act or omis- rather modified to be more descriptive and less
sion by a child’s parent or other caregiver that criterion-focused. The effect that these
deprives the child of basic age-appropriate needs modifications have in terms of inter-rater
and thereby results or has reasonable potential to reliability and clinical utility is in need of further
result, in physical or psychological harm to the evaluation.
Application of Concept in Couple and lower service utilization rates for other types of
Family Therapy medical problems (e.g., Law and Crane 2000).
This type of evaluation of the health cost benefits
Scientifically-based changes in the DSM-5 and of couple and family therapy is crucial for
proposed for the ICD-11 codes for family prob- addressing reimbursement issues related to treat-
lems and violence have potential to facilitate ment and prevention of relational problems within
communication and lead to improved health different countries.
care services, if used in a reliable and valid However, changes in the DSM-5 and ICD-11
way. Findings from the ICD-11 field trial sug- are only relevant for public health if they are used
gest there may be an impact of the new criteria widely and reliably. There are many implementa-
on in the context of a mental health diagnosis. tion barriers that need to be addressed for this to
Clinicians who were presented with the ICD-10 occur. This will require programs in diverse health
codes for adult relational problems compared to care fields to include training in coding of family
those presented with the ICD-11 proposed codes problems and family violence as a standardized
were more likely to underdetect a relational part of the curricula. Close attention to implemen-
problem when a mental health disorder was tation practices of the codes is also required,
also present (Heyman et al. 2017). If a relational including quality assurance, among current prac-
problem, such as intimate partner violence, is titioners across countries. For example, there are
not detected in the context of a mental health some difficulties with exact translation of “non-
assessment, this could lead to inappropriate accidental,” which is used for the family maltreat-
treatment planning as illustrated in the clinical ment definitions, and this may require additional
example provided in the next section. Rather clarification and training in some languages and
than only considering psychiatric disorders as cultures. Further, more continuing education
presenting problems, the ICD-11 proposed opportunities in the area of classification of family
criteria may result in increased detection of problems and violence are also needed.
relational problems and referrals to couple and Moreover, coding processes in the DSM-5 and
family therapy. ICD-11 operate within health care systems and in
The current coding structure of the ICD-9 or many countries, relationship codes are not reim-
ICD-10, which is used to allocate health care bursable, which can negatively influence coding
expenditures in most countries, including the and treatment decisions. Couple and family ther-
United States, provides limited information to apists can play an important role in addressing
health care providers and policy makers about these barriers by increasing interdisciplinary com-
relational problems. The new criteria sets have munication and dissemination activities, as well
potential to provide more reliable documentation as by engaging in health care policy decision-
of relational problems across health care facilities making processes.
around the world. This can facilitate communica-
tion and referrals to couple and family therapists
from health professionals, who may first see cases Clinical Example
of family problems and violence, such as in pri-
mary care, emergency rooms, pediatric clinics, or Martha is a 27-year-old woman who has been mar-
gynecological clinics. Couple and family thera- ried to her husband, Phillip, for the last five years.
pists may have a better mechanism to gauge the Although the relationship was going really well the
health economic benefits of their services within first few years, Phillip and Martha now argue fre-
the health care system with the proposed ICD quently. The arguments, especially when Phillip is
changes. Some preliminary studies that have drinking, often end with them screaming at each
reviewed health care records over time have other and her crying herself to sleep. Martha has
shown that couple or family therapy results in considered getting divorced, but when she
suggested this to Phillip, he threatened her and said, Relationship Distress and Partner Psycho-
“If you even think about that, you are going to regret logical Abuse are coded as the presenting
it.” Martha has become increasingly fearful for her problems. The initial session focuses on
safety. She is experiencing frequent headaches and developing an immediate safety plan for
stomach pains. She feels hopeless about her situa- Martha as well as conducting a behavioral
tion and is not sure what to do. and family health assessment.
C
Option 1: No diagnosis; Treatment of physical
symptoms
Martha goes to see her primary care doctor, References
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Groothues, C., et al. (2006). Do the effects of early severe
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Heyman, R. E., Wamboldt, M. Z., Kaslow, N., &
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anxiety disorder and prescribes her an anxi- problems: Reliable assessment and the ICD-11.
olytic medication and some pain medica- New York: Springer.
tion. She returns home to Phillip. Foran, H. M., Whisman, M. A., & Beach, S. R. H. (2015).
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depression and anxiety disorders, as well DSM-5 and ICD-11 may promote improved screening
as relational problems and violence. After and treatment. Family Process, 54, 17–32.
noting Martha’s response on the screener Heyman, R. E., Kogan, C. S., Foran, H. M., Burns, S. C.,
for clinically significant psychological Slep, A. M. S., Wojda, A. K, Keeley, J. W.,
Rebello, T. J., & Reed, G. M. (2017). A case-controlled
abuse and intimate partner relationship dis- field study evaluating ICD-11 proposals for relational
tress, Dr. Meet provides a referral to a prac- problems and family maltreatment. Unpublished man-
titioner, Dr. Smith, who specializes in uscript. New York University.
couple and family problems; she works in Kiecolt-Glaser, J. K., & Wilson, S. J. (2017). Lovesick:
How couples’ relationships influence health. Annual
the integrated primary care clinic, too. She Review of Clinical Psychology, 13, 421–443.
is able to meet with her 30 min later. The Law, D., & Crane, D. (2000). The influence of marital and
ICD/DSM codes for Intimate Partner family therapy on health care utilization in a health
454 CLFC Fatherhood Program
maintenance organization. Journal of Marital and Introduction

Family Therapy, 26, 281–291.
Lissau, I., & Sorensen, T. I. (1994). Parental neglect during
childhood and increased risk of obesity in young adult- The Creating Lasting Family Connections
hood. Lancet, 343, 324–327. Fatherhood Program (CLFCFP) is a manualized
Manly, J. T., Kim, J. E., Rogosch, F. A., & intervention designed to help men (and women) in
Cicchetti, D. (2001). Dimensions of child maltreatment paternal roles experiencing (or at risk for) family
and children’s adjustment: Contributions of develop-
mental timing and subtype. Development and Psycho- dissonance through any form of physical or
pathology, 13, 759–782. emotional separation who wish to return to their
Slep, A. M. S., Heyman, R. E., & Foran, H. M. (2015). paternal role in their own family and community.
Child maltreatment: Definitions of relational processes Family separation might be due to marital
in DSM-V and ICD-11. Family Process, 54, 17–32.
Smith, T. W., Uchino, B. N., Berg, C. A., & Florsheim, difficulties, military service, mental health or sub-
P. (2012). Marital discord and coronary artery disease: stance use disorder treatment, incarceration, out-
A comparison of behaviorally defined discrete groups. of-town work assignments, or other challenging
Journal of Consulting and Clinical Psychology, circumstances. The CLFCFP consists of three
80, 87–92.
Thomas, C., Hypponen, E., & Power, C. (2008). Obesity standard modules (parenting and family relation-
and type 2 diabetes risk in mid-adult life: The role of ship skills, effective communication/refusal skills
childhood adversity. Pediatrics, 121, 1240–1249. and family alcohol and other drug prevention and
Wamboldt, M., Cordaro, A., & Clarke, D. (2015). Parent- intervention) delivered in 16 to 18 two-hour
child relational problem: Field trial results, changes in
the DSM-5, and proposed changes for the ICD-11. sessions.
Family Process, 54, 33–47. CLFCFP is designed to modify the attitudes
Whisman, M. A. (2001). The association between depres- of participants and help them to (1) strengthen
sion and marital dissatisfaction. In S. R. H. Beach (Ed.), families and establish strong family harmony,
Marital and family processes in depression (pp. 3–24).
Washington, DC: American Psychological Association. (2) enhance parenting skills for intergenerational
Whisman, M. A. (2007). Marital distress and DSM-IV psy- prevention, and (3) minimize the likelihood of
chiatric disorders in a population-based national survey. further personal problems for all family members
Journal of Abnormal Psychology, 116, 638–643. (e.g., substance use, violence, risky sexual behav-
ior, prison recidivism).
The Three Standard CLFCFP Modules

CLFC Fatherhood Program Raising Resilient Youth. Participants learn and
practice effective communication skills to use
Ted N. Strader1,2, Christopher Kokoski1, David with their families, friends, and co-workers,
Collins3, Steven Shamblen3 and Patrick including listening to and validating others’
Mckiernan4 thoughts and feelings. Participants also
1
Council on Prevention and Education: enhance their ability to develop and implement
Substances (COPES), Louisville, KY, USA expectations and consequences with others,
2
CLFC National Training Center, Resilient including spouses, coworkers, friends, and
Futures Network, LLC, Louisville, KY, USA children. This training enhances a sense of
3
Pacific Institute for Research and Evaluation competence for achieving connectedness and
(PIRE), Beltsville, MD, USA bonding between marriage partners, parents
4
University of Louisville, Louisville, KY, USA and children, and workplace relationships
(Strader and Noe 1998a).
Getting Real. Participants examine their
Name of Model responses to the verbal and nonverbal commu-
nication they experience with others. In a
The Creating Lasting Family Connections ® group setting, participants receive personalized
Fatherhood Program: Family Reintegration coaching on effective communication skills,
(CLFCFP) including speaking with confidence and
CLFC Fatherhood Program 455
sensitivity, listening to and validating others, prevention. The CLFC Series represents the
sharing feelings, and matching body language intersection of treatment and prevention services
with verbal messages. This promotes the skills for families (Strader et al. 2013). Each of the
of self-awareness and mutual respect while three CLFC programs is separately listed on
focusing on helping participants combine SAMHSA’s National Registry of Evidence-based
thoughts, feelings, and behavior in a way that Programs and Practices (NREPP).
leads them to generate powerful, meaningful, C
and palatable messages to others (Strader
et al. 1998). Prominent Associated Figures
Developing Positive Parental Influences.
Participants develop a greater awareness of Drawing on earlier works with Dr. Tim Noe and
facts and feelings about substance use, abuse, Warrenetta Crawford Mann, the CLFC Father-
and dependency; review effective approaches hood Program was developed in the early 2000s
to prevention; and develop a practical under- by Ted N. Strader, M.S., a Certified Chemical
standing of intervention, referral procedures, Dependency Counselor, a Certified Prevention
and treatment options. This module includes Specialist and Executive Director of the Council
an examination of childhood and family expe- on Prevention and Education: Substances, Inc.
riences involving alcohol/drugs, personal and Teresa Strader, L.C.S.W, and Christopher Kokoski
group feelings, and attitudes toward alcohol assisted with the development of support materials.
and drug issues, as well as an in-depth look at The CLFCFP curriculum has been recognized on
the dynamics of chemical dependency and its the National Registry of Evidence-based Programs
impact on relationships and families (Strader and Practices (NREPP) and as a winner of the
and Noe 1998b). Exemplary Program Award provided by the
National Association of State Alcohol and Drug
The CLFCFP program also includes an optional Abuse Directors, SAMHSA’s Center for Substance
module covering HIV prevention (2 to 3 sessions Abuse Prevention and the National Prevention Net-
that may include HIV testing) for at-risk work. In 2013, the John C. Maxwell Leadership
populations: The ABC 3(D) Approach to HIV, Team named Mr. Strader one of the top 10 leaders
Hepatitis and Other Sexually Transmitted Dis- in the USA serving youth and families.
eases Prevention. This optional module is a
candid examination of the primary modes of
transmission of HIV, hepatitis, and other sexually Theoretical Framework
transmitted diseases. This training concludes with
effective preventive measures to reduce or eliminate The CLFC Fatherhood Program integrates an
risk of infection. Healthy sexual expression is rec- eclectic combination of personal, couple, family,
ognized, discussed, and supported (Strader 2012). and community strengthening theoretical frame-
The CLFCFP includes case management and works. These frameworks are translated into a struc-
referral capability. A 6- to 9-day CLFCFP Certi- tured series of sequential, developmental, and
fication Training is required for access to imple- experiential activities for participants. CLFCFP
mentation materials. incorporates Experiential Learning Theory (Kolb
The CLFC Fatherhood Program is one of 1975) by providing an interactive program with a
three programs comprising the Creating Lasting strategic mix of role plays, games, brainstorms,
Family Connections (CLFC) Curriculum Series. guided imagery, reflective exercises, demonstra-
The Series also includes the Original CLFC Pro- tions, and group discussions. Participants are invited
gram and the CLFC Marriage Enhancement Pro- to involve themselves in practicing or “experienc-
gram. The CLFC Curriculum Series addresses the ing” the ideas, concepts, and skills shared in the
intergenerational and chronic nature of addiction sessions and to engage in reflective thought and
and the family’s role in both recovery and group discussion (Johnson 1997; Satir 1983).
Risk and Resiliency Theory (Hawkins et al. Populations in Focus

1992) serves as a major underpinning of the pro-
gram. Specific exercises build resiliency across The CLFC Fatherhood Program was developed
the domains of self, family, work, and community. for Caucasian and African American men (and
Building from strengths, the program focuses on women in paternal roles) from urban, suburban,
both intra- and interpersonal skill development and rural areas in the US experiencing (or at risk
including verbal and nonverbal communication for) family dissonance through any form of phys-
(with an emphasis on listening and validation), ical or emotional separation who wish to return to
how to say no (refusal skills) and family manage- their paternal role in their own family and com-
ment practices to help prevent negative outcomes munity. Family separation might be due to marital
and mitigate known risk factors. Further, CLFCFP difficulties, military service, mental health or sub-
combines Social Learning Theory (Bandura stance use disorder treatment, incarceration, out-
1977) and Therapeutic Alliance (Bordin 1979) of-town work assignments, or other challenging
through the positive rapport established between circumstances. The program is implemented in
staff and participants and through staff modeling gender-specific (all male or all female) groups of
of appropriate relationship behaviors. Developing selective and indicated populations as designated
respected interpersonal connections is key in by the Institute of Medicine (IOM) Classification
promoting growth in both personal and family System.
behavioral dynamics. For example, in the group
“educational sessions,” two program staff serve
in roles often perceived more as facilitators of Strategies and Techniques Used in
information and role models of new possibilities Model
rather than as “therapists.” A range of non-
judgmental, inclusive, and positive facilitation The CLFC Fatherhood Program incorporates a
skills (Strader and Stuecker 2012) result in a rich variety of strategies and techniques to appeal
Therapeutic Alliance between the CLFCFP to the full range of adult learning styles,
trained facilitators and participants. This alliance cultural differences, personalities, and prefer-
can be carried into private case management ses- ences. Learning strategies and techniques include
sions that, when needed, can lead to deeper per- brief lectures, role plays, guided imagery, reflec-
sonal work or other necessary referrals for more tions, discussions, brainstorms, facilitator demon-
specific therapeutic interventions. strations, storytelling, and interactive games.
Key elements of Cognitive Behavioral Ther- CLFCFP facilitators are trained and certified to
apy (Beck 1993) are incorporated into group implement the program. CLFCFP provides facil-
exercises. Participants are invited to participate itators of differing gender, age, race, and experi-
in a process of individualized coaching and ence to relate to the largest number of participants.
personal reflection to examine new possible CLFCFP facilitators role model the skills of the
ways to self-correct unhelpful thinking and CLFC Fatherhood Program, therefore providing
behaviors. CLFCFP integrates this system of information within a relational and nonjudgmen-
established theories which are expressed in the tal context. Facilitators listen and validate partic-
program design, exercises, activities, and imple- ipant thoughts and feelings, provide clear and
mentation protocols. Each of these theories relates sensitive feedback, and express their own emo-
to the central belief described in Building Healthy tions as a means to manage group participation
Individuals, Families and Communities that and interaction throughout the program sessions.
“deep healthy connections build strong protective The concept of “influence versus control” is
shields to prevent harm and to provide both nur- threaded throughout the entire CLFC Fatherhood
turing and healing support” (Strader et al. 2000, Program. Facilitators both role model and man-
p. 17). The book refers to this concept as age the program under the belief that participants
“connect-immunity.” learn best when they can voluntarily choose their
CLFC Fatherhood Program 457
own preferred level of participation (i.e., active skills (e.g., communication skills, conflict reso-
discussion, interactive practice, quiet listening, lution skills, emotional awareness, relationship
etc.) for each activity in each program session. satisfaction). Recidivism data were provided by
Throughout the CLFC Fatherhood Program, the KY Department of Corrections for this pro-
facilitators incorporate motivational interviewing ject as well. For both projects, the evaluation
and trauma-informed care techniques into interac- examined whether the changes in the interven-
tions with participants (Strader and Stuecker tion group were more positive than the changes C
2012). Culturally sensitive case management and in the comparison group. Hierarchical Linear
ongoing supports supplement the program con- Modeling (HLM) was used for nearly all ana-
tent. Facilitators refer participants to appropriate lyses. For recidivism, a simple logistic regres-
service providers, as needed. sion analysis was used. Results for the
SAMHSA-funded project showed intervention
significant effects on HIV knowledge, spiritual-
Research About the Model ity, and intentions to binge drink. Results for the
ACF-funded project showed intervention
The CLFC Fatherhood Program was imple- effects on nine separate relationship skills. At
mented in two projects, funded by Substance follow-up, results showed that for program par-
Abuse and Mental Health Services Administra- ticipants in the first project the odds of
tion (SAMHSA) and the Administration for recidivating were 3.7 times less likely than for
Children and Families (ACF) between 2005 participants in the comparison group. Similarly,
and 2011, with 345 and 500 participants, respec- for the second project, the odds of recidivating
tively. Participants had received substance for the program participants were 2.9 times less
abuse treatment while incarcerated. Both pro- likely than for the comparison participants
jects included all four CLFCFP modules and (McKiernan et al. 2013).
case management services. In the SAMHSA- In another SAMHSA-funded project (Collins
funded project, there were 249 individuals in et al. 2017), the CLFCFP program was imple-
the intervention group and 96 in a comparison mented with African-American females. The
group. Participants were predominately male, in same modules were used as in the standard
their mid-thirties, of low socioeconomic status, CLFCFP program, with sensitivity to the
and 53% in both groups were reportedly African-American female target population. The
African-American. A majority had a high program was implemented with 175 women and
school diploma or GED. In the ACF-funded their results were compared to a convenience
project, there were 387 individuals in the inter- sample of 44 women who were similar on back-
vention group and 113 individuals in the treat- ground characteristics. Results showed significant
ment as usual comparison group. Most were in increases in the proportion of individuals getting
their mid-thirties. Almost two-thirds (62%) HIV tested and getting the results from the tests, a
were White and 37% African-American. Less larger decrease in intimate partner abuse over the
than half were employed at baseline. past 3 months, and larger increases in all three
A majority had a high school diploma or GED. relationship skills measured relative to the com-
Most reported having a child. parison group.
For the SAMHSA-funded project, question-
naires completed at three waves included demo-
graphic data and measures of substance use and
other behaviors, risk, and protective factors. Case Example
Recidivism data were provided by the KY
Department of Corrections for this project. For Having been recently released from prison,
the ACF-funded project, questionnaires at three Austin (fictitious name used here to protect his
waves included measures of nine relationship identity) chose to voluntarily participate in the
CLFC Fatherhood Program (CLFCFP) from Cross-References

October 2012 to February 2013 as part of his
reentry aftercare plan. Even as he answered the ▶ Creating Lasting Family Connections Program
questions on the Screening and Program Place-
ment Survey, he began to understand the
destructive nature of his relationship with sub- References
stances. While quietly participating at first, Aus-
tin warmed up to the two program facilitators Bandura, A. (1977). Social learning theory. Englewood
Cliffs: Prentice Hall.
and connected to the entire group that included
Beck, A. T. (1993). Cognitive therapy of substance abuse.
several other previously incarcerated individ- New York: Guilford Press.
uals. In the Developing Positive Parental Influ- Bordin, E. S. (1979). The generalizability of the psycho-
ences module, Austin began to understand how analytic concept of the working alliance. Psychother-
apy: Theory, Research and Practice, 16, 252–260.
powerfully his addiction had affected his rela-
Collins, D. A., Shamblen, S. R., Strader, T. N., &
tionship with his children. Subsequently, Austin Arnold, B. B. (2017). Evaluation of an evidence-
recommitted to attending his Alcoholics Anon- based intervention implemented with African-American
ymous meetings. Six weeks into the program, women to prevent substance abuse, strengthen relation-
ship skills, and reduce risk for HIV/AIDS. AIDS Care,
Austin voluntarily accepted and completed a
29(8), 966–973.
referral to an economic stability program on Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk
job search and job readiness skills at Goodwill and protective factors for alcohol and other drug prob-
Industries through which he eventually gained lems in adolescence and early adulthood: Implications
for substance abuse prevention. Psychological Bulletin,
part-time employment. As Austin volunteered
112(1), 64–105.
for several role-plays in the Getting Real mod- Johnson, D. W. (1997). Reaching out: Interpersonal
ule, he made a second discovery. In one of the effectiveness and self-actualization. Boston: Allyn &
role plays, he exclaimed, “I never realized how Bacon.
Kolb, D. A., & Fry, R. (1975). Toward an applied theory of
much my tone of voice and the words I use
experiential learning. In C. Cooper (Ed.), Theories of
affected other people.” He made a personal and group process. London: Wiley.
public commitment to the group to “do better” McKiernan, P., Shamblen, S., Collins, D., Strader, T., &
for his children by trying to use a more sensitive Kokoski, C. (2013). Creating lasting family connec-
tions: Reducing recidivism with community-based
tone and choosing words that were less likely to
family strengthening model. Criminal Justice Policy
hurt his children’s feelings. Austin had Review, 24, 94–122.
another realization during the Raising Resilient Satir, V. (1983). Conjoint family therapy. Palo Alto:
Youth module. He discovered how to manage Science and Behavior Books.
Strader, T. N. (2012). ABC 3(D) approach to HIV, hepatitis
his feelings by embracing and nurturing them
and other sexually transmitted diseases prevention
instead of ignoring them or covering them up trainer manual and participant notebook for the creat-
with episodes of intoxication. He commented: ing lasting family connections ® program. Louisville:
“I can’t wait to share this with my kids.” After Resilient Futures Network.
Strader, T. N., & Noe, T. (1998a). Raising resilient youth
finishing the CLFCFP, Austin reported
training manual and participant notebook for the cre-
excitement because he acted upon his dream to ating lasting family connections program. Louisville:
enroll in college. Subsequently, Austin Resilient Futures Network.
successfully completed his first year of college Strader, T. N., & Noe, T. D. (1998b). Developing positive
parental influences training manual and participant
while maintaining his part-time position.
notebook for the creating lasting family connections
Later Austin reported that he had obtained a program. Louisville: Resilient Futures Network.
full-time position doing sanitation work, while Strader, T. N., & Stuecker, R. (2012). Creating lasting
maintaining his sobriety and continuing to family connections ®: Secrets to successful facilitation.
Louisville: Resilient Futures Network, LLC.
attend his Alcoholics Anonymous meetings.
Strader, T. N., Noe, T. D., & Crawford-Mann, W. (1998).
He also completed all requirements of his Getting real training manual and participant notebook
parole and reported that he now has more time for the creating lasting family connections program.
to spend with his two children. Louisville: Resilient Futures Network.
CLFC Marriage Enhancement Program 459
Strader, T. N., Noe, T., & Collins, D. (2000). Building participants to develop greater self-awareness
healthy individuals, families, and communities: and an increased capacity for communication,
Creating lasting connections. New York: Kluwer/
Plenum Publishers. conflict resolution, emotional awareness, emo-
Strader, T. N., Kokoski, C., & Shamblen, S. R. (2013, tional expression, commitment, and trust.
July 25). Intersection of treatment and prevention: Two certified trainers implement the module-
Prevention and recovery-informed care. SAMHSA based program with a group of 4 to 15 couples
Recovery to Practice E-Newsletter, 14. Retrieved from
http://www.npnconference.org/wp-content/uploads/ through one of the following implementation C
2017/09/Strader-Kokoski-Shamblen-ENewsletter.pdf. options: (1) an 8- to 10-session format (with 2-h
sessions), (2) a 2- to 3-day weekend retreat for-
mat, or (3) an 18- to 20-session format (with 2-h
sessions), which includes all modules. A 3- to
CLFC Marriage Enhancement 5-day CLFCMEP Certification Training is
Program required for access to implementation materials.
CLFCMEP includes three instructional, inter-
Ted N. Strader1,2, Christopher Kokoski1, David active, and stand-alone training modules in the
Collins3, Steven Shamblen3 and Patrick following three skill areas:
Mckiernan4
1
Council on Prevention and Education: • The Marriage Enhancement module consists
Substances (COPES), Louisville, KY, USA of 12 marriage-focused, facilitator-guided
2
CLFC National Training Center, Resilient exercises designed to strengthen marriage
Futures Network, LLC, Louisville, KY, USA through the learning of open, nondefensive
3
Pacific Institute for Research and Evaluation communication skills. Partners develop a
(PIRE), Beltsville, MD, USA shared vision, review family of origin experi-
4
University of Louisville, Louisville, ences, recognize the difference between
KY, USA thoughts and feelings and how they are sepa-
rate but related, recognize both positive and
negative traits in each partner, understand part-
Name of Model ner needs and how to practice active listening
and echoing, provide emotional validation and
The Creating Lasting Family Connections ® compassion, and learn to use effective strate-
Marriage Enhancement Program (CLFCMEP) gies for conflict resolution (Strader 2012).
• The Getting Real module is designed to
enhance marital relationships through clear
Introduction and honest communication, and the setting of
boundaries through guided role plays that
The Creating Lasting Family Connections ® involve saying “No” with warmth and firmness
Marriage Enhancement Program (CLFCMEP) coupled with deep sensitivity and compassion
is a manualized program for couples in which (Strader et al. 1998).
one or both partners have been physically and/or • The Developing Positive Parental Influences
emotionally distanced because of relational diffi- module is intended for couples interested in
culties or separation due to military service, men- positively influencing their children or other
tal health, or substance use disorder treatment, family members. Participants are expected
incarceration, out-of-town work assignments, or to develop a greater awareness of facts and
other challenging circumstances. feelings about drug use and dependence; to
Relying largely on cognitive change and rela- examine childhood and family experiences
tional skills training, the goal of CLFCMEP is to involving alcohol/drugs; to review effective
build and/or strengthen a couple’s relationship approaches to prevention; and to develop a
skills by providing structured opportunities for practical understanding of intervention,
460 CLFC Marriage Enhancement Program
referral procedures, and treatment and recov- Theoretical Framework

ery options. This module also examines atti-
tudes toward alcohol and drug issues, the The CLFC Marriage Enhancement Program inte-
dynamics of chemical dependence, and its grates an eclectic combination of personal,
impact on marriages and families (Strader couple, family, and community strengthening
and Noe 1998). theoretical frameworks. These frameworks are
translated into a structured series of sequential,
developmental, and experiential activities for
Case management is a critical component
participating couples. CLFCMEP incorporates
of CLFCMEP, and program implementers are
Experiential Learning Theory (Kolb 1975) by pro-
strongly encouraged to understand how to assess
viding an interactive program with a strategic mix of
a wide variety of needs of participants and link
role plays, games, brainstorms, guided imagery,
them to additional support services in the
reflective exercises, demonstrations, and group dis-
community.
cussions. Participants are invited to be open-minded
The CLFC Marriage Enhancement Program is
in order to involve themselves in practicing or
one of three programs comprising the Creating
“experiencing” the ideas, concepts, and skills shared
Lasting Family Connections ® (CLFC) Curricu-
in the sessions and to engage in reflective thought
lum Series. The Series also includes the Original
and group discussion (Johnson 1997; Rogers 1951).
CLFC Program and the CLFC Fatherhood Pro-
Drawing on the couple and family therapy
gram: Family Reintegration. The CLFC Curricu-
work of Virginia Satir, Harville Hendrix, and
lum Series addresses the intergenerational and
John Bradshaw, the program invites couples to
chronic nature of addiction and the family’s role
review relational dynamics from early childhood
in both recovery and prevention. The CLFC
experiences with a specific focus on the effects of
Series represents the intersection of treatment
a family history of addiction or substance use
and prevention services for families (Strader
disorders provided in the Developing Positive
et al. 2013). Each of the three CLFC programs is
Parental Influences module (Bradshaw 1990;
separately listed on SAMHSA’s National Registry
Hendrix 1988; Satir 1983).
of Evidence-based Programs and Practices
Risk and Resiliency Theory (Hawkins et al.
(NREPP).
1992) serves as an underpinning of the program.
Specific exercises build resiliency across the
domains of self and family. Building from
Prominent Associated Figures strengths, the program focuses on both intra- and
interpersonal skill development including verbal
Drawing on earlier works with Dr. Tim Noe and and nonverbal communication (with an emphasis
Warrenetta Crawford Mann, the CLFC Marriage on listening and validation); how to say no
Enhancement Program was developed in the (refusal skills); and relationship management
early 2000s by Ted N. Strader, M.S., a Certified practices to help prevent negative outcomes and
Chemical Dependency Counselor, a Certified mitigate known risk factors. Further, CLFCMEP
Prevention Specialist and Executive Director combines Social Learning Theory (Bandura
of the Council on Prevention and Education: 1977) and Therapeutic Alliance (Bordin 1979)
Substances, Inc. Teresa Strader, L.C.S.W, Brooke through the positive rapport established between
Arnold and Christopher Kokoski assisted with staff and participants and through staff modeling
the development of support materials. The of appropriate relationship behaviors. Developing
CLFCMEP curriculum has been recognized on respected interpersonal connections is key in
the National Registry of Evidence-based Pro- promoting growth in both personal and family
grams and Practices (NREPP). In 2013, the John behavioral dynamics. For example, in the group
C. Maxwell Leadership Team named Mr. Strader “educational sessions,” two program staff served
one of the top 10 leaders in the USA serving youth in roles often perceived more as facilitators of
and families. information and role models of new possibilities
CLFC Marriage Enhancement Program 461
rather than as “therapists.” A range of non- facilitator demonstrations. CLFCMEP facilitators

judgmental, inclusive, and positive facilitation are trained and certified to implement the pro-
skills (Strader and Stuecker 2012) result in a gram. CLFCMEP provides facilitators of differing
Therapeutic Alliance between the CLFCMEP gender, age, race, and experience to relate to the
trained facilitators and participants. This alliance largest number of participants. CLFCMEP facili-
can be carried into private case management ses- tators role model the skills of the CLFC Marriage
sions that, when needed, can lead to deeper per- Enhancement Program and provide information C
sonal work or other necessary referrals for more within a relational and nonjudgmental context.
specific therapeutic interventions. Facilitators listen and validate participant thoughts
Key elements of Cognitive Behavioral Ther- and feelings, provide clear and sensitive feedback,
apy (Beck 1993) are incorporated into group exer- and express their own emotions as a means to
cises. Participants are invited to participate in a manage group participation and interaction
process of individualized coaching and personal throughout the program sessions. The concept of
reflection in order to self-correct unhelpful think- “influence versus control” is threaded throughout
ing and behaviors. CLFCMEP integrates this sys- the entire CLFC Marriage Enhancement Program.
tem of established theories, which are expressed Facilitators both role model and manage the pro-
in the program design, exercises, activities, and gram under the belief that participants learn best
implementation protocols. Each of these theories when they can voluntarily choose their own pre-
relates to the central belief described in Building ferred level of participation (i.e., active discussion,
Healthy Individuals, Families and Communities interactive practice, quiet listening, etc.) for each
that “deep healthy connections build strong activity in each program session. Throughout the
protective shields to prevent harm and to CLFC Marriage Enhancement Program, facilita-
provide both nurturing and healing support” tors incorporate motivational interviewing and
(Strader et al. 2000, p. 17). The book refers to trauma-informed care techniques into interactions
this concept as “connect-immunity.” with participants (Strader and Stuecker 2012). Cul-
turally sensitive case management and ongoing
support supplements the program content. Facilita-
Populations in Focus tors refer participants to appropriate service pro-
viders, as needed.
The CLFC Marriage Enhancement Program is
designed for married or committed couples in
which one or both partners have been physically Research About the Model
and/or emotionally distanced because of relational
difficulties or separation due to military service, The CLFC Marriage Enhancement Program was
mental health, or substance use disorder treat- implemented through a “Healthy Marriage Initia-
ment, incarceration, out-of-town work assign- tive” grant from the Administration for Children
ments, or other challenging circumstances. and Families from 2006 to 2011. Participants were
250 married individuals (with at least one partner
who was recently released from either prison
Strategies and Techniques Used in or substance abuse treatment, or both) who vol-
Model untarily participated in the intervention group
(n = 230) or a program typically offered to those
The CLFC Marriage Enhancement Program being released from prison (n = 20). The indi-
incorporates a rich variety of strategies and tech- viduals were predominately African-American
niques to appeal to the full range of adult learning (57%) or Caucasian (40%). 45% lived with their
styles, cultural differences, personalities, and spouse, 83% had children, and about two-thirds
preferences. Learning strategies and techniques reported living with their children and being
include brief lectures, role plays, guided imagery, independently housed. Most had a high school
reflections, discussions, brainstorms, and diploma or GED and 54% were employed.
462 CLFC Marriage Enhancement Program
Questionnaires were completed at each of three parents while growing up. Next, the couple made
waves that included items about nine relationship some connections between the hurt and pain they
skills. Analyses examined whether there were felt growing up in their own families and, in
changes over time among participants in the inter- Derek’s case, the frustrations he was feeling in
vention group. A convenience sample of compa- this relationship. This provided Derek and Isabell
rable husbands being released from prison with deeper insight into themselves, their relation-
allowed for an examination of this change for ship and how their earlier family life was affecting
male intervention participants compared to male their expectations, interactions, and responses to
comparison participants who were receiving each other. As the program progressed, they
treatment as usual aftercare services. Hierarchical learned and practiced the skills of active listening
Linear Modeling (HLM) was used in nearly all and validating each other’s thoughts and feelings
analyses to examine whether there was differen- with compassion. When they realized that Isabell
tial change in relationship skills between 115 hus- was trying to “re-parent” Derek by being control-
bands in intervention group and 20 husbands in ling, they made a powerful, positive shift by work-
comparison group. ing together to uncover and nurture Derek’s past
Relationship skills remained relatively con- hurts and address some of his unmet needs. This
stant for the comparison group, but improved for realization gave both Derek and Isabell greater
the intervention group. Specifically, the targeted insight and compassion into the ongoing chal-
skills showed a large increase between pre- and lenges in their relationship. Derek said, “Wow!
posttest for the intervention group and the level of I think we’re learning how to fight fair.” Near the
relationship skills increased slightly between end of CLFCMEP, they both committed to taking
posttest and follow-up. Pattern of changes in rela- several small actions every day or every week as an
tionship skills was nearly identical for husbands expression of love for each other to help rejuvenate
and wives (Shamblen et al. 2013). the romantic feelings they had experienced in the
early stages of their relationship. Ten weeks later
they reported that their relationship went from feel-
Case Example ing very distant to closer than ever now that Isabell
was less controlling and more understanding of
At first, Isabell and her spouse Derek (fictitious Derek’s needs. Isabell stated that Derek was now
names are used to protect true identities) were showing more sensitivity to her emotional needs
hesitant to participate in the CLFC Marriage too. At a 6-month follow-up session, they both
Enhancement Program. Derek had a history of reported that they are now able to listen to each
past arrests and brief incarceration, and both other and respect how each other are feeling –
reported that they were in substance abuse recov- something they reported that they could not do
ery. In the Screening and Program Placement Sur- before the program. Isabell thanked the CLFCMEP
vey meeting, the couple indicated they had all but facilitators most of all for showing her that her
given up on their marriage. They agreed that there feelings are real and deserve her and her husband’s
was probably nothing they could learn that would attention and nurturance. She also stated that her
help them communicate. However, they decided participation in the sessions changed her outlook
to try something anyway because they had heard on herself-worth. Derek said he felt hopeful and
about the “Marriage Class” (CLFCMEP) from excited because he thought it was important that
some friends who were also in recovery. their young daughter could now have two loving
In an early exercise where Derek and Isabell parents for years to come.
listed their goals for their marriage, both were
pleasantly surprised to see how much their per-
sonal hopes for their relationship aligned. Isabel Cross-References
noted with excitement that one of Derek’s goals
was that their daughter would have two loving ▶ Creating Lasting Family Connections Program
Client-Therapist System in Integrative Problem Centered and Integrative Systemic Therapy 463
References
Client-Therapist System in
Bandura, A. (1977). Social learning theory. Englewood Integrative Problem Centered
Cliffs: Prentice Hall.
Beck, A. T. (1993). Cognitive therapy of substance abuse.
and Integrative Systemic
New York: Guilford Press. Therapy
Bordin, E. S. (1979). The generalizability of the
psychoanalytic concept of the working alliance. Psy- William M. Pinsof C
chotherapy: Theory, Research and Practice, 16,
Pinsof Family Systems, LLC, Chicago, IL, USA
252–260.
Bradshaw, J. E. (1990). Homecoming: Reclaiming and
championing your inner child. New York: Bantam
Books. Introduction
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk
and protective factors for alcohol and other drug prob-
lems in adolescence and early adulthood: Implications The Integrative Problem Centered (Pinsof 1995)
for substance abuse prevention. Psychological Bulletin, and Integrative Systemic Therapy (Pinsof et al.
112(1), 64–105. 2017) perspectives define the therapeutic playing
Hendrix, H. (1988). Getting the love you want: A guide for
field as consisting of the client system and the
couples. New York: Henry Holt and Company.
Johnson, D. W. (1997). Reaching out: Interpersonal effec- therapist system, which together constitute the
tiveness and self-actualization. Boston: Allyn & therapy system. This entry explains the deriva-
Bacon. tion, the meaning, and rationale for these
concepts.
group process. London: Wiley.
Rogers, C. (1951). Client-centered therapy: Its current
practice, implications and theory. London: Constable. The Client System
Satir, V. (1983). Conjoint family therapy. Palo Alto:
Science and Behavior Books. Since the 1970s, as the integrative movement
Shamblen, S., Arnold, B. B., McKiernan, P., Collins,
emerged in psychotherapy, the movement’s
D. A., & Strader, T. N. (2013). Applying the creating
lasting family connections marriage enhancement primary concern has been intra-modality
program to high-risk marriages. Family Process, integration – primarily integrating individual
52(3), 477–498. psychotherapy models. There have also been
Strader, T. N. (2012). Marriage enhancement program
intra-modality forays in couple therapy and
trainer manual and participant notebook for the creating
lasting family connections® program. Louisville: Resil- family therapy (Breunlin et al. 1992, 1997).
ient Futures Network. Pinsof (1983, 1995) was the first integrative the-
Strader, T. N., & Noe, T. D. (1998). Developing positive orist to encompass inter-modality as well as intra-
parental influences training manual and participant
modality integration, initially bringing together
program. Louisville: Resilient Futures Network. individual and family (including couple) therapies
Strader, T. N., & Stuecker, R. (2012). Creating lasting (1983) and later integrating them with biological
family connections ®: Secrets to successful facilitation. therapies (1995).
Integrating across modalities creates the prob-
Strader, T. N., Noe, T. D., & Crawford-Mann, W. (1998).
Getting real training manual and participant notebook lem of what to call the target system. Individual
for the creating lasting family connections program. therapy targets the client or patient, couple ther-
Louisville: Resilient Futures Network. apy targets the couple, and family therapy targets
Strader, T. N., Noe, T., & Collins, D. (2000). Building healthy
the family. To resolve this dilemma, Pinsof origi-
individuals, families, and communities: Creating lasting
connections. New York: Kluwer/Plenum Publishers. nally proposed the term “patient system” (Pinsof
Strader, T. N., Kokoski, C., & Shamblen, S. R. (2013, 1983, 1984) and later “client system” (1995),
July 25). Intersection of treatment and prevention: defining it as all of the people involved in the
Prevention and recovery-informed care. SAMHSA
maintenance and/or resolution of the presenting
Recovery to Practice E-Newsletter, 14. Retrieved
from http://www.npnconference.org/wp-content/uploads/ problem. This definition was problem centered, in
2017/09/Strader-Kokoski-Shamblen-ENewsletter.pdf. that the presenting problem defined the client
464 Client-Therapist System in Integrative Problem Centered and Integrative Systemic Therapy
system. For instance, with a conflictual couple, siblings), but it also impacts the indirect system
the client system for their conflict includes them, (grandmother), which may in turn impact the
possibly their children, their parents (family of direct system (grandmother feeling hurt and
origin), and some close friends. With a depressed withdrawing her support, etc.). The indirect cli-
adolescent boy, in addition to him, the client sys- ent system concept helps the therapist never
tem includes his family, close friends, and possi- forget that his/her interventions with the people
bly some of his teachers and other people at in the room (the direct client system) will impact
school. The boundary between the client system client system members not in the room (the
and the rest of the people in the clients’ lives is indirect client system), and that those effects
ineluctably ambiguous. may well generate intra-systemic feedback that
The problem with the client system concept affects the outcome of therapy.
is that it is too broad when it comes to the From the client system perspective, the distinc-
pragmatic decision-making about which mem- tion between therapeutic modalities is not what
bers to include directly in therapy. To deal with the therapist does in the session, but who is in
that problem, Pinsof (1995) differentiated the the room – where in the client system the therapist
client system into two distinct subsystems: the draws the boundary between direct and indirect
direct and indirect client systems. The direct systems. The clinical question becomes what is
client system consists of all the members of the the difference between a transference interpreta-
client system directly involved in therapy at any tion and an interaction stimulation in an individual
particular moment. The indirect client system context, a couple context, or a family context? The
consists of the members of the client system intervention is not attached to a modality but to
not directly involved at that particular point. the therapy model.
The clinical value of the indirect client sys-
tem concept is that it forces the therapist to be
aware and considerate of the members of the The Therapist System
client system who are not in therapy room, but
who will be affected by his or her interventions Although family-oriented therapists apply sys-
into the client system. For instance, in working tems theory to their clients, they seldom apply
with a family with a defiant and conduct disor- systems theory to the systems of which they
dered 10-year-old, the therapist becomes aware are a part, particularly the therapist system.
that the mother’s mother provides childcare for The therapist system consists of all of the
the identified patient and his siblings most after- people engaged in providing therapy to the
noons during the week. It is also clear that the client system (Pinsof 1995; Pinsof et al.
identified patient’s mother has absented herself 2017). Obviously, it includes the therapist.
from providing any discipline or behavioral Additionally, it includes any consultants to
consequences for her son, deferring instead to the therapist, any clinical supervisors and/or
her mother or her husband, when he is home. co-supervisees of the therapist, and any other
The mother owns and manages her own beauty therapists working with the client system. As
parlor, which keeps her away from home a good with the client system, the exact boundary
deal of the time. When she is home, she does not between the therapist system and the rest of
want to be the disciplinarian. the therapist’s colleagues, family, and friends
As the therapist encourages the mother to is necessarily ambiguous.
take more leadership with her son, she asks Like the client system, the therapist system can
what impact that might have on her husband’s and should be differentiated into direct and indi-
and her mother’s roles in the family. The thera- rect subsystems. Typically the therapist is the only
pist asks that question because she understands member of the direct system, unless supervisors,
that her intervention with the mother not only consultants, and team members directly enter the
affects the direct system (husband and other session (as in live supervision/consultation). It can
Client-Therapist System in Integrative Problem Centered and Integrative Systemic Therapy 465
also be useful for therapists who are working with problem for which they are seeking help. Some of
the same client system but have very different the same people may get together for another
perceptions of a client to do a session together to episode at future points to address a different
better coordinate their perspectives. The coordi- problem, constituting a different therapy system.
nation of different therapists working with differ- A therapy system is a distinct, open, dynamic, and
ent members of a client system (e.g., the couple living system,
therapist and the individual therapists of each of C
the partners) is a very difficult task, but the more at
odds their perspectives, the more crucial becomes
Therapy Systems and the Therapeutic
coordination.
Alliance
Obvious examples in which the therapist
system can be problematic occur when the thera-
To address therapeutic and working alliances
pist and the supervisor are in conflict about a
within a therapy system, Pinsof and Catherall
case or when a supervision team is dysfunctional
(1986) and Pinsof (1994, 1995) delineated the Inte-
and unable to provide consistent support and
grative Therapy Alliance Model and scales to mea-
guidance to a therapist-member. At these points,
sure the alliance. Structurally, this model views
the therapist system needs to become a therapeutic
alliances existing between all of the possible sub-
target in itself, turning its therapeutic skills on
systems in the therapy system. The most renowned
itself or bringing in an external consultant.
systemic alliance is between the direct client sys-
tem and the direct therapist system, which usually
includes the therapist and at least one of the clients.
The Therapy System However, it is important to note that Pinsof (1994)
delineated within-systems alliances to address alli-
The therapy system is the clinical system, orga- ances between clients and alliances between thera-
nized around a presenting problem that encom- pists. Obviously, when clients are not allied with
passes both the client and the therapist systems. each other (e.g., husband and wife), the therapy
Their physical (who, what, and where) and con- will be in trouble, as it will be when therapists
versational (what to whom, where) interaction working with the same client system are not allied.
constitutes the interaction between them. The life The working rule is that there needs to be strong
of a therapy system is co-terminus with an episode alliances between the most important (key) sub-
of therapy. In essence, two groups of people come systems of the therapy system for therapy to be
together in order to help one group/person solve a successful.
Client System Therapist System
Indirect Direct Direct Indirect
Client-Therapist System in Integrative Problem Cen- Basic Books. Copyright 1995 by Basic Books, an imprint
tered and Integrative Systemic Therapy, Fig. 1 The of Perseus Books, LLC, a subsidiary of Hachette Book
Therapy Systems. (Adapted from Integrative Problem- Group, Inc. Adapted with permission)
Centered Therapy (p. 6) W. M. Pinsof 1995, New York:
466 Closed Systems in Family Systems Theory
Conclusion Pinsof, W. M., & Catherall, D. R. (1986). The integrative

psychotherapy alliance: Family, couple, and individual
therapy scales. Journal of Marital and Family Therapy,
The concepts of the client, therapist, and therapy 12, 137–151. https://doi.org/10.1111/j.1752-
systems were created to facilitate the complete 0606.1986.tb01631.x.
integration of family and multisystemic thinking Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow,
and practice into the broader field of integrative J. L., Rampage, C., & Chambers, A. L. (2017). Inte-
grative systemic therapy: Metraframeworks for
psychotherapy. In concert with the concept of problem solving with individuals, couples and fami-
indirect and direct subsystems, they were lies. Washington, DC: American Psychological
designed to map the terrain of psychotherapy Association Press.
such that therapists, regardless of who is in the
therapy room, never forget that they are interven-
ing into, and are themselves, part of larger systems
that impact both the process and outcome of any Closed Systems in Family
psychotherapy (Fig. 1). Systems Theory
Dawn M. Wirick and Lee A. Teufel-Prida

Cross-References Evanston, IL, USA
▶ Breunlin, Douglas C.
▶ Catherall, Donald Name of Theory
▶ Integrative Systemic Therapy
▶ Lebow, Jay L. Closed Systems in Family Systems Theory
▶ MacKune-Karrer, Betty
▶ Pinsof, William M.
▶ Schwartz, Richard C. Introduction
▶ Therapeutic Alliance in Couple and Family
Therapy A closed system refers to a self-contained fam-
ily system that employs impervious boundaries
with the outside world (Simon et al. 1985). Due
References to its impermeable boundary system with extra-
familial contexts, a closed system resists influ-
Breunlin, D. C., Schwartz, R. C., & Mac Kune-Karrer, B. ences to change. Minimal interactions with the
(1992). Metaframeworks: Transcending the models of
outside environment render the family system
family therapy. San Francisco: Jossey-Bass.
Breunlin, D. C., Schwartz, R. C., & Mac Kune-Karrer, B. unable to accommodate significant social
(1997). Metaframeworks: Transcending the models of demands from external social institutions
family therapy (Rev. ed.). San Francisco: Jossey-Bass. (Minuchin 1974). Failing to integrate informa-
Pinsof, W. M. (1983). Integrative problem centered
tion external to the closed system demonstrates
therapy: Toward the synthesis of family and individual
psychotherapies. Journal of Marital and Family the system’s challenges with navigating the
Therapy, 9, 19–35. https://doi.org/10.1111/j.1752- change/continuity continuum. Due to rigid
0606.1983.tb01481.x. external boundaries and minimal interaction
Pinsof, W. M. (1994). An integrative systems perspec-
with the extrafamilial environment, family
tive on the therapeutic alliance: Theoretical, clinical,
and research implications. In A. O. Horvath & members navigate change/continuity primarily
L. S. Greenberg (Eds.), The working alliance: The- via an internal channel. Therefore, external
ory, research, and practice (pp. 173–195). Oxford: information used to balance change and conti-
Wiley.
nuity does not figure centrally into a closed
Pinsof, W. M. (1995). Integrative problem-centered ther-
apy: A synthesis of family, individual, and biological system, thereby increasing isolation and famil-
therapies. New York: Basic Books. ial dysfunction (Minuchin 1974).
Closed Systems in Family Systems Theory 467
Conversely, an open system possesses func- level of dysfunction due to its desire to disregard
tionally flexible boundaries with the outside order and to resist change.
world (Simon et al. 1985). The presence of more Eleanor Wertheim in her article entitled, Fam-
permeable boundaries permits a free exchange of ily unit therapy and the science and typology of
information and resources between the family unit family systems (1973), in the Journal, Family Pro-
and the larger systems. Individual members in an cess, proposed a theoretically derived three-
open system navigate the change/continuity con- dimensional typology of family systems. More C
tinuum by extending the family outward into the specifically, she concluded that two subtypes of
larger community space, and as a result, incorpo- closed family systems existed, namely closed-
rate the exterior culture, into the family system disintegrated family system and closed-pseudo-
(Kantor and Lehr 1975). An open system incor- integrated family system. In both types of closed
porates outside information and resources when family systems, homeostatic control is established
navigating the change/continuity continuum, through family rules that do not permit feedback
thereby making the open system capable of inte- from external sources.
grating external stimuli and the benefits of
resources into the existent internal system.
Description
Prominent Associated Figures A closed system is one in which the boundaries

between the system and environment prevent out-
Salvador Minuchin (1974) initially outlined the side information from entering the system (Simon
concept of boundaries, in his book, Families and et al. 1985). According to Kantor and Lehr (1975),
Family Therapy. Minuchin discussed how some in a closed system, the mechanism that regulates
families attempt to solely rely upon themselves, both incoming and outgoing information is
independent from the external world, and as governed by an authority figure such as a
the distance between family members decreases, parent(s). Examples of a closed system include:
enmeshed boundaries result. According to parental control over social media; lack of paren-
Minuchin, due to attempted cut-off from the out- tal permission to attend social excursions, scrutiny
side world, a closed system may lack the on the part of parent(s) related to communication
resources needed to adapt and change under with persons outside of the immediate family sys-
stressful circumstances. tem; and messages that persons outside of the
David Kantor and William Lehr (1975) in their family cannot be trusted.
book, Inside the Family: Toward a Theory of Goals of a closed system are centered around
Family Process, conceptualized three family privacy, self-protection, and in some family sys-
types: (1) open, (2) closed, and (3) random. In tems, secretiveness. Members who abide by the
the open system, they concluded that order and rules of maintaining privacy and secrets are
change result from a balanced interaction between rewarded, whereas those who attempt to share
a family system and its outside environment. In information with outsiders are punished. Above
the closed system, the family attempts to prevent all, privacy is to be maintained by all members.
outside influences from entering the system, Likewise, in accordance with preservation of
thereby, resulting in an imbalance between order privacy, closed systems employ formal teaching
and change. According to Kantor and Lehr processes centered around maintaining key family
(1975), a closed system attempts to maintain themes, traditions, and values as a trans-
order, while attempting to thwart change. In the generational process.
random system, there is a general sense of disor- Boundaries, as defined by Minuchin (1974),
ganization in which the family system resists indicate that a closed system employs rigid
change and order. According to Kantor and Lehr boundaries with the outside world, while
(1975), a random family system possesses a high employing enmeshed boundaries within the
468 Closed Systems in Family Systems Theory
family system. In closed systems, family members self-sufficient social system that protects against
may employ overly protective measures to shield dangers from external intrusions and divergent
a child from the outside world while employing points of view within. However, attempts to sus-
overly submissive behaviors within the system, tain a behavioral boundary around a family cannot
thereby demonstrating enmeshed intrafamily be maintained because a living system must par-
boundaries. By isolating from the outside world, ticipate in the larger society. To maintain this myth
family members overly rely upon one another of complete self-sufficiency within the “rubber
for resource management, information, and need fence,” family members stretch to incorporate
gratification. those persons, experiences, and behaviors that fit
According to Wertheim (1973), a closed family into the family framework/possess complementar-
system, homeostatically, is controlled by firmly ity and contract to exclude those who do not
established family rules with little acceptance for possess complementarity/fit (Simon et al. 1985).
spontaneous feedback either from the individual Within a family therapy context, persons in a
within or from systems external to the family unit. closed system may conclude that the therapist is
In addition, Wertheim’s conceptualization of a either to be excluded from the family system or
closed system-disintegrated type highlighted a incorporated into the family system. When a non-
low level of consensual morphostasis. Consensual family member, such as a therapist is incorporated
morphostasis is derived from an appropriately into the family system and its rules, one is said to
balanced, intrafamily distribution of power. The be within in the “rubber fence” (Wynne et al.
term, consensual morphostasis refers to genuine 1958). Whether a therapist is incorporated or
stability of the family system that is consensually excluded, new experiences perturbate the system,
validated by its members (Wertheim 1973). yet the system accommodates to the perturbations
Another form of closed system conceptualized by without changing its organizing principles.
Wertheim (1973) was the closed system-pseudo-
integrative type. In this type of closed system,
there is a high level of forced morphostasis. Forced Clinical Example of Application of
morphostasis is rooted in intrafamily power imbal- Theory in Couples and Families
ance. The term is synonymous with pseudo-
mutuality, as coined by Wynne et al. (1958), and Jerry and Ana have 2 children, their daughter
refers to an apparent stability of the family system, Amy who is 12-years-old and their son John
when there is an absence of genuine and consensual who is 14-years-old. Jerry and Ana have been
validation by its members. Forced morphostasis married for 20-years. Jerry and Ana have entered
contributes to within-family alienation, individual family therapy because Amy reportedly no longer
alienation, and disturbed functioning in the system wants to follow rules set forth by Jerry. Amy has
as a whole (Wertheim 1973). also begun to question the family’s religious ori-
entation and no longer desires to be home-
schooled. Jerry indicates that John complies with
Relevance to Couple and Family Therapy all rules, looks forward to attending church func-
tions and flourishes in all aspects of the home-
In order to explain boundaries within closed fam- schooling curriculum. Jerry states that all interac-
ily systems, Wynne (1970) introduced the term tions within the family were harmonious until
“rubber fence” to describe a process through Amy turned 12. According to Jerry, when Amy
which a family implements an elastic boundary turned 12, Ana began to grant Amy the latitude to
that helps them to maintain a sense of closeness/ express her opinions. Ana appeared to agree with
relatedness within the system. The process is Jerry and became tearful when she shared that she
designed to thwart the threat of divergence from made mistakes with Amy that put the family
within and to prevent intrusion from outside of the at-risk of no longer being close-knit. Jerry and
system. Therefore, the system attempts to act as a Ana state that they share the same ideas around
Coaching in Bowen Family Therapy 469
parenting, and that children should be “seen and Simon, B. F., Stierlin, H., & Wynne, L. C. (1985). The
not heard.” Ana shares that she and Jerry agree language of family therapy: A systemic vocabulary and
sourcebook. New York: Family Process Press.
about parenting. Ana wants to use therapy to Wertheim, E. (1973). Family unit therapy and the science
correct her parenting mistakes, so that both chil- and typology of family systems. Family Process, 12(1),
dren know that parents are to be obeyed and not 361–376.
questioned. Wynne, L. C. (1970). Communication disorders and the
The family therapist assessed the extent to
quest for relatedness in families of schizophrenics.
American Journal of Psychoanalysis, 30(1), 100–114.
C
which this family employed a closed system. Wynne, L. C., Ryckoff, I. M., Day, J., & Hirsch, S. I.
The family therapist concluded that this family (1958). Pseudo-mutuality in the family relations of
functioned within a closed model. Both Ana and schizophrenics. Psychiatry, 21(1), 205–220.
Jerry shared that they viewed their family unit as
highly self-sufficient and wanted to minimize
external influences from entering the family sys- Coaching in Bowen Family
tem. As both Jerry and Ana incorporated the fam- Therapy
ily therapist into their closed system, the therapist
was able to assist the family in naming their sys- Tara Schlussel and Molly F. Gasbarrini
tem as “closed.” Benefits and costs of employing a California School of Professional Psychology,
closed system were discussed with Jerry and Ana, Alliant International University, Los Angeles,
and the concepts of continuity/change within a CA, USA
closed system as opposed to an open system
were discussed. Over the course of therapy, Jerry
and Ana were able to see that they had been Name of the Strategy or Intervention
excluding Amy from the closed system by identi-
fying her as the family member who was bringing Coaching in Bowen Family Therapy
in ideals from the outside that were threatening to
the system (e.g., norms around being 12 years of
age). In addition, Jerry and Ana ultimately recog- Introduction
nized that by excluding their children from out-
side influences, they were, in fact, sheltering them Bowen Family Therapy utilizes a multigenerational
from the realities of life. approach, addressing conflicts that arise when indi-
viduals experience severe anxiety (Miller 2010).
Coaching in Bowen Family Therapy refers to one
Cross-References technique associated with Bowen Family Therapy,
where the clinician works with an individual or
▶ Boundaries in Structural Family Therapy couple who is driven, self-aware, and prepared to
▶ Kantor, David address relationship patterns and triangles within
▶ Minuchin, Salvador their family (Miller 2010). A prerequisite for begin-
▶ Morphogenesis in Family Systems Theory ning “coaching” is that the individual must demon-
▶ Morphostasis in Family Systems Theory strate control over his or her emotional reactivity
▶ Pseudomutuality in Family Systems and a sufficient level of insight about recurring
patterns of communication between family mem-
bers (Miller 2010). Throughout the intervention, the
References individual expands his or her awareness of self, as
well as conflicts that tend to reoccur within the
Kantor, D., & Lehr, W. (1975). Inside the family: Toward family system (Miller 2010). Subsequently, the cli-
a theory of family process. San Francisco: Jossey-
Bass, Inc.
nician challenges the individual to diverge from the
Minuchin, S. (1974). Families and family therapy. Cam- daily patterns of interaction that prevent him or her
bridge, MA: Harvard University Press. from achieving differentiation.
470 Coaching in Bowen Family Therapy
Theoretical Framework coaching couples, the Bowenian therapist main-

tains communication between each individual,
Bowen Family Therapy is a family systems rather than encouraging the dyad to interact with
approach that recognizes the multigenerational one another (Hoffman 1976). Bowen preferred
patterns of behavior that impact an individual or this form of communication as it reduces anxiety
family’s behavior. Bowenian therapy involves and irrationality, which he presumed to fuel the
working with an individual, couple, or family to patterns of reactivity and dysfunction within fam-
address how problems may be rooted in previous ilies (Hoffman 1976). This method also affords
generations. This framework draws from systems the therapist additional authority and influence
thinking in that an individual is viewed as part of a (Hoffman 1976). As the therapist communicates
family or emotional unit. The individual is able to with one individual at a time, Bowen’s coaching
identify how his or her behavior follows a pattern, technique allows for two distinct treatments to
stemming back to the family of origin, and thus co-occur for each of two dyads (Hoffman 1976).
gains further insight into patterns of dysfunction The ultimate goal of coaching is for each individ-
that have persisted through generations. There are ual to experience a reduction in anxiety and an
a wide array of tools and techniques that may be ability to maintain independence and autonomy
utilized to conduct Bowen Family Therapy, while remaining connected to one another (Baker
including genograms, process questions, relation- 2015; Goldenberg and Goldenberg 1996).
ship experiments, the neutralization of the symp-
tomatic triangles, coaching, “I-position,” and
displacement stories (Miller 2010). During Description of the Strategy or
Bowen Family Systems couple coaching, the cou- Intervention
ple’s relationship is not conceptualized in terms of
illness, mental health, or diagnostic categories During coaching in Bowen Family Therapy, the
(Baker 2015). By viewing the couple through an therapist begins to coach each spouse in order to
intergenerational framework, each member is increase their levels of differentiation and gain
understood as intertwined with his or her respec- awareness about each of their families of origin
tive family and is evaluated by his or her position (Bowen 1978). This requires the individuals to
on the continuum of differentiation (Baker 2015). have some degree of insight about the behavior
patterns within their families (Miller 2010). In the
initial session, the coach works with the couple to
Rationale for the Strategy or explore each member’s family of origin, extended
Intervention family, and relationship with one another other, by
generating a family diagram or genogram (Baker
Bowen sought to find a term that encompassed the 2015). When couple coaching, it is important to
therapist’s role in therapy with couples, which consider the concept of the emotional triangle, as
ultimately led him to coin the term “coaching” an anxious couple has the tendency to involve a
(Baker 2015). Bowen incorporated the term third individual, in order to regain balance in the
“coach” rather than common terminology, such couple’s relationship (Baker 2015). This third
as clinician or therapist, to prevent pathologizing individual may take the shape of a therapist,
the couple and refraining from implementing a friend, colleague, relative, child, or coach (Baker
medical model that may portray the couple as ill 2015). It is essential that the coach is
and in need of a cure (Baker 2015). detriangulated and remains aware of the challenge
Bowen believed the term “coach” accurately to uphold neutrality throughout the coaching ses-
reflected neutrality of the therapist while embody- sion, thereby allowing the couple to achieve dif-
ing the concept of an active expert who coaches ferentiation (Baker 2015).
both individual players and the team as a whole Children under the age of 18 years are not
with the utmost capability (Baker 2015). While usually involved in a coaching session, although
Coaching in Bowen Family Therapy 471
they often endure many of the symptoms (Baker applicable to each member of the couple and their
2015). Occasionally, another family member, family system and modify less suited elements,
such as a grandparent or adult daughter or son, depending on the couple’s needs and preferences.
may be invited to participate in the couple While there remains a need for studies examining
coaching session, in order to provide the coach the effect of couple coaching on individual and
with additional perspectives into the family sys- overall couple functioning, research utilizing
tems issues addressed by the couple (Baker 2015). Bowen Family Theory has evaluated couple rela- C
While incorporating additional family members tionships. Skowron and Friedlander (1998) have
provides knowledge about the family systems developed a scale for measuring differentiation
relationships, it is optimal to include no more (Baker 2015). In addition, Schnarch and Regas
than three people, including the “coach.” (2008) created the Crucible Differentiation Scale
Restricting the number of participants in session (CDS) which examines differentiation of self.
to three individuals limits the potential formation Klever (2001, 2003, 2004, 2005a, b, 2008a, b,
of triangles and enables the coach to localize 2009) has explored levels of differentiation among
complete attention on the couple (Baker 2015). couples and the impact on both couple and family
During the coaching process, couples are gen- systems functioning (Baker 2015). Further research
erally seen for 1 hour, once a week, during which is needed to empirically demonstrate the effects of
time the family history is formulated and assess- couple coaching on couple and individual levels of
ments are conducted (Baker 2015). After the cou- differentiation, anxiety, and reactivity, utilizing a
ple’s anxiety begins to decrease, they are seen Bowenian Family Systems approach.
every other week and eventually on a monthly
schedule or less regularly (Baker 2015). The cou-
ple’s decision regarding the frequency of Case Example
coaching sessions will ultimately depend on
their management of regular ongoing stressors Dan and Julia sought therapy in order to learn to
and reactivity within relationships (Baker 2015). co-parent and to communicate more effectively
While plans and strategies for change are formu- with one another in their relationship. The couple
lated during sessions, the couple’s real work is had grown distant and angry toward one another
viewed as occurring outside of sessions, when over the past 5 years, during which Dan had
daily stressors and events test each individual’s become increasingly disengaged and passive-
reactivity and level of differentiation (Baker aggressive with Julia. Julia had begun feeling
2015). A goal of couple coaching is for couples abandoned by Dan’s “emotional leave of absence”
to acquire the skills “to work on their relationship and dismissal of her parenting style with their
more effectively at home” (Baker 2015, p. 255). children (an 8-year-old daughter and a 12-year-
If symptoms are acute and intense, clients are old son). Julia’s reaction to Dan’s disengagement
encouraged to explore potential medication con- involved angry verbal outbursts with frequent
sultations. In addition, the couple is instilled with threats to divorce him.
curiosity about the emergence of symptoms During the first session, the coach described
within the broader sense of their family systems her role as a Bowenian family therapist to distin-
relationship or their “multigenerational emotional guish the work from other types of individual/
unit” (Baker 2015). couple therapy work that Julia and Dan had com-
pleted in the past. In the first few sessions, the
Empirical Support for the Efficacy of Coaching coach encouraged the couple to direct their con-
in Bowen Family Therapy versations to her in order to reduce the level of
Throughout the coaching process, the coach reactivity and verbal aggression that was
explores and measures the success of the coaching exchanged among them. The coach began by
technique for each couple. The coach continues to gathering information about the couple’s separate
incorporate aspects that prove beneficial and families of origin and individual relationships
472 Coaching in Bowen Family Therapy
with their parents. Directing the attention toward relating onto her relationship with her husband.
understanding their families of origin helped to By also encouraging Dan’s involvement in the
de-escalate the couple’s negative emotional dis- process of weaving a connection with Julia’s
course while increasing their capacities toward a father, Dan became a vital, active force rather
curious and introspective stance. Upon creating than a detached and passive-aggressive partner.
family genograms, the couple was able to view the Once their levels of anxiety decreased, Julia
transgenerational transmission patterns of behav- and Dan learned to become less emotionally reac-
ior that had locked them into highly reactive and tive and to de-escalate conversations that were
repetitive patterns. This process allowed the cou- potentially combustive. Upon recognition of
ple to take responsibility for their individual roles their modes of relating through triangulation,
in their relationship and dysfunctional communi- multigenerational transmission, emotional cutoff,
cation patterns as opposed to blaming one another. and projection, Julia and Dan were able to lower
Through the use of family diagrams, Dan was their anxiety and increase their level of individual
able to see that he was conflating his wife with and couple’s level of differentiation. This led to
his controlling and overpowering mother who improved co-parenting style and enabled them to
made it difficult for him to develop a solid refrain from using their children for triangulation
sense of self. Dan’s passive-aggressive behavior or projection in order to lower their anxiety and
with his mother was now transferred to his wife stabilize their relationship.
whenever Julia would express a strong need or
desire in their dyad. Dan developed insight about
his role in triangulating their son into acting Cross-References
oppositional and disrespectfully to his mother.
Dan was encouraged to build a healthier and ▶ Bowen, Murray
more differentiated relationship with his mother ▶ Couple Therapy
and to demonstrate firmer boundaries with her. ▶ Differentiation of Self in Bowen Family
He was able to verbalize his frustrations to his Systems Theory
mother and, as a result, engaged in fewer ▶ Emotional Cutoff in Bowen Family Systems
passive-aggressive behaviors toward his wife. Theory
Julia’s mother died when she was 12 years ▶ Family Projection Process
old, leaving her to be raised by her father. Grow- ▶ Family Therapy
ing up, Julia felt dismissed and devalued by her ▶ Genogram in Couple and Family Therapy
father, noting that the only times she felt heard ▶ Multigenerational Transmission Process in
were during moments where she expressed Bowen Therapy
intense bouts of rage, which would successfully ▶ Triangles in Bowen Family Therapy
incite a reaction in him. In anticipation of the
birth of her first child, Julia had asked her father
to be present and supportive of her. When her References
father instead left for Japan with a new and
young girlfriend, Julia decided to cease commu- Baker, K. G. (2015). Bowen family systems couple
nication with her father, cutting him out of her coaching. In A. S. Gurman, J. L. Lebow, D. K. Snyder,
life. Upon further work, Julia began to start A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.),
Clinical handbook of couple therapy (5th ed.,
communicating with her father and heal old pp. 246–267). New York: Guilford Press.
wounds. Julia’s work to bridge the cutoff with Bowen, M. (1978). Family therapy in clinical practice.
her father allowed room for emotional intimacy New York: Jason Aronson.
with Dan who remained supportive and engaged Goldenberg, I., & Goldenberg, H. (1996). Family therapy
an overview (4th ed., pp. 165–186). Pacific Grove
during this difficult period. The coach helped Brooks/Cole Publishing Company.
Julia develop awareness of how she was trans- Hoffman, L. (1976). Foundations of family therapy.
ferring her early father-daughter pattern of New York: Garner Press.
Coalition in Couple and Family Therapy 473
Klever, P. (2001). The nuclear family functioning scale: Triangulation in Bowen Family Systems
Initial development and preliminary validation. Fami- Theory
lies, Systems, and Health, 19, 397–410.
Klever, P. (2003). Intergenerational fusion and nuclear family
functioning. Contemporary Family Therapy, 25, 431–451. From a Bowen family systems theory perspective,
Klever, P. (2004). The multigenerational transmission of triangulation is a rigid process that occurs as a
nuclear family processes and symptoms. American result of excess chronic anxiety (Bowen 1978).
Klever, P. (2005a). Multigenerational stress and nuclear A primary dyad is not considered to be a stable C
family functioning. Contemporary Family Therapy, relationship from this perspective due to the diffi-
27, 233–250. culty with which two people manage the chronic
Klever, P. (2005b). The multigenerational transmission of anxiety experienced within the relationship.
family unit functioning. American Journal of Family
Therapy, 33, 253–264. Therefore, creating an emotional triangle by
Klever, P. (2008a). The primary triangle and variation in bringing a third member into the primary dyad is
nuclear family functioning. Contemporary Family thought to stabilize the relationship by allowing
Therapy, 31, 140–159. the chronic anxiety to have more avenues to dis-
Klever, P. (2008b). Triangles in marriage. In P. Titelman
(Ed.), Triangles: Bowen family systems theory perspec- perse and allowing the primary dyad to better
tives (pp. 245–264). Binghamton: Haworth Press. regulate the emotional distance within the rela-
Klever, P. (2009). Goal direction and effectiveness, emo- tionship. Emotional triangles are not problematic
tional maturity, and nuclear family functioning. Jour- provided they remain flexible. Contrarily, triangu-
nal of Marital and Family Therapy, 35, 308–324.
Miller, A. (2010). Instructor’s manual for Bowen family lation becomes problematic as it is a rigid process
therapy with Philip Guerin, MD. Mill Valley: Psycho- in which the third member is chronically brought
therapy.net. into the primary dyad as the sole means of dis-
Schnarch, D. M., & Regas, S. (2008). The Crucible differ- persing the chronic anxiety. In these circum-
entiation scale: Assessing differentiation in human
relationships. Unpublished manuscript. stances, the relationship between two of the
Skowron, E. A., & Friedlander, M. L. (1998). The differen- members of the triangle becomes fused, while
tiation of self inventory: Development and initial valida- the other member is cut off from the relationship.
tion. Journal of Counseling Psychology, 45, 235–246. The third “member” of an emotional triangle is
often a person. However, in triangulation, that
third member often becomes a symptom. Three
types of symptoms are thought to present: rela-
Coalition in Couple and tional conflict, symptom development in one or
Family Therapy both members of the primary dyad (couple), or
symptom development in a child (Friedman
George M. Simon1 and Heather Katafiasz2 1991). Little is written regarding the presentation
1
The Minuchin Center for the Family, of relational conflict, although intimate partner
Woodbury, NJ, USA violence is thought to be an extreme version of
2
The University of Akron, Akron, OH, USA relational conflict (Bartle and Rosen 1994).
Symptom development in one member of the
primary dyad often presents as an individual or
Introduction relational issue. For instance, an individual issue
may be job instability or overworking, mental
Prominent in the descriptions of family functioning health diagnoses, or substance use, while a rela-
offered by the earliest approaches to family therapy tional issue may be infidelity. More than one
is the notion of the dysfunctional triangle. Versions symptom may be triangulated depending on the
of this notion can be found in Bowen family sys- amount of excess chronic anxiety within the rela-
tems theory (BFST), in the strategic therapy tionship, with both members of a couple pre-
(ST) developed by Jay Haley and Chloe Madanes, senting with symptoms. Often when symptoms
and in structural family therapy (SFT), developed develop within the primary dyad, the relational
by Salvador Minuchin and his colleagues. processes within the emotional system evolve,
474 Coalition in Couple and Family Therapy
co-emerging to form an “overfunctioner” and structural configuration almost invariably seen

“underfunctioner” dynamic (Kerr and Bowen by SFT to be dysfunctional.
1988). In this dynamic, both members of the cou- As it is understood by SFT, a coalition is the
ple have similar basic levels of differentiation, but joining of two or more family members of differ-
one member develops a higher functional level of ing generations in conflict against one or more
differentiation than the other member. other members of the family (Minuchin 1974).
The next type of symptom in triangulation is For example, a man may join with his mother in
the development of symptoms within a child. The conflict against his wife. Similarly, a woman may
likelihood that a child will be triangulated into the join with one of her children in conflict against her
primary dyad is not well understood, but is partner. A given family might have two coalitions,
believed to depend on sibling position (Friedman each opposed to the other: for example, mother
1991), family context, and personality character- and oldest child arrayed against father and youn-
istics. Symptoms that develop within children gest child.
allow the primary dyad to communicate to resolve Coalitions can be stable or shifting. In the
the symptom, while not having to face the issues former case, the “allies” remain such over time
within their relationship. More frequent triangula- and in varying contexts, so that if one were to
tion into the primary dyad by children will lead eavesdrop at random times on family transactions,
over time to the development of lower differenti- one would always see the “allies” arrayed against
ation in those children. Serving an important func- the common “enemy.” In the case of shifting
tion for their family, launching can be a difficult coalitions, referred to in the SFT literature as
process for these children, who have not learned “triangulation,” a member of the family shuttles
how to be independent, yet connected to their back and forth between two different “camps”
family members. Often launching results in cutoff within the family (Minuchin 1974). A particular
from their family of origin, at least temporarily. child, for example, might sometimes be arrayed
The patterns of managing chronic anxiety learned with one parent against the other and, at a later
in their family of origin are then brought into time, join the second parent against the first.
future relationships, with those adults now repeat- It is not the conflict entailed by coalitions that
ing those same patterns with their own significant renders them dysfunctional. In the view of SFT,
others and children, in a process known as the conflict is not only inevitable in family life, it is
family projection process. also necessary in order to activate latent family
resources and empower the family to execute the
tasks associated with any given stage in its
Coalition in Structural Family Therapy development.
Conflict, however, can achieve this adaptive
Like most other early approaches to family ther- function only if it remains focused. Coalitions
apy, SFT views the family as a system of muddle the focus of conflict, precisely as a result
interacting parts, with the functioning of each of the intergenerational enmeshment that lies at
part being both caused by and causative of the their heart. It is because they muddle conflict,
functioning of the other parts (Minuchin 1974; depriving it of its adaptive value, that SFT
Minuchin et al. 1978). At any given stage of a deems coalitions dysfunctional. A simple exam-
family’s development, the way in which its parts ple will illustrate the kind of muddling produced
interact tends to be stable, with the result that the by coalitions.
family can be thought of as having a structure that A husband observes his wife chronically infan-
can be mapped. A family’s structure is deemed tilizing their adolescent son in a manner that he
functional if it allows the family to execute the finds highly reminiscent of the way she typically
tasks associated with its developmental stage. If relates to him. The husband rarely complains
the structure inhibits the execution of these tasks, directly to his wife about her stance toward him;
it is deemed dysfunctional. A coalition is a however, he loses no opportunity to join his son
Coalition in Couple and Family Therapy 475
when the latter begins to complain angrily to his systems become so preoccupied with control that
mother about her infantilization. The young man members begin to resort to covert means to
invariably welcomes his father’s support, and the attempt to control the system. Symptoms are one
two proceed in unison to berate the mother about such means. Another is what Haley (1977) termed
the inadequacy of her parenting. The ensuing “the perverse triangle.”
episode of conflict is focused simultaneously on Recognizable in ST’s description of the per-
both a parenting issue (overtly) and a spousal verse triangle is the structural feature referred to in C
issue (covertly). This muddling of the focus of SFT as a coalition: the joining of two persons of
the conflict would, by itself, all but guarantee different generations, generally a parent and a
that the conflict will not resolve itself in any kind child, in opposition to a third person, generally
of adaptive shift in the way the family members the parent’s partner. However, ST’s distinctive
relate to each other. However, the way in which preoccupation with power and control can be
the members behave in the conflictual transaction seen in its focus on an aspect of the
further fates the conflict to be nonproductive. The intergenerational coalition not adverted to in
son’s dependence on his father to be the spokes- SFT, namely, the fact that its existence is denied
man for his cause during the exchange makes him by the members of the family system who are
look “young” and immature to his mother, thereby party to it. It is precisely this denial that allows
eliciting nothing more from her than an entrench- the allies within the coalition to use their alliance
ment in her infantilizing stance toward the son. as a covert weapon in their struggle to gain rela-
Meanwhile, the mother’s perception that it is inap- tional control within the family system.
propriate for her husband to be supporting their Inevitably, the coalition involved in the per-
son in opposition to her has no other effect than to verse triangle fails to gain for the allies the rela-
elicit from her exactly the kind of one-up postur- tional control that they seek. Quite the contrary, in
ing toward the husband that he finds so objection- fact, the coalition has no other effect than to elicit
able. Finally, the father and son’s shared more of the particular behavior by the target of the
experience of the mother as being self-righteously coalition over which the allies were seeking to
obstinate during the transaction solidifies their exercise control in the first place. As a result, the
coalition and primes them for their next united struggle for control within the perverse triangle
confrontation of her. frequently escalates over time, with the introduc-
tion of symptomatic behavior by one or more
participants in the triangle serving as the mecha-
Coalition in Strategic Therapy nism of escalation. Tragically, symptoms prove to
be as ineffective in gaining the symptom-bearer(s)
The variety of ST developed by Jay Haley and control of the family system as was the coalition.
Chloe Madanes shares with SFT all of the latter Precisely for that reason, once introduced into the
model’s notions of family structure (Haley 1976). circular interactions within the perverse triangle,
However, even as it employs the concepts of symptoms have the effect of further reinforcing
family structure, ST is marked by a focus on and stabilizing the triangle.
power that, while certainly not absent from SFT,
is nowhere near as prominent in the latter
approach as it is in ST. Clinical Example
ST views people in relationship as almost
invariably devoted to the project of controlling While they have much in common, the descriptions
the rules that govern the relationship. Such a proof the dysfunctional triangle provided by each of the
ject is foolhardy, since the systemic nature of clinical models discussed in this article are marked
relationships renders it impossible for one partic- by varying emphases that are reflective of the dif-
ipant to unilaterally control the rules of the circu- fering underlying assumptions and preoccupations
lar relational system. Nonetheless, some family of each of the models. These varying emphases
476 Coalition in Couple and Family Therapy
result in considerably differing prescriptions offered therapist can see the husband and wife in couple
by the models to undo the deleterious effects that all sessions that are utilized to prompt the husband to
of them see as resulting from the presence of dys- express directly to his wife his objections to the
functional triangles within families. Since it lies way that she typically relates to him. The therapist
outside the scope of an article such as this to provide expects that she will need to devote considerable
clinical examples of how all three of the models energy during such sessions to blocking a shift of
respond to triangles, we will close the article with focus from spouse talk to parenting talk.
a brief description of how the SFT therapist typically
intervenes to restructure a coalition.
The reader will recall that SFT identifies coali- Cross-References
tions as dysfunctional as a result of the muddling
of the focus of conflict that they inevitably pro- ▶ Boundary Making in Couple and Family
duce. Faced with this muddling, SFT responds to Therapy
the presence of coalitions in client families by ▶ Challenge in Structural Family Therapy
endeavoring to mark a boundary between the ▶ Complementarity in Structural Family Therapy
“allies” in the coalition (Minuchin and Fishman ▶ Enactment in Couple and Family Therapy
1981). This boundary marking creates a context in ▶ Family Development in Structural Family
which each of the members of the coalition can Therapy
fight the fight that is proper to her or him and fight ▶ Family Function and Dysfunction in Structural
that fight on his or her own. Among the techniques Family Therapy
utilized in SFT to undermine coalitions are enact- ▶ Mapping in Structural Family Therapy
ments, unbalancing and challenging. ▶ Power in Family Systems Theory
Let us imagine that the family described earlier ▶ Unbalancing
in the section on SFT presents itself for treatment
to an SFT therapist after the adolescent’s school
psychologist contacts the parents to inform them References
that he is adjusting poorly to high school “due to
poor social skills.” First-session enactments allow Bartle, S., & Rosen, K. (1994). Individuation and relation-
the therapist to map the coalition detailed above, ship violence. American Journal of Family Therapy,
22(3), 222–236.
along with the complementarity to which it is Bowen, M. (1978). Family therapy in clinical practice. In
recursively linked. Family therapy in clinical practice (pp. 467–528).
Armed with her assessment of the family’s New York: Aronson, Inc.
structure, the therapist contemplates three broad Friedman, E. H. (1991). Bowen theory and therapy. In A.
S. Gurman & D. P. Kniskern (Eds.), Handbook of
interventive strategies that she can utilize to family therapy (Vol 2) (pp. 134–170). New York:
attempt to restructure the family system. First, Brunner/Mazel.
she can elicit enactments between mother and Haley, J. (1976). Problem-solving therapy: New
son, in which the two are asked to negotiate new strategies for effective family therapy. San Francisco:
Jossey-Bass.
rules for their relationship that are congruent with Haley, J. (1977). Toward a theory of pathological systems.
the son’s adolescent status. As the two struggle to In P. Watzlawick & J. Weakland (Eds.), The interac-
accomplish this task, the therapist anticipates that tional view (pp. 31–48). New York: Norton.
she will need repeatedly to block the father from Kerr, M., & Bowen, M. (1988). Family evaluation:
An approach based on Bowen theory. New York:
entering the enactments. A second strategy entails W W Norton & Co.
the therapist’s probing for possible areas of con- Minuchin, S. (1974). Families and family therapy.
flict between the father and son. Should any such Cambridge, MA: Harvard University Press.
areas be identified, the therapist can attempt to Minuchin, S., & Fishman, H. C. (1981). Family therapy
utilize unbalancing to elicit and to amplify conflict Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psycho-
between the two, in the interest of marking a somatic families: Anorexia nervosa in context.
firmer boundary between them. Finally, the Cambridge, MA: Harvard University Press.
Coalition in Structural Family Therapy 477
Description
Coalition in Structural Family
Therapy Coalitions in structural family therapy are dysfunc-
tional alliances between at least two family mem-
Jessica M. Moreno1 and Sarah K. Samman2 bers against another member. A stable coalition is a
1
California State University, Sacramento, fixed and inflexible union, for example, between a
Sacramento, CA, USA mother and daughter that becomes a dominant part C
2
Alliant International University, San Diego, of the family’s everyday functioning (Minuchin
CA, USA et al. 1978). A detouring coalition is when the
pair hold a third party responsible for their difficul-
ties with one another, whereby decreasing the
Name of Concept pair’s relational stress (Minuchin et al. 1978).
Coalition in structural family therapy

Family Therapy
Introduction
In order to apply the concept of coalition when
Salvador Minuchin developed structural family conducting a couple or family therapy session, the
therapy based on the belief that family is more therapist would (1) recognize the coalition in
than a group of individuals with shared biology. the interactional patterns in the room, (2) bring
Family members relate to one another and create the coalition to the attention of the couple or
agreements and allyships, i.e., alliances, demon- family, and (3) discuss the effect of the coalition
strated through certain arrangements that govern on the overall functioning of the family.
their relational and interactional patterns. These
arrangements, though not always overtly
expressed or known by the family, form a struc- Clinical Example
ture whereby each family member abides by and
behaves accordingly (Minuchin 1974). Structural The Gonzalez family is comprised of Maria, a
family therapists believe the way some family 36-year-old cisgender female Mexican-American;
members organize can serve a functional or Carlos, a 37-year-old cisgender male Mexican-
dysfunctional purpose. Structural family thera- American; and their two biological children Ileana,
pists view coalitions as a dysfunctional alliance. their 12-year-old cisgender daughter, and Rodrigo,
their 10-year-old transgender son. The Gonzalez’s
were referred to family therapy by Rodrigo’s 6th
Theoretical Context for Concept grade teacher who reported that Rodrigo acted dis-
ruptively and defiantly in class. During the first
According to Aponte and Van Deusin (1981), session, the therapist asked the family for an enact-
every interaction in a family is a statement ment by playing a board game to observe family
about boundaries, alignments, and power. interactional patterns. Within minutes, the therapist
Boundaries dictate the roles, rules, and interac- noticed that Maria and Ileana were sitting close to
tional patterns of a family. Alignments are one another, with Carlos and Rodrigo sitting on
healthy alliances that demonstrate how support- opposite sides of the table. The mother and daughter
ive or unsupportive a family member is with were whispering to one another, smiling, and seem-
another. Power is not static or absolute and can ing to enjoy themselves. Carlos also seemed fully
depend on each member and situation, and it is engaged in the game. Meanwhile, Rodrigo appeared
largely related to how actively or passively fam- consistently more withdrawn as the game pro-
ily members combine alliances. gressed as evidenced by lacking eye contact with
478 Code of Ethics in Couple and Family Therapy
Maria and Ileana, looking down solemnly, and dem-

onstrated general disengagement from the game. Code of Ethics in Couple and
Once the therapist noticed the coalition between Family Therapy
Maria and Ileana against Rodrigo, she interrupted
the game by asking the following questions, “I Bobbi J. Miller and Rachel Weddle
noticed that you, Maria and Ileana, seemed to have Regis University, Denver, CO, USA
had a really good time playing the game with one
another. I also noticed that you may have purpose-
fully ignored Rodrigo. I wonder what it was like for Introduction
Rodrigo to feel left out and excluded? Rodrigo, what
was it like for you to watch your mom and sister Practitioners in the field of mental health are
connecting and having a good time, while you were consistently faced with complicated and ambig-
over there looking disconnected? Were there other uous situations in therapy which require them to
times you felt left out in the family? By whom? Has make decisions about the “best option” for pro-
your father ever noticed? How often does this hap- tecting the welfare of their clients. The codes of
pen? What does this look like?” After asking open- ethics within the multiple disciplines in mental
ended questions, the therapist engaged the family in health arose out of a need to quantify some of
a dialogue about what happens in the family when the agreed-upon boundaries of practice and to
Maria and Ileana exclude Rodrigo. give guidance to practitioners as they were nav-
igating decisions without clear-cut answers.
Codes of ethics in couple and family therapy
are unique in that they are created to address
Cross-References some of the complicated issues that arise from
having more than one individual to consider in
▶ Alliance in Family Relationships thinking about one’s “client.”
▶ Boundaries in Structural Family Therapy
▶ Complementarity in Structural Family Therapy
▶ Enactment in Structural Family Therapy
▶ Family Development in Structural Family Theoretical Context for Codes of Ethics
Therapy in Couple and Family Therapy
▶ Family Function and Dysfunction in Structural
Family Therapy Purpose of Codes of Ethics
▶ Joining in Structural Family Therapy Codes of ethics serve three main purposes: first
▶ Tracking in Structural Family Therapy and foremost to protect the public; second, to
▶ Training Structural Family Therapists protect the profession from governmental intru-
▶ Triangles and Triangulation in Family Systems sion; and finally, to protect practitioners from
Theory the public (Wilcoxon et al. 2012). They serve to
provide guidance to practitioners in determining
acceptable boundaries of sound clinical deci-
References sion in a given mental health field. This provides
autonomy for a profession in determining their
Aponte, H. J., & Van Deusin, J. M. (1981). Structural
family therapy. In F. M. Dattillo & L. J. Bevilacqua
own best practices. In addition, they provide
(Eds.), Comparative treatments for relationship support for determining when intervention is
dysfunction (pp. 45–57). New York: Springer. necessary to remediate concerning therapist
Minuchin, S. (1974). Families and family therapy. behavior. Finally, they provide some direction
Cambridge, MA: Harvard University Press.
Minuchin, S., Rosman, B. L., & Baker, L. (1978).
about what constitutes malpractice, which
Psychosomatic families: Anorexia nervosa in context. allows more clarity for all involved when com-
Cambridge, MA: Harvard University Press. plaints arise from clients.
Code of Ethics in Couple and Family Therapy 479
Development of Codes of Ethics on compliance into one focused more on under-

The development and use of codes of ethics is standing and utilizing the ethical principles
fairly new to the mental health field as a whole. undergirding the profession as a whole. Codes
The first code of ethics specific to the field of developed in a discretionary fashion focus on
couple and family therapy was crafted by the providing practitioners with philosophical guid-
American Association of Marriage and Family ance to making decisions. These codes are spe-
Therapy (AAMFT) and accepted by member- cific to areas where the field has not yet taken a C
ship in 1962. These codes continue to be definitive stance on a course of action, but
updated as the context of therapy evolves and instead are recognized as areas replete with
in response to concerns raised about practice in ambiguity (Wilcoxon et al. 2012). One specific
the field. For example, significant changes were example are codes specific to multiple relation-
made in the January 2015 revision of the ships. The AAMFT Code of Ethics allows that
AAMFT Code of Ethics to clarify questions situations arise in which multiple relationships
specific to the use of technology in practice cannot be avoided. However, they also provide
(Caldwell, 2015). These types of changes have discussion regarding the concerns embedded in
caused some to view codes of ethics as more multiple relationships the practitioner needs to
“reactive than proactive,” which is a common take steps to avoid, including “exploiting trust
concern noted specific to relying solely on these and dependency.” They also instruct the practi-
codes for guidance in sound ethical decision- tioner to document all steps taken to avoid these
making. As of the 2015 revision, the AAMFT repercussions when such a relationship is
Code of Ethics has been revised ten times unavoidable (AAMFT 2015).
since 1962. Discussions of the codes within the context
Overall, codes of ethics in the field of couple of mandatory and discretionary actions can lead
and family therapy are based on the underlying to the false assumption that some decisions
ethical principles put forth by Beauchamp and practitioners make are “cut and dry.” However,
Childress (e.g., Autonomy, Beneficence, Justice, even mandatory actions are replete with their
etc.) consistent with the codes of ethics of other own hidden areas of uncertainty. For example,
mental health disciplines. However, the applica- in the case of “duty to warn and protect,” a
tion of these ideas in the codes specific to couple provider is left with the question of when a
and family work is different based on the defini- client represents an actual threat to the public
tion of who constitutes the client (Murphy and and invokes this duty on the part of the
Hecker 2016). clinician.
Mandatory Versus Discretionary Codes of Couple and Family Therapy

All of the ethical standards within the codes reflect Arguably, the AAMFT Code of Ethics is the
one or more of the ethical principles and either most widely recognized code of ethics
a mandatory or discretionary stance. A mandatory governing couple and family therapist. How-
stance outlines actions a practitioner absolutely ever, there are other codes therapists ascribe to
should not take (restrictive) or must take that address elements of practice with couples
(obligatory) in order to stay within the boundaries and family or are fully focused on the practice
of the codes. For example, the “duty to warn” and of systemic therapy. These include, but are not
the “duty to protect” are obligatory mandates that limited to: the Association for Family Therapy
necessitate a practitioner warn specific other and Systemic Practice in the UK Code of
(s) and/or take steps to protect the public from a Ethics (AFT 2013); International Association
client who poses a risk of harm to others of Marriage and Family Counselors Ethical
(Wilcoxon et al. 2012). Codes (IAMFC 2017); and the European Fam-
A discretionary stance, on the other hand, ily Therapy Association Code of Ethics (EFTA
moves from decision-making based primarily 2012).
480 Code of Ethics in Couple and Family Therapy
Description of Codes of Ethics in Couple Client Welfare

and Family Therapy By expanding the definition of client from one
individual to many, the responsibility of the
The discussion regarding the impact of treating a therapist to attend to multiple levels of client
systemic unit on the ethical elements of therapy and welfare also expands. The therapist now must
how they are addressed in codes of ethics could balance what is best for each of the individuals
address several areas of consideration. Three of the in therapy both against one another and against
foundational areas will be discussed below. the standard of what is best for the treatment unit
as a whole (Wilcoxon et al. 2012). Several con-
Definition of the Client flicts can arise when these elements are in con-
Arguably, the most significant difference between trast with one another. For example, when the
codes governing the practice of couple and family needs of the individual are in stark contrast to
therapy compared with those covering other the needs of the system. While the ethical codes
domains of mental health practice is the presence of couple and family therapy do not address
of a systemic unit as the client. The transition of these conflicts directly, they do provide some
the definition of client from one individual to discretionary codes that have been applied to
multiple individuals in relationship to one another thinking through situations related to this
changes the foundational questions being asked dilemma. These include codes specific to multi-
by the practitioner regarding their work with the ple relationships (AAMFT 2015, Standard 1.3)
“client.” Among these questions are “what does and conflicts of interest (AAMFT 2015, Stan-
client autonomy in decision-making look like dard 3.4). The onus of the responsibility is put
when there is disagreement among members of on the therapist to be as clear as possible about
the system?” whom is the client and whose interests are being
promoted, along with the need to be circumspect
Systems and Confidentiality about clinical decisions that would compromise
In contrast to codes of ethics focused more specifi- this ability (e.g., seeing both a couple for rela-
cally on individual practice, codes of ethics in Cou- tional issues and one of the members for indi-
ple and Family Therapy address nuanced areas of vidual issues).
confidentiality specific to having multiple individ-
uals as part of treatment. Specifically, they address
the need to protect both the confidences of the Application of Codes of Ethics in Couple
system and the confidences of individuals within and Family Therapy
the system. For example, the AAMFT Code of
Ethics specifies how to handle confidentiality within The application of codes of ethics in Couple and
and outside of the treatment unit when providing Family Therapy is ever present in the professional
systemic therapy: “When providing couple, family, life of a systemic practitioner. Therapists are
or group treatment, the therapist does not disclosure obliged to agree to a code of ethics at several
information outside the treatment context without a points in their careers, including but not limited
written authorization from each individual compe- to: (1) when they begin training; (2) to join many
tent to execute a waiver. . . the therapist may not professional organizations; and (3) when they
reveal any individual confidences to others in the become licensed. As part of this process, they
client unit without the prior written permission of are agreeing to be held accountable to mandates
the individual” (AAMFT 2015, Standard 2.2). Pro- embedded in the statutes and a process by which
viders additionally have to deal with some limits to they are held to expectations commensurate with a
their control regarding information shared in session professional of their ilk. This essentially means in
because of the presence of others in the room. areas in which discretion is required, they will be
Ethical codes guide practitioners to inform clients held to the standard of what most other practi-
fully about these risks. tioners similar to them would do in the same
Cognition in Couple and Family Therapy 481
situation. These decisions are always held in light References

of the interpretation of the codes of ethics in
Couple and Family Therapy they are accountable American Association for Marriage and Family Therapy.
(2015). AAMFT code of ethics. Alexandria: Author.
to, as interpreted by their peers.
Retrieved from http://www.aamft.org/iMIS15/
AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx.
Association for Family Therapy and Systemic Practice
in the UK. (2013). AFT code of ethics. Warrington: C
Clinical Example of Codes of Ethics in Author. Retrieved from: http://www.aft.org.uk/
Couple and Family Therapy SpringboardWebApp/userfiles/aft/file/Ethics/Code%
20of%20Ethics%202013.pdf.
Caldwell, B. (Ed.). (2015). User’s guide to the 2015
Andrew and Grace bring their 18-year-old son AAMFT code of ethics. Alexandria: AAMFT.
Joshua to family therapy. Upon asking the family European Family Therapy Association. (2012). Code of
what brought them to therapy, Joshua informs the ethics of the European Family Therapy Association.
therapist that he does not want to be in treatment Oslo: Author. Retrieved from: http://www.europeanfa
milytherapy.eu/code-of-ethics-of-the-european-family-
and is being “forced” by his parents to attend. The therapy-association/.
parents acknowledge they are forcing him to International Association of Marriage and Family Coun-
attend by refusing to pay his car insurance if selors. (2017). IAMFC code of ethics. Alexandria:
he does not show up to sessions. Author. Retrieved from: http://www.iamfconline.org/
public/IAMFC-Ethical-Code-Final.pdf.
In consulting the 2015 AAMFT Code of Murphy, M. J., & Hecker, L. (Eds.). (2016). Ethics and
Ethics, the therapist recognizes she has an issue professional issues in couple and family therapy
specific to Standard 1.2(d). This standard within (2nd ed.). New York: Taylor & Francis.
the Code specifies the therapist gain consent from Wilcoxon, S. A., Remley, T. P., & Gladdin, S. T. (2012).
Ethical, legal, and professional issues in the practice of
all individuals who are part of the treatment marriage and family therapy (5th ed.). Upper Saddle
unit and that consent generally necessitates the River: Pearson.
client “has freely and without undue
influence expressed consent” (AAMFT 2015).
While Andrew and Grace meet this criterion,
Joshua clearly does not. The wording in this Cognition in Couple and
code provides a mandatory component the thera- Family Therapy
pist must attend to, including receiving consent
from all parties involved and making sure the Kathleen A. Eldridge and Caroline Kalai
consent was freely given. The discretionary com- Graduate School of Education and Psychology,
ponent of making this decision includes the pro- Pepperdine University, Los Angeles, CA, USA
cess she may go through to probe whether it is
possible to get Joshua’s freely given consent and
to assist the family in making a decision about Name of Concept
how to proceed if he will not give it and she,
therefore, may not be able to see him as part of Cognition in Couple and Family Therapy.
family therapy.
Introduction
Cross-References
The field of psychology refers to cognition as an
▶ Ethics in Couple and Family Therapy individual’s ability to process information in order
▶ Supervising Ethical Issues in Couple and to perform certain psychological functions and
Family Therapy behaviors (Fuchs and Milar 2003). This term is
▶ Supervising Legal Issues in Couple and Family also used in branches like social psychology and
Therapy social cognition to refer to an individual’s
482 Cognition in Couple and Family Therapy
attitudes, beliefs, attributions, and interpersonal of depression postulates that an individual’s mood
dynamics (Relvin 2013; Sternberg and Sternberg and behavior are affected by perceptions and
2009). Cognition shapes and influences individ- interpretations of events throughout life. The the-
uals’ interpretations, behaviors, and emotions in ory also involves three levels of thought, includ-
interpersonal relationships and is therefore well ing situational automatic thoughts, intermediate
integrated into couple and family treatment beliefs, and deeper core beliefs or schemas,
methods. This entry will specifically focus on which are absolute beliefs about the self, the
the psychological concept of cognition within world, and the future, developed through life’s
the area of couple and family psychotherapy. experiences.
While Beck’s cognitive theory focuses on
altering an individual’s cognitions to improve
Theoretical Context for Concept psychological functioning, similar theories also
describe how cognitions influence one’s relation-
Although originally coined to describe a person’s ships with others (Dattilio 1998, 2010).
thinking and awareness in the fifteenth century, Appraisals, assumptions, and interpretations of
early Greek philosophers first contemplated cog- behavior are cognitions that impact relationships
nition before the field of psychology emerged. between family members and partners. Therefore,
Interest in human experiences, such as the inner Ellis adapted his A-B-C theory of rational emotive
workings of the mind, led one well-known philos- therapy to help couples and families in distress.
opher, Aristotle, to explore cognitive processes He posited that marital dysfunction results when
that we identify today as memory, perception, individuals hold irrational beliefs and extreme
and mental imagery. This interest was further negative evaluations of their partners and their
explored and expanded by many pioneering sci- relationship.
entists who contributed greatly to the study of As knowledge evolved about the influence of
psychology and cognitive science (Matlin 2013). cognition on relationship functioning, the integra-
These scientists included Wilhelm Wundt, who tion of cognition into therapeutic work with cou-
focused on the human cognitive process of intro- ples and families in distress also expanded. Early
spection and inner feelings, and Hermann studies found that specific methods, such as cog-
Ebbinghaus, who studied various aspects of learn- nitive restructuring, significantly enhanced the
ing and memory pertaining to language. Thereaf- effectiveness of behavioral interventions (Ellis
ter, Mary Whiton Calkins paved the way for 1962; Mahoney 1974; Margolin and Weiss 1978;
cognitive theories, such as the recency effect in Meichenbaum 1977). In the 1980s and 1990s,
human learning and memory (Best 1999). Donald Baucom and Norman Epstein developed
In the mid-late twentieth century, cognitive cognitive-behavioral couple therapy (Baucom
theories pertaining to treatment of mood disorders et al. 2015; Epstein and Baucom 2002), one of
emerged through Albert Ellis’ work in rational the leading methods for treating distressed cou-
therapy (later called rational emotive therapy; ples. Their approach includes specific cognitive
Ellis 1962, 1982) and Aaron Beck’s cognitive methods that have now been adapted to treat a
behavioral therapy (Beck 1995; Beck et al. broad range of couples and will be discussed
1979). A psychiatrist regarded as the “father of further throughout this entry.
cognitive therapy,” Aaron Beck sought to help
individual clients cope with psychological symp-
toms through management of emotions, thoughts, Description
and behaviors. Most notably, he introduced the
central role of thoughts, specifically negative and Aaron Beck’s work describes the most readily
maladaptive cognitive distortions, in developing a accessible cognitions as automatic thoughts, or
vulnerability to depression and in maintaining “stream-of-consciousness” ideas, beliefs, and
psychological conditions. Beck’s cognitive theory images that an individual forms, moment-to-
moment, in daily life situations. Automatic refers 8. Fortune telling. The expectation that a situa-
to the spontaneous quality of the cognitions that tion will turn out badly without adequate evi-
are not carefully deliberated or thoughtfully dence. “If I initiate a conversation with him,
developed. He described all automatic thoughts then he will just walk away.”
that lead to depression as consequences of cogni- 9. Emotional reasoning. The assumption that
tive distortions. In the context of couple and fam- emotions reflect the way things really are.
ily therapy, similar types of cognitive distortions “You make me feel bad; therefore, you must C
about partners or family members are thought to be a bad partner.” “I feel like a bad son;
be associated with relationship distress and are therefore, I am a bad son.”
therefore helpful to identify: 10. Disqualifying the positive. Recognizing only
the negative aspects of a situation while
1. Magnification and minimization. Exaggerat- ignoring the positive. One might receive
ing or minimizing the importance of events many compliments from a partner but focus
and the behaviors of others. One might on the single piece of negative feedback.
believe a partner or family member’s mis- 11. “Should” Statements. The belief that things
takes are excessively important (“You spent should be a certain way. “I should always be
our weekly budget for groceries so now we happy around my partner.”
won’t be able to buy that house!”) or that a 12. All-or-Nothing Thinking. Thinking in abso-
partner or family member’s efforts are lutes such as “always,” “never,” or “every.”
unimportant (“Using coupons won’t save us A wife might criticize her husband for buying
any money for that house”). the wrong item from the store, which leads
2. Catastrophizing. Seeing only the worst pos- her husband to believe: “My wife is never
sible outcomes of a situation. “If she doesn’t happy with anything I do.”
want to date me, then no one will ever want to
date me and I will die alone.” The work of Epstein and Baucom provides
3. Overgeneralization. Making broad interpre- another description of three types of cognitions
tations from a single or few events. “My that are salient in couples and families: (1) the
partner got angry with me for doing that. He most surface and situational reactions to specific
is always angry with me for everything.” incidents and behaviors, such as selective atten-
4. Magical thinking. The belief that acts will tion, attributions, and expectancies; (2) intermedi-
influence unrelated situations. “We are good ate level beliefs that are less situational but
people – bad things, problems, and conflicts broader in scope, such as assumptions and stan-
shouldn’t happen to us.” dards; and (3) an individual’s deepest layer of
5. Personalization. The belief that one is automatic cognitive processing, such as relation-
responsible for events outside of one’s own ship schemas.
control. “My mom is always upset. She Reactions to events. In selective attention, indi-
would be fine if I did more to help her.” viduals pay closer attention to certain aspects of
6. Jumping to conclusions/arbitrary inference. dialogue, behavior, or interactions with their part-
Interpreting the meaning of a situation with ners, thereby selecting aspects of events that are
little or no evidence. For example, a husband either positive or negative. Conflict ensues when
concludes that his wife is having an affair partners selectively choose negative aspects of
when she comes home late from work. events or select different aspects of events due to
7. Mind reading. Interpreting the thoughts and unique perspectives. Based upon the attended
beliefs of others without adequate evidence. selection, an individual will then make attribu-
“I know exactly what his intentions were. tions, or inferences, to interpret and/or explain
I don’t need to ask.” Although plausible, others’ behaviors. If an individual selectively
mind reading goes beyond available evidence attends to negative aspects of events in the rela-
to make invalid conclusions. tionship, then it follows that he/she will make
negative inferences about the other person. This Standards differ from assumptions because
cognitive trap leads partners to view the other they pertain to beliefs that are not based in specific
person’s negative behaviors as enduring, charac- events or previous reactions to their partners;
terological traits, which not only causes them to rather, they are values and personal beliefs about
justify their own behaviors as reactions to their characteristics that one “should” or “should not”
partners, but contributes to expectations and pre- have in a relationship or family. These beliefs can
dictions about future negative behaviors based on develop outside of the current relationship and
the preceding cognitions. An example of selective may be values learned from the family of origin,
attention, disqualifying the positive, was previ- education, religion, and/or previous relationships.
ously described in the list of common cognitive They become problematic when partners or fam-
distortions. For instance, if one partner cleaned ily members hold opposing standards. For exam-
the house, but then the other partner complains ple, couples may have different beliefs about how
about the laundry not being done, then selectively relationships should operate with regard to gender
attending to chores that have not been completed roles, closeness/togetherness vs. separateness,
might lead to inferences about one’s partner as financial standards of living, cultural or religious
behaving in lazy, forgetful, inefficient, or disorga- involvement, sex and intimacy, or parenting. For
nized ways. Not only might this lead to the other instance, an individual may have developed a
partner feeling unappreciated, it can also lead to standard that one partner in a relationship should
future conflicts as well if these negative inferences be responsible for caregiving, while the other
evolve into characterological assumptions in one should handle all the finances. If the other partner
another (“My partner is a lazy person” or “My holds a different standard, such that both partners
partner is so ungrateful and doesn’t notice all the share these responsibilities as observed in his/her
good things I do”). As seen in this example, selec- family of origin, then this couple might face con-
tive attention can lead to the development of char- flict about the division of responsibilities.
acterological assumptions, which influence Automatic cognitive processing. In addition to
attributions and expectancies between partners. standards, beliefs, or reactions to specific events,
Broad beliefs. Reactions to particular events there is the activity of human cognition described
often contribute to more global beliefs made as information processing. Because so much of
about one’s partner, which in turn influence reac- cognitive processing is automatic and out of one’s
tions to events. Assumptions, for instance, are awareness, it relies heavily on existing core
generalized beliefs about others that have devel- schemas about people and relationships instead
oped and then serve as the basis for attributions in of using deliberate and careful processing of
specific situations. Therefore, if a husband holds each unique situation or event. Cognitive thera-
the assumption that his wife is inconsiderate based pists help partners and family members become
upon previous reactions to particular events, then more aware of their cognitive processing instead
his wife’s future behaviors will be assumed to of allowing it to remain automatic.
reflect her inconsiderate nature. For example, if Epstein and Baucom also summarize a distinc-
he believes his wife to be inconsiderate as a result tion between relationship schematic processing,
of selective attention to previous events (e.g., she in which partners process their daily lives through
forgot to include a card in his birthday gift), then a relational schema (considering the relationship
he will develop the assumption that she is incon- and how things may impact one’s partner or rela-
siderate in other situations as well (“She’s so tionship), and individual schematic processing, in
inconsiderate; she didn’t even offer me some of which partners process information through an
her snack”). Conversely, if he holds the assump- individual schema (focused on one’s individual
tion that she is a thoughtful and considerate per- functioning and unaware of others). Findings
son, then he might believe that she forgot to share indicate that relationship schematic processing is
her snack because she was distracted by the day’s associated with higher satisfaction in relation-
events. ships, and improvement in relationship-schematic
processing among male partners is associated While Socratic questioning can help an indi-
with increased satisfaction of their wives. vidual gain insight, guided discovery involves a
broader range of techniques to guide partners in
their discovery of one another. The therapist
Application of Concept in Couple and encourages partners to be inquisitive and curious
Family Therapy about each other to learn more about one another,
rather than relying on the therapist to uncover C
The application of cognition in couple and family underlying thoughts as in Socratic questioning.
therapy stems from influences from behavioral This includes helping partners clarify their pre-
couple therapy, which aims to change behavioral existing standards, expectations, and differences,
patterns; cognitive therapy, which aims to change as well as problem-solving.
negative cognitions; and cognitive psychology Other cognitive strategies include
research on information processing. Thus, psychoeducation on intimate relationships and
cognitive-behavioral couple therapy (CBCT; the role of cognitions, coaching clients to weigh
Baucom et al. 2015; Epstein and Baucom 2002), the advantages and disadvantages of their cogni-
described next, was developed to target all the tions, and considering the worst possible out-
aforementioned components to treat couples in comes of situations in order to challenge
distress most effectively. negative predictions. In addition, therapists can
The focus of CBCT is on increasing awareness use a “downward arrow” technique to tap into
through interventions that target behavioral inter- underlying meanings of partners’ cognitions and
actions, emotions, and cognitive processing, as uncover the origins of their beliefs by exploring
change in one influences the others. Treatment previous situations that led to current negative/
begins with thorough assessment of multiple irrational thinking (e.g., unresolved issues).
domains of the relationship through question- Lastly, identifying patterns in previous relation-
naires, therapist observation, and information ships that have led to similar negative conse-
gathered during joint and individual sessions. quences can motivate partners to interrupt those
Cognitions and cognitive processing (e.g., selec- patterns by altering their cognitions.
tive attention, attributions, expectancies, assump- As couples understand their cognitive patterns
tions, standards) are included in this assessment. (with their partner and as individuals), treatment
Homework assignments are used to keep partners progresses to then incorporate behavioral inter-
engaged in treatment between sessions and con- ventions, such as communication and decision-
sistently working to improve their insight and making skills training, role-taking (i.e., partners
apply learned skills outside of the therapy room. switch roles and play different perspectives in
Treatment methods that examine individuals’ order to focus on their partners’ experiences),
cognitions in order to help partners gain insight and behaving as if they had different cognitions
include Socratic questioning and guided discov- (i.e., temporarily acting) in order to discover pos-
ery. Socratic questioning involves the therapist sible positive responses by their partner.
asking a series of questions to help individuals Although most cognitive-based therapies, like
understand their logic and reevaluate their think- CBCT, were developed and are largely practiced
ing. This method induces conscious thinking with individuals or couples, comparable methods
about the logic involved in one’s cognitions and apply in the treatment of families (Patterson
consideration of alternative explanations or infor- 2014). For instance, methods in the practice of
mation that might support or negate those cogni- family therapy similarly include cognitive
tions. Because questioning individuals in the restructuring techniques to help family members
presence of their partners can be delicate, the better monitor the validity of their cognitions
therapist must remain empathic and avoid unsuc- (how accurate or true one’s thoughts are in a
cessful or counterproductive confrontations that given situation) and the appropriateness of their
might negatively impact the therapeutic alliance. cognitions (the utility of one’s beliefs given the
possibility that family members hold different stan- when Mark initiates discussion over certain issues
dards). Other cognitive methods include teaching or makes certain requests, such as not leaving
family members how to actively and consciously dishes and bills around the house. He states that
assess their cognitions in any given situation Sarah has a tendency to “breakdown over little
through self-monitoring (noticing one’s thoughts) things” because she doesn’t work through larger
and challenging negative thoughts that arise in issues. He wants to understand why these situa-
order to de-escalate (Dattilio 1998). In general, the tions lead to large arguments. Sarah also believes
structure remains similar (i.e., assessment phase, that they argue over petty things such as an unbal-
treatment phase, brief, directive, and collaborative), anced distribution of chores and her control over
so that cognitive distortions, dysfunctional thinking, tasks like paying the bills, which she does not
and information processing can be explored with allow Mark to handle. She states that when she
family members as they are with couples. gets angry, “everything turns red” and she feels
“rage.” To de-escalate, Sarah reports that she
abruptly leaves the scene.
Clinical Example Lastly, Mark and Sarah both report not having
any time to spend with each other due to their
The case material used to illustrate the application work schedules. They both work in the entertain-
of cognitive methods in couple and family therapy ment industry, alternating work hours in order to
comes from an engaged couple that decided to manage childcare. After completing work in the
work through their unresolved conflicts before morning and afternoon, Sarah comes home to care
getting married. They sought treatment at a local of their son while Mark works in the evening.
community mental health center where they were When Mark arrives home, Sarah is too tired
seen for 25 weekly therapy sessions. when he initiates conversation or sexual intimacy.
Background. Mark and Sarah, an intercultural As a result, Mark and Sarah rarely spend quality
couple, are engaged and in their mid-twenties. time together and have sex approximately once a
Mark is of Eastern decent and Sarah is Caucasian. month. Both enjoy the intimacy when it occurs
They have been together for 4 years and have a and want to enhance their sexual relationship.
3-year-old son. This couple entered treatment History, conceptualization, and treatment
with several complaints, including (1) regaining goals. At the onset of treatment, a thorough
trust following infidelity, (2) difficulty coping assessment was conducted to gain an understand-
with negative emotions, and (3) decline in quality ing of the couple’s current relationship function-
time together and intimacy. ing. The therapist met with the couple together for
Specifically, Sarah admitted to kissing a friend a joint session followed by individual sessions
at a party and, as a result, Mark worries that Sarah with each partner to gather individual histories.
has kept other secrets from him and does not feel The information presented below is an integration
comfortable setting a wedding date. He wants to of their histories.
understand whether there is a problem in the rela- Mark and Sarah met at a mutual friend’s party
tionship or something that he may have done and were immediately attracted to one another.
wrong to lead Sarah to kiss someone else; how- After leaving the party together, they engaged in
ever, he also does not want to interrogate her. unprotected sex. When Sarah learned that she was
Sarah also wishes to understand why the indis- pregnant, she and Mark started dating and then
cretion occurred and learn ways to improve their moved in together after their son was born.
communication. The couple reported differences Both partners come from large families; how-
in responding to disagreements. Specifically, ever, they described their roles very differently.
Sarah tends to yell and curse in front of their Sarah grew up in a conservative religious home
son, while Mark tends to withdraw or stonewall and was the eldest child who was often responsi-
in order to avoid escalating arguments. This leads ble for the caregiving of her younger siblings. She
Sarah to storm off. Usually, arguments begin experienced significant physical and sexual abuse
and witnessed the abuse of her siblings as well. (Silence)

Mark I just don’t want her to feel attacked or
She also experienced intimate relationship trauma make her feel bad.
involving drug abuse, physical abuse, and sexual Therapist So you believe that Sarah will feel
assault. Mark is the youngest of his siblings and attacked and that she will feel bad if you
reported a history of emotional neglect as well as openly speak about some of your concerns
directly to her?
abandonment by his father. Conflicts were rare as Mark Yes.
family and cultural values taught him to avoid any Therapist I see. And then what might happen? C
emotional expression. He also endured relation- Mark I don’t know. . . She’ll shut down.
ship trauma when his previous partner passed Therapist And how did you come to this
conclusion. . . that she will feel attacked or
away following a major accident. Emotionally, she will shut down?
Sarah tends to avoid confrontation/communica- Mark Well, that’s what usually happens when
tion and bottle up her emotions until they are I try to talk about something at home, and
expressed in angry outbursts and crying spells. even now I can sense that she isn’t
comfortable.
She described “going from 0 to 100.” Mark does Therapist Sarah, let’s check in. Is this how you feel?
not display his emotions and presents as calm and Sarah Not exactly. I mean, yes it’s a bit weird
sometimes aloof. He tends to initiate communica- and difficult to hear his complaints.
tion, but is often met with rejection by Sarah so his I know he’s not trying to make me feel bad
because we came here to fix this.
concerns are left unresolved. An assessment of Therapist So I wonder if some of your
safety revealed no violence in their relationship communication barriers, like the one we
or toward their child. just observed here, somehow relate to
Initially, both partners were hesitant to speak or assumptions about the other
person. . .what each of you believe the
glanced over at one another with restraint. other might be thinking or feeling. . . and
Because each partner was able to speak readily making predictions about how the other
and elaborate comfortably about their concerns might react, possibly based on previous
during individual sessions, it appeared that the conflicts. Does this sound accurate?
feeling of safety was lacking between partners
rather than with the therapist. As such, the thera-
(Nodding)
pist deemed it necessary to discuss their fears
about couple therapy to uncover the cognitions Mark Yes
Therapist So the work that we will be focusing on in
underlying their communication barriers. When here will be to slowly uncover the
the couple returned for their feedback appoint- thoughts and beliefs that you hold about
ment, the therapist facilitated a discussion about one another. We can discover some of the
this observation: negative ways you think about situations,
which, in turn, affects your mood and your
behavior – including your
Therapist I’d like to share an observation with the communication. The focus will be on your
both of you. It was apparent during our thought patterns, as it seems that a lot of
initial meeting that the both of you have a the communication is happening in your
difficult time communicating with one own minds, rather than directly with each
another, and I imagine that this is probably other, and then negatively displayed by
the same obstacle you face at home. Yet your behaviors.
both of you have lots to say. . .it just
wasn’t spoken with ease in each other’s
presence.
Mark and Sarah’s relationship concerns can be
Mark Yea. . . I guess we aren’t used to talking
about it. understood through a cognitive conceptualization
Sarah . . .yea, especially to someone else. It feels given that they both harbor maladaptive beliefs
like tattle tailing. and expectations about how their partner might
Therapist I understand completely. So it’s difficult to
respond to them. Communication is stalled when
talk about your problems with each other
or with me when you are in the presence of cognitive distortions either skew the reality of
one another. what happened in a given situation or falsely
explain the other person’s behavior. Much of this relationships and the origins of their thought pat-
is rooted in their individual histories and the way terns. Initially, Mark discovered how his father leav-
they have learned to process information in their ing him, his ex-girlfriend passing away, and feeling
families of origin and prior relationships, as well rejected for emotional expression in his family of
as in their current relationship. Over time, Mark origin led to an assumption that he would be aban-
and Sarah began to function by their own inter- doned/rejected by Sarah if he upset her with dia-
pretations and expectations rather than actively logue around their issues. Thereafter, with
testing their logic. A combination of their person- encouragement and practice, Mark was able to
ality differences, their learned approach to emo- share his thoughts and feelings with less fear that
tional expression, their individual and relationship Sarah would get upset or leave him.
schemas, and their resulting intermediate and sit- Meanwhile, the downward arrow helped Sarah
uational beliefs has led to significant problems uncover the underlying beliefs she developed (e.g.,
and ineffective coping through withdrawal, infi- “I am unlovable,” “I am unsafe in close relation-
delity, and emotional outbursts. ships”) and how they contribute to feelings of fear
As strengths, Mark and Sarah are motivated to and anger when conflict arises with Mark. Through
improve their relationship and move toward mar- Socratic questioning, the therapist gently asked
riage. They are in love, eager to work through Sarah a series of questions to explore the logic that
their problems, committed to therapy, and trust has contributed to her believing she is unloved:
their therapist. They encourage one another to
Therapist Now that we understand how Mark’s
succeed. Additionally, their division of responsi-
requests or desire to talk about any issue
bilities in caring for their son illustrates how they leads you to think he might not love you,
cooperate, care, and support one another. They are let me ask you – what are the ways that a
both hard-working in their careers and respect person who loves someone might
demonstrate that feeling?
each other. Mark openly expresses that he is
Sarah I’m not really sure.
proud of Sarah’s recent promotion. Therapist OK, let’s see. . . how did you know earlier
Following introduction to the treatment in your relationship that he loved you?
approach, the therapist shared this conceptualiza- Sarah I guess the way we were was different. We
didn’t fight very much.
tion with the couple in a feedback session. There-
Therapist OK, so, according to this logic, arguing
after, treatment recommendations and goals were might mean there is less love. That would
discussed. It was important to help Mark and feel pretty threatening. I wonder, could
Sarah communicate effectively so that therapy there be any other reason, other than not
loving you, that you two might argue or
remained an emotionally safe environment.
that he might have certain requests you
Then, Mark and Sarah’s emotional disconnect don’t like?
and mistrust could be addressed through cognitive Sarah We’ll argue when we want different things
methods aimed to uncover relationship fears and or when I feel like he is trying to change
me or is unhappy.
schemas. The therapist also explained how their
Therapist When you think he is trying to change
emotions would be targeted by understanding you, or you think that he is unhappy with
their individual thoughts and learning how to you. Any other reason?
reevaluate them. Helping them regain control of Sarah I’m not sure.
Therapist I wonder, has he told you directly that he is
their emotions through cognitive strategies would
unhappy with you or that he doesn’t love
further facilitate effective and productive commu- you?
nication around more sensitive issues. Sarah No.
Treatment began with psychoeducation as this
was the couple’s first experience in couple therapy.
Second, cognitive methods were used to improve As the session continued, Sarah was able to see
communication. Guided discovery and downward how her cognitions prevented her from engaging
arrow methods elicited each partner’s specific in meaningful and productive dialogue with
thoughts regarding conflict and communication in Mark. Guided discovery helped Sarah obtain a
Cognitive Behavioral Couple Therapy 489
new perspective (“I am loved and safe, even dur- Margolin, G., & Weiss, R. L. (1978). Comparative evalu-
ing conflict”) that enabled her to engage in new ation of therapeutic components associated with behav-
ioral marital treatments. Journal of Consulting and
experiences, such as tolerating discomfort in Clinical Psychology, 46, 1478–1486.
order to maintain longer dialogue. These Matlin, M. (2013). Cognition (8th ed.). Hoboken: Wiley.
cognitive changes facilitated better communica- Meichenbaum, D. (1977). Cognitive-behavior modifica-
tion, reduced emotional arousal, and enabled tion: An integrative approach. New York: Plenum
experiences of safety between partners, which
Press.
Patterson, T. (2014). A cognitive behavioral systems
C
allowed further work on issues of trust and approach to family therapy. Journal of Family Psycho-
fidelity. therapy, 25(2), 132–144.
Relvin, R. (2013). Cognition: Theory and practice.
New York: Worth Publishers.
Sternberg, R. J., & Sternberg, K. (2009). Cognistive psy-
Cross-References chology (6th ed.). Belmont: Wadsworth, Cengage
Learning.
▶ Baucom, Donald
▶ Cognitive-Behavioral Family Therapy
▶ Epstein, Norman
Cognitive Behavioral Couple
▶ Schemas in Families
Therapy
Donald H. Baucom and Melanie S. Fischer

University of North Carolina at Chapel Hill,
References
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Baucom, D. H., Epstein, N. B., Kirby, J. D., & LaTaillade,
J. (2015). Cognitive-behavioral couple therapy. In A. S.
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Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).
Cognitive therapy of depression. New York: The Synonyms
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Best, J. (1999). Cognitive psychology (5th ed.). Hoboken:
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Dattilio, F. M. (Ed.). (1998). Case studies in couple and marital therapy (BMT); Cognitive-behavioral
family therapy: Systemic and cognitive perspectives. marital therapy (CBMT)
Dattilio, F. M. (2010). Cognitive-behavioral therapy with
couples and families: A comprehensive guide for clini-
cians. New York: The Guilford Press. Introduction
Ellis, A. (1962). Reason and emotion in psychotherapy.
New York: Lyle Stuart.
Ellis, A. (1982). Rational-emotive family therapy. In A. M. Cognitive-behavioral couple therapy (CBCT)
Home & M. M. Ohlsen (Eds.), Family counseling and evolved during the early 1980s, drawing heavily
therapy (pp. 302–328). Itasca: Peacock. upon its theoretical foundations from behavioral
Epstein, N. B., & Baucom, D. H. (2002). Enhanced
cognitive-behavioral therapy for couples.
couple therapy (BCT), individual cognitive ther-
Washington, DC: American Psychological apy (CT), and basic cognitive and social psychol-
Association. ogy research on information processing. In early
Fuchs, A. H., & Milar, K. S. (2003). Psychology as a formulations of BCT, principles of social learning
science. In D. K. Freedheim (Ed.), Handbook of psy-
chology (pp. 1–26). Hoboken: John Wiley.
and social exchange theories were applied to help
Mahoney, M. J. (1974). Cognition and behavior modifica- couples achieve a more satisfying balance of pos-
tion. Cambridge: Ballinger. itive to negative behaviors. That is, relationship
490 Cognitive Behavioral Couple Therapy
distress was defined largely by an excess of neg- gaining prominence in other applications and
ative and deficit of positive behavioral exchanges across countries. Within the United States, How-
between partners. Patterns of reinforcement and ard Markman (along with Elizabeth Allan, Scott
punishment of desirable and undesirable behav- Stanley, Galena Rhoades) applied similar behav-
iors were assessed with systematic functional ana- ioral principles to helping healthy couples
lyses, and partners were trained in communication enhance their relationships through the PREP pro-
and problem-solving skills as well. Communica- gram, currently described as a relationship educa-
tion skills training was deemed to be central in tion approach, and others have continued similar
treatment both because (a) it is a major vehicle for efforts across a variety of settings and countries
reinforcement or punishment between adults and (e.g., Guy Bodenmann, James Cordova, Kristina
(b) communication serves as a medium through Coop Gordon). In Germany, Kurt Hahlweg
which other important domains of relationship conducted large-scale treatment studies of BCT
functioning are addressed. However, over time, and relationship education, varying different treat-
it became clear that a strictly behavioral approach ment parameters to optimize treatment. Likewise,
was limited in addressing the numerous sources of Kim Halford began demonstrating the efficacy of
relationship distress that couples might encounter. the interventions in Australia. As the treatment
In particular, a purely behavioral approach ignores approach evolved, K. Daniel O’Leary, Steven
the central role of internal experiences, i.e., cog- Beach, and their colleagues began exploring the
nitions and emotions, in relationship functioning efficacy of BCT for treating couples who experi-
as noted below. The integration of cognitive and ence relationship distress along with depression.
emotional factors into the theoretical and treat- As noted above, the theoretical model for BCT
ment models denoted the evolution of BCT into broadened, particularly beginning in the 1980s
CBCT. Still, researchers and clinicians treating when the role of cognitive and emotional factors
relationships from a social learning perspective began to gain prominence in addressing relation-
continue to vary in the relative emphasis they ship functioning which led to corresponding treat-
place on behavioral, cognitive, and emotional fac- ment evolutions. D. Baucom collaborated with
tors in understanding and treating couples’ rela- Norman Epstein, who had a strong background
tionships. Hence, the current discussion includes a in cognitive-behavior therapy, to develop their
consideration of what some would call behavioral version of cognitive-behavioral couple therapy
couple therapy and what others would call which gives strong consideration to cognitive
cognitive-behavioral couple therapy, all under and emotional factors, along with behavioral fac-
the inclusive name of cognitive-behavioral couple tors in relationship functioning. Art Freeman,
therapy. Frank Dattilio, and others applied similar princi-
ples from cognitive therapy into their own varia-
tions of cognitive-behavioral couple therapy.
Prominent Associated Figures Likewise, recognizing this restriction of focusing
solely on behavioral factors, Jacobson and
Robert L. Weiss and Richard Stuart were two of Andrew Christensen developed integrative behav-
the early contributors to conceptualize couples’ ioral couple therapy (IBCT) which makes a pri-
relationship functioning from a behavioral per- mary distinction between behavior change and
spective in the 1960s. In the 1970s, these concep- acceptance; while IBCT is viewed as a treatment
tualizations were translated into a treatment to be differentiated from CBCT, it maintains its
protocol by Neil Jacobson and Donald Baucom, behavioral heritage and is part of the ongoing
and the first randomized controlled trial of behav- evolution in couple treatment.
ioral couple therapy was conducted with a purely As described below, the field of CBCT has
behavioral focus; Jacobson and Gayla Margolin continued to evolve as specific domains of rela-
published a book on behavioral couple therapy tionship functioning (e.g., intimate partner vio-
soon thereafter. At the same time, BCT was lence, O’Leary; Amy Holtzworth-Monroe;
Gregory Stuart; Epstein; infidelity, Gordon, Doug- experiences (Baucom and Epstein 1990). Conse-
las Snyder, D. Baucom; David Atkins and quently, BCT practitioners gradually incorporated
Christensen), additional populations such as cou- principles and interventions from individual cog-
ples experiencing psychopathology (e.g., Melanie nitive therapies such as those developed by Beck
Fischer, Cynthia Bulik, Jennifer Kirby, Brian and colleagues (e.g., Beck et al. 1979) into their
Baucom, D. Baucom, Michael Worrell, Sarah work. Broadly speaking, the goal of the cognitive
Corrie, and Jonathan Abramowitz; Steven Sayers; component of CBCT is to help couples monitor C
Mark Whisman; Candice Monson and Steffany their own thinking that influences their relation-
Fredman; David Miklowitz; Jeremiah Schumm ship, to evaluate the appropriateness and validity
and, Timothy O’Farrell; Barbara McCrady; of those cognitions, and to revise them as needed.
Diane Chambless) or medical problems (Francis Further, more recent enhancements of CBCT
Keefe, Laura Porter, D. Baucom, and Tamara place greater emphasis on assessing and interven-
Sher; Katherine Baucom; Halford and Jennifer ing with partners’ emotional processes and expe-
Scott; Nina Heinrichs and Tanja Zimmermann; riences rather than relying on changes in
Alan Fruzzetti), and new modalities of interven- cognitions and behaviors to affect emotions indi-
tion such as web-based interventions (e.g., Brian rectly; that is, minimized or exaggerated/
Doss) are addressed from a social learning per- dysregulated emotional responses may warrant
spective. Others have focused on the adaptation of intervention in their own right (Epstein and
CBCT and behaviorally based relationship educa- Baucom 2002).
tion to specific populations, including ethnic/ CBCT also takes a contextual perspective that
racial minorities (primarily Black/African- emphasizes characteristics of the two individuals,
American couples) in the United States (e.g., the dyad, and environmental demands or stressors
Shalonda Kelly, Jaslean LaTaillade), LGBTQ that influence the quality of relationship function-
couples (Sarah Whitton, Shelby Scott, Brian ing. Within this framework, (a) a healthy relation-
Buzzella), and non-Western countries/cultures ship contributes to the growth and well-being of
(e.g., Epstein). The above are only representative both partners, (b) the couple forms a well-
domains and contributors as the field continues to functioning team, and (c) the couple responds
grow and expand. adaptively to external demands on their relation-
ship by using their individual and relational
resources. Consequently, CBCT therapists sys-
Theoretical Framework tematically assess a range of factors regarding
couple coping with demands in their life together
As noted above, the current theoretical model as it relates to their presenting concerns and rela-
began with a focus almost entirely on the role of tionship distress. Consistent with this contextual
positive and negative behavioral exchanges in perspective, characteristics related to each part-
relationship distress, including communication ner’s identity and cultural background, such as
as a central form of behavior exchange within race/ethnicity, gender, sexual orientation, ability
intimate relationships. However, theoreticians status, and SES, are an integral part of case
and clinicians became aware that it was not only conceptualization.
how each person behaved that was important. In
addition, each person’s perception of those behav-
iors was central in both their behavioral and emo- Populations in Focus
tional response. That is, each member’s
idiosyncratic interpretations of relationship CBCT was developed to assist couples who are
events, causal attributions for a partner’s behavior, experiencing relationship distress and has been
and enduring cognitive schemas about close rela- applied in numerous settings in various countries,
tionships have marked influence on their behav- primarily the United States, Western Europe, and
ioral responses and subjective emotional Australia to assist these couples. Whereas the
empirical findings noted below indicate that described as individual problems, psychopathol-
CBCT is efficacious in alleviating relationship ogy and medical conditions exist in an interper-
distress, most of the applications of the treatment sonal context where they interact reciprocally
and research findings are based on middle-class with the couple’s relationship. As a result, there
white couples, most of whom are legally married. has been a burgeoning interest in applying CBCT
Although there has been some research identify- principles and interventions to couple-based inter-
ing particular challenges and experiences of cou- ventions where the focus is the couple working
ples based on their cultural backgrounds, there together in treatment to assist with individual psy-
have been few empirical studies exploring chological difficulties and health concerns.
CBCT adaptations that take specific experiences A fuller description of such interventions and
of diverse populations into account or directly their empirical status is provided elsewhere (c.f.,
address specific strengths and challenges associ- Fischer et al. in press).
ated with a wide range of backgrounds and iden-
tities. For example, divorce rates tend to be higher
among some ethnic/racial minority groups in the Strategies and Techniques Employed
United States, which has been attributed to in CBCT
stressors that disproportionally affect minority
couples such as economic hardships, exposure to Given the equal emphasis placed on behavior,
violence, and daily experiences of micro- cognitions, and emotions in CBCT, a brief
agressions and racism. Generally, relationship description of interventions central to CBCT is
quality tends to be lower in the presence of such provided below. A full description of the range
pervasive stressors. Likewise, research on the of CBCT interventions is provided in Epstein and
unique experiences of LGBTQ couples and their Baucom (2002).
impact on relationship functioning is similarly
scarce, although there are a number of challenges Interventions for Modifying Behavior
that are important to consider, such as lack of CBCT has maintained its emphasis on helping
support from family members and other forms of partners interact in more constructive ways, with
minority stress. Treatment adaptations for specific the intent of simultaneously creating positive cog-
populations have been discussed more systemati- nitive and emotional changes. The wide range of
cally in recent years. However, couple therapists behavioral interventions can be viewed as falling
need to be aware of within-group diversity for any into two broader behavior change categories:
couple entering therapy, regardless of their group guided behavior change and skills-based
membership on any dimension (e.g., race/ethnic- interventions.
ity, sexual orientation, gender identity, SES, phys- Guided behavior change. Guided behavior
ical ability, etc.), and adapt the treatment change interventions do not involve developing
accordingly. There clearly is a need for further new skills but rather draw on the couple’s existing
research investigating the effects of tailoring cou- skills. For example, if the couple has stopped
ple interventions to the needs of particular minor- making efforts to be kind and thoughtful to each
ity groups. other in general, the therapist and couple might
Researchers and clinicians have come to rec- decide that every day, each partner will make a
ognize that although the interventions employed specific effort to do something nice for the other
in CBCT were designed to promote behavioral, individual that does not require extensive time or
cognitive, and affective changes among couples effort and that might be sustainable over time
experiencing relationship distress, these same (e.g., preparing a cup of coffee for the other per-
strategies can be employed to assist couples living son or sending a text message). Also, more focal
with other concerns as well, such as one partner guided behavior changes address specific key
experiencing individual psychopathology or med- issues or important relationship themes, such as
ical concerns. Whereas such issues typically are intimacy building, social support, or improved
individual functioning, for example, partners tak- include selective attention (what each individual
ing turns putting the children to bed so that each notices about the partner and the relationship),
person occasionally has predictable individual attributions (inferences about causes of relation-
time to relax at night within their hectic schedules. ship events and partner behaviors), expectancies
Thus, without learning any new skills, the couple (predictions of what will occur in the relationship
might be encouraged to engage in a series of in the immediate and distant future), assumptions
behavior changes to respond to one or both part- (beliefs about what people and relationships are C
ners’ needs and preferences. actually like), and standards (beliefs about what
Skills-based interventions. In other circum- people and relationships should be like).
stances, a couple might benefit from new skills for CBCT therapists help the couple to identify
more adaptive interactions. The therapist and assess their cognitions for appropriateness
usually introduces skills-based interventions, and validity and work with them to develop
such as communication training, by providing more balanced views of themselves, their part-
psychoeducation about the skills and their ners, their relationship, and how they interact
purpose, followed by coaching the couple in with the environment. Many specific strategies
practicing the new skills in session and planning used in individual cognitive therapy apply here
further practice through homework. For exam- as well, techniques such as Socratic questioning
ple, communication training typically differenti- and the “downward arrow” method, evaluating
ates between two major types of communication: the logic behind a cognition, or weighing advan-
(a) conversations focused on sharing thoughts tages and disadvantages of a cognition, each
and feelings which have the goal of understand- applied with modifications given that partners
ing each other and feeling understood and may criticize each other for their cognitions. In
(b) decision-making or problem-solving conver- addition, having an individual’s partner present in
sations which are more task-oriented and the room allows CBCT therapists to use a differ-
intended to help the couple reach a resolution ent type of intervention called guided discovery.
on some issue. Guidelines for each type of con- These interventions have the goal of creating
versation are discussed as recommendations to experiences between partners that allow one or
be adapted by the couple to their unique style, both persons to rethink their point of view and
rather than strict rules. These communication develop a different perspective on the partner or
skills are then applied to address areas of con- relationship, without directly questioning an indi-
cerns specific to the couple. vidual’s beliefs and minimizing their defensive-
ness in the presence of the other individual.
Interventions Focused on Cognitions
Similar to cognitions that are targeted in individ- Interventions Focused on Emotions
ual CBT, partners are likely to hold strong beliefs An important development in CBCT is to address
about their relationship and have well-established emotional experiences and processes explicitly,
patterns of cognitions regarding how a partner rather than relying on changing cognitions and
should behave, why their partner is behaving the behaviors to affect emotions indirectly. Couples
way he or she does, what they predict their rela- entering therapy often show extreme patterns in
tionship will look like in the future, and so the expression of emotions, with one or both
on. These cognitions can strongly influence an partners either displaying restricted or excessive
individual’s behavioral and emotional responses emotional responses. Understanding the pro-
to a partner (e.g., “You agreed to watch the chil- cesses involved in partners’ difficulties with emo-
dren while I go out so that you don’t have to spend tions allows the therapist to select appropriate
time with me.”) Several types of cognitions that interventions. First, many individuals have diffi-
are commonly addressed in CBCT and are culty experiencing specific (or any) emotions or
discussed more extensively elsewhere (Epstein are very uncomfortable if they do. A number of
and Baucom 2002). These cognitive factors strategies based on emotionally focused couple
therapy (Johnson and Greenberg 1987) are used in Efficacy Research

CBCT to help individuals access and heighten CBCT and other behaviorally based couple treat-
their emotions in a safe atmosphere. On the other ments that are based in social learning theory have
hand, some partners experience and express a been examined in clinical trials for over four
high level of negative emotional intensity, with decades. Over time, early interventions
difficulty regulating strong emotions. Along with approaches that more narrowly included only
in-session therapist strategies to contain intense behavioral interventions (BCT) have undergone
emotions, the application of interventions from important changes to address cognitions and emo-
dialectical behavioral therapy (Linehan 1993) in tions more directly as in CBCT. Several meta-
an interpersonal context can be helpful in analyses and major reviews have examined the
addressing poorly regulated strong negative emo- efficacy of this broad range of behavioral and
tions in CBCT. For example, teaching the couple cognitive-behavioral couple therapy approaches
how to mindfully focus on the current moment across trials in the United States, Europe, and
can be helpful in keeping distress from one Australia. Even though these various reviews
domain of the relationship from infiltrating other have employed differing criteria for inclusion,
aspects of their life. they reach the same conclusion: behaviorally
based couple therapies are efficacious for the
treatment of relationship distress, and the findings
Conclusions
are similar when these interventions are employed
In summary, CBCT addresses relationship distress
across countries. It also has become clear that a
by applying interventions that address behavioral,
given component of CBCT typically produces
cognitive, and emotion-focused interventions,
change in the targeted domains (e.g., communica-
taking individual, couple, and environmental fac-
tion skills or cognitive distortions); however, the
tors of relationship functioning into account.
amount of change in overall relationship satisfac-
CBCT is not a manualized treatment. Rather,
tion among behaviorally based couple therapies
practitioners conduct a thorough assessment of
tends to be equal. It is possible that overall effi-
the aforementioned factors and develop an
cacy may be greater when the targeted domains in
in-depth case conceptualization. Based on this
a given treatment match the domain in which a
conceptualization and the couple’s treatment
couple requires the most change, although this
goals, a treatment plan with a tailored sequence
question has not been examined systematically
of intervention is employed.
in empirical research. In addition, applications to
specific issues including infidelity, intimate part-
ner violence, and separation/divorce have been
Empirical Status of CBCT investigated as well. Discussing these applica-
tions to specific relationship concerns is beyond
A large number of empirical investigations dem- the scope of the current discussion, but reviews
onstrate the centrality of various behaviors, cog- and treatment descriptions are available elsewhere
nitions, and emotions in adaptive and maladaptive (Gurman et al. 2015). Since the aforementioned
relationship functioning (see Baucom and Epstein major meta-analyses, there has been only one
1990, for a review of these basic research find- large randomized controlled trial of behaviorally
ings). Findings from these investigations have based couple therapies, comparing the efficacy of
been taken into account in the development of traditional behavioral couple therapy (BCT or, as
CBCT interventions described above and which the authors refer to it, TBCT; a version of couple
have been investigated subsequently in a number therapy with almost exclusive focus on behavioral
of treatment outcome investigations demonstrat- change with little emphasis on cognitions or emo-
ing the efficacy of CBCT as noted below. tions, unlike more modern treatments such as
CBCT) and integrative behavioral couple therapy negative communication both predict improve-
(IBCT) (Christensen et al. 2004). Both treatments ments in relationship adjustment as would be pre-
resulted in similar improvements in relationship dicted by CBCT. While these recent findings are
satisfaction with a large overall effect size and no promising, additional evidence is needed before
differences in overall effects (despite differences researchers and clinicians can be confident that
in pace of change during treatment) at post- the factors responsible for creating improvements
treatment and 5-year follow-up. in relationship satisfaction in CBCT have been C
isolated.
Effectiveness Research
Despite numerous efficacy trials of behaviorally
Case Example
based couple therapies in controlled settings, only
four effectiveness studies of couple therapy in
A brief summary of CBCT with Samantha and
real-world settings have been conducted over the
Sean is described in order to demonstrate how
last several decades. Of note, three of the four
the broad range of behavioral, cognitive, and emo-
studies employed an eclectic mix of couple ther-
tional intervention strategies available are adapted
apy approaches that were not necessarily
to the needs of a specific couple. The couple had
evidence-based nor behavioral/cognitive behav-
sought treatment 3 years after the birth of their
ioral in nature. However, given the dearth of
first child, Emily. During the initial evaluation,
effectiveness research, these studies provide the
both partners reported having been quite happy
closest estimation of effects in community set-
during the early years of their marriage, spending
tings that are available. Two studies were
a lot of time together with their shared love of the
conducted in Germany, one in Norway and one
outdoors and physical exercise. They also partic-
with military veterans in the United States.
ipated in community and environmental organi-
Broadly, the results of these four studies suggest
zations together which provided them a sense of
that while still demonstrating improvement in
common purpose in line with shared values.
relationship distress, the effect of the treatment
Before Emily’s birth, they both worked full-time
are not as strong as those evidenced in randomized
and were financially stable. They agreed that they
controlled trials conducted with significant super-
wanted Samantha to stay home after Emily was
vision and control regarding selection criteria (see
born which involved a notable shift in both of
Fischer and Baucom in press for a more detailed
their roles. Samantha’s life changed in major
review of these effectiveness studies).
ways from having a successful, active profes-
sional life to spending most of her day with a
Mechanisms of Change 3-year-old and occasional time with other mothers
Attempts to isolate the mechanisms of change in and their children. Sean felt much more pressure
CBCT have been mixed. Early studies with small as the sole breadwinner and was working hard to
sample sizes made it difficult to detect mecha- get promoted, along with taking a second job to
nisms of change and, thus, were unsuccessful in provide extra income for the family. Thus they
isolating factors that are central to promoting both had less time and energy at home when
increases in relationship satisfaction. However, they were together. When Sean came home, he
more recent efforts indicate that to the extent reported feeling exhausted and just wanting to
that couples make behavioral changes in areas relax. Samantha also reported that she was tired
targeted for that particular couple in therapy, by the end of the afternoon and needed Sean’s
their relationship satisfaction improves. help when he arrived. In addition, she noted that
Likewise, increases in self-reported positive frequently she was waiting all day to have a con-
communication and decreases in self-reported versation with another adult and became
disappointed when Sean turned to the television or part-time to her law practice; with this increased
worked on the computer. The nature of their con- financial income, Sean would stop moonlighting
versations also shifted as Samantha reported that and spend more time with the family. Sean and
she did not have very interesting things to con- Samantha also discussed how to spend more time
tribute these days. As a lawyer, she previously had with each other and agreed that it was easier to
talked to Sean about her interesting and compli- have lunches together during the day when they
cated cases, but now she felt she did not have had regular child care, than to arrange evening
much to say other than describing her and Emily’s outings. They also agreed that Sean had spent
activities of the day. She felt that Sean often little time developing his relationship with
seemed distracted or exhausted when they did Emily. Therefore, they agreed that each weekend
try to talk, resulting in Samantha frequently he would spend one morning or afternoon with
“blowing up” and Sean, therefore, avoiding con- Emily, which would also give Samantha time to
versations all together. herself. The stresses of parenthood also highlighted
The therapist concluded that a major factor in each partner’s typical style of dealing with stress;
their relationship difficulties involved their transi- Samantha was a person who liked to address it
tion to parenthood and struggling to adapt to the directly, whereas Sean tended to withdraw. Sean
demands of this new stage of their family life clarified that it was particularly difficult for him to
cycle. In particular, with their role overload and discuss problematic issues when Samantha became
frequent arguments, each partner tended to no angry and expressed her feelings loudly. With
longer notice the positive aspects of their relation- ongoing effort, Samantha learned to express her
ship or the other person’s efforts. Consequently, to distress in a more contained way. Sean explained
counteract this selective attention to negativity, as that he feared that when Samantha became loud,
an early intervention, the therapist asked each there would be “explosions,” as he had witnessed
partner to write down one positive thing that the between his parents while growing up. The thera-
other person did each day and to compliment or pist emphasized the importance of him continuing
express appreciation to that individual for these the conversations so that he could experience his
actions. A significant portion of treatment relationship with Samantha as different and noted
involved helping Samantha and Sean recognize that discussing difficult issues does not inevitably
that they were in a new phase of their family life lead to destructiveness.
cycle with Emily as a 3-year-old. The therapist Overall, couple therapy was quite helpful to
taught the partners communication skills, which Samantha and Sean. Treatment included an
helped them to share their thoughts and feelings emphasis on cognitive factors (shifting negative
more fully about these new roles and to reach selective attention in the relationship, standards
decisions or problem-solve around the many for this phase of marriage, and Sean’s fear of
daily decisions needed with a young child. These “explosions” with Samantha), emotional factors
communication skills also were used in important (Samantha’s efforts to contain her anger to a
discussions about the couple’s standards for what greater degree and Sean’s efforts not to withdraw
their relationship should be like with a 3-year-old during such interactions when he sensed danger),
child. As they continued with these discussions, and behavioral factors (including numerous dis-
they concluded that they had drifted away from cussions and problem-solving interactions
their own value system. Whereas financial secu- resulting in significant behavior change). Therapy
rity remained important to the couple, they confor Samantha and Sean lasted approximately
cluded that during this phase of their life, they 6 months, with weekly sessions tapering off over
wanted to live a simpler lifestyle and focus on the course of treatment. The demands of family
their marriage, each other, and Emily. Samantha life with a young child continued, but the couple
also concluded that her role had become too learned effective ways to address these concerns
restricted as a mother and that their current roles while enjoying the pleasures that came with
put her in danger of stifling her personal growth Emily, along with recommitting to their relation-
and well-being. They agreed that she would return ship and giving it a higher priority.
Cognitive-Behavioral Family Therapy 497
Baucom, D. H., & Epstein, N. B. (1990). Cognitive- Cognitive-behavioral family therapy (CBFT) was
behavioral marital therapy. New York: Brunner/Mazel.
born as the family therapy correlate to cognitive-
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).
Cognitive therapy of depression. New York: Guilford behavioral therapy. That is, it integrates behavior-
Press. ism and cognitive approaches and applies them to
Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., family systems. Because of its flexibility and con- C
Baucom, D. H., & Simpson, L. E. (2004). Traditional
tinued evolution, CBFT is able to focus on a
versus integrative behavioral couple therapy for signif-
icantly and chronically distressed married couples. variety of problems, from promoting changes
Journal of Consulting and Clinical Psychology, 72(2), within individuals in families to altering family
176–191. https://doi.org/10.1037/0022-006x.72.2.176. interaction styles. Furthermore, CBFT provides
the fundamental principles and techniques to var-
behavioral therapy for couples: A contextual approach.
Washington, DC: American Psychological ious empirically supported interventions and
Association. programs.
Fischer, M. S., Baucom, D. H., & Cohen, M. J. (in press).
Cognitive-behavioral couple therapies: Review of the
evidence for the treatment of relationship distress, psy-
chopathology, and chronic health conditions. Family Prominent Associated Figures
Process.
Gurman, A. S., Lebow, J., & Snyder, D. K. (Eds.). (2015).
Clinical handbook of couple therapy (5th ed.). Donald Baucom at the University of North
New York: Guilford Press. Carolina
Johnson, S. M., & Greenberg, L. S. (1987). Emotionally Norman Epstein at the University of Maryland
focused marital therapy: An overview. special issue:
psychotherapy with families. Psychotherapy, 24(3S), Gerald Patterson at the Oregon Social Learning
552–560. Center at the University of Oregon
Linehan, M. M. (1993). Cognitive-behavioral treatment of Neil Jacobson at the University of Washington
borderline personality disorder. New York: Guilford Andrew I. Schwebel at the Ohio State University
Press.
Shadish, W. R., & Baldwin, S. A. (2005). Effects of behav- Frank Dattilio at Harvard Medical School and the
ioral marital therapy: A meta-analysis of randomized University of Pennsylvania
controlled trials. Journal of Consulting and Clinical
Psychology, 73(1), 6–14. https://doi.org/10.1037/
0022-006X.73.1.6. Theoretical Framework
Core Concepts
The main concepts of CBFT are rooted in behav-
Cognitive-Behavioral Family iorism and cognitive-behavioral therapy. First,
Therapy within the paradigm of behaviorism, operant con-
ditioning is used as the central mechanism of
Jing Lan and Tamara G. Sher change. Social learning theory is incorporated
The Family Institute, Northwestern University, by interpreting symptoms as learned responses
Evanston, IL, USA and emphasizing the impact of social reinforcers
on shaping behaviors. Social exchange theory is
also a primary component of CBFT, asserting that
Name of Model people strive to maximize rewards and minimize
costs in relationships. Thus, behaviors can be
Cognitive-Behavioral Family Therapy (CBFT) changed directly by maximizing positive
exchanges and minimizing negative exchanges
(Lebow 2014; Lebow and Stroud 2016).
Synonyms Second, from the perspectives of cognitive
therapy, CBFT posits that an individual’s percep-
Behavioral family therapy (BFT) tions and inferences are shaped by relatively
498 Cognitive-Behavioral Family Therapy
stable underlying schema, which can be learned programs that will assist them in bringing about
early in life from primary sources which then change. Families then carry out the programs as
influence an individual’s automatic thoughts and the therapists monitor the progress and setbacks.
emotional responses in significant relationships. Throughout the process, therapists need to take an
Given the amount of shared experiences within a active role in designing and implementing specific
family, individuals often develop jointly held strategies and are required to have persistence,
beliefs that constitute a family schema. If the patience, knowledge of learning theory, and spec-
family schema involves cognitive distortions, it ificity in working with families (Gladding 2019).
may result in dysfunctional interactions (Dattilio
2009). Rationale for the Model
As the term implies, CBFT is the deliberate and
Theory of Change theory-based integration among cognitive ther-
As an integration of behaviorism, CBT, and sys- apy, behavior therapy, and family therapy. As
tem theory, CBFT views thoughts and behaviors such, its history can be seen as paralleling the
as central to the (dys)functioning of the family. history of cognitive-behavioral therapy (CBT)
Thus, the underlying principle of CBFT is that the generally. At its most basic, CBFT has its roots
behavior of one family member leads to certain in behavior therapy. During the 1960s and early
behaviors, cognitions, and emotions within the 1970s, behaviorists applied learning theory, with a
other family members. Those other family mem- particular focus on stimulus and response, to fam-
bers then affect the cognitive and behavioral pro- ily systems in order to train parents in behavior
cesses of the original family member in what is modification. Parallel to the addition of a cogni-
known as a feedback loop. Accordingly, the most tive component to traditional behavior therapy
efficacious pathways to change are seen as those practices, behavioral family therapy soon trans-
that directly alter dysfunctional thoughts and itioned to cognitive-behavioral family therapy
behavioral patterns in a family system through with an added emphasis on the need for attitude
changes at the individual and relationship levels. change to promote behavior modification. Here,
Specifically, the basic premise of behaviorism the system of the family was the focus of not just
is that behavior is maintained by its consequences. behavioral plans to encourage more adaptive
Thus, behavior will change when the contingen- responses to stimuli, but also helping family mem-
cies of reinforcement are altered. According to bers see how their thinking about themselves and
behaviorism, the general intent of therapy is to each other in the family can facilitate growth.
extinguish undesired behavior and reinforce pos-
itive alternatives. Similarly, the central tenet of a
cognitive approach is that our interpretation of Populations in Focus
other people’s behavior affects the way we
respond to them. Accordingly, the primary aim CBFT has been used across diverse presenting
of CBFT is to help family members recognize problems and forms of psychopathology. With
distortions in their thinking, restructure it, and the foci on increasing parenting skills and facili-
modify their behavior in order to improve their tating positive family interactions, CBFT has pro-
interactional patterns. Furthermore, with the ved effective for families with conduct problems,
incorporation of systems theory, CBFT maintains oppositional defiant disorder (ODD), child anxi-
the focus on interactive aspects of the family ety, depression, pediatric obsessive-compulsive
rather than on internal processes of individuals. disorder (OCD), pediatric bipolar disorder, eating
CBFT therapists take on the roles of experts, disorders, attention deficit/hyperactivity disorder
teachers, collaborators, and trainers. Therapists (ADHD), and trauma symptoms.
help families identify dysfunctional behaviors CBFT has also been found to be effective
and thoughts and then work with them to set up across various cultures and subcultures. For
behavioral and cognitive-behavioral management example, research conducted in several countries
with families from various racial and socioeco- characteristics of each family member and the
nomic groups has demonstrated the efficacy of family as a whole and how the interactions
psychoeducational behavioral family therapy in between family members maintain or detract
reducing family stress and patient relapse of from optimal functioning. As a result, the thera-
major mental disorders (Lucksted et al. 2012). pist constantly assesses different behavioral and
This approach is largely based on CBFT princi- cognitive patterns within and between family
ples and procedures. Another example is trauma- members. Although assessment never really C
focused cognitive-behavioral therapy (TF-CBT) ends, it tends to begin with a functional analysis
which has been applied in multiple cultures and of the behaviors of the family members. The func-
proved to be feasible for treating traumatized chil- tional analysis derives from three main sources of
dren of an Asian population (Kameoka information: individual and joint interviews with
et al. 2015). the family members, self-report questionnaires
Although there is limited empirical evidence and inventories, and the therapist’s behavioral
for the cultural sensitivity of CBFT, some multi- observation of family interactions (Dattilio
cultural strengths can be addressed based on its 2009). In addition, other methods of assessment
tenets. First, CBFT asserts that each individual is can include more formal psychological testing
different in his or her own right. Thus, CBFT and appraisals, consultation with previous thera-
therapists are taught to be careful in understanding pists and other mental health providers,
and defining behavioral norms and recognizing genograms, assessing motivation to change, and
that family values and relational interactions differ identifying automatic thoughts, core beliefs, cog-
between families and between cultures. Second, a nitive distortions, and schema.
central tenet of CBFT is that the therapist partners A number of valid and reliable measures have
with the family throughout the therapeutic pro- been developed to provide an overview of key
cess. As a result, differences in cultures are areas of family functioning. For example, ques-
discussed and brought to light so that all members tionnaires developed to assess general family
of the process understand expectations and norms. functioning include the Family Environment
Last but not least, its fundamental concepts tend to Scale (Moos and Moos 1986), the Family Assess-
be easily understood across diverse populations. ment Device (Epstein et al. 1983), and the Self-
Report Family Inventory (Beavers et al. 1985).
Other, more specialized assessment tools include
Strategies and Techniques Used in the Family Adaptability and Cohesion Evaluation
Model Scales-III (Olson et al. 1985), Family Coping
Coherence Index (McCubbin et al. 1996), and
CBFT applies cognitive-behavioral principles and the Family of Origin Inventory (Stuart 1995). In
techniques to family systems. In CBT for individ- addition to written measures, CBFT therapists
uals, assessment and education are basic and often rely on observational assessment tools
important components and a focus across the such as observing family members’ interacting
treatment. The same is true for CBFT. Within as they normally would or providing the family
CBFT, we can divide the primary interventions with specific topics for discussion in order to
into two categories: those that assess and modify obtain a behavioral sample of the family.
behavior patterns and those that assess and modify Once the therapists have completed a func-
distorted and extreme cognitions. tional analysis of family behavior, they move to
an instructor role as they teach families about the
Assessment and Education cognitive-behavioral model. This includes pro-
In order to intervene with families, several aspects viding a brief didactic overview and periodically
of their functioning have to be understood referring to specific concepts during the therapy.
including how the system functions in different In this way, the families can better understand the
contexts, the unique strengths, and problematic roles their cognitive distortions have played in the
interactions and how they inadvertently reinforce Cognitive-Behavioral Family Therapy, Table 1 Some
undesirable behaviors. It is also important for reinforcers in operant conditioning (Gladding 2019)
families to understand and buy into the idea that Techniques Brief description
improvements in relationships often happen Classical In families, classical conditioning is
through deliberate, rule-governed strategies conditioning used to associate a person with a
gratifying behavior, such as a pat on
(such as direct instruction and skill training) and the back or a kind word
that most problems are solvable with constructive Positive A positive reinforcer is usually a
skills and actions. Thus, families may be encour- reinforcement material (e.g., food or money) or a
aged to attend lectures, read books and watch social action (e.g., a smile or praise)
videos together, and have discussions based on that increases desired behaviors
Extinction Extinction is the process by which
what they have heard, read, or seen (Dattilio 2009;
previous reinforcers of an action are
Goldenberg et al. 2017). withdrawn so that behavior returns to
its original level
Intervention Techniques Time-out The process of time-out involves
CBFT emphasizes behavior change. The cogni- removing children from an
environment in which they have been
tive component of the intervention comes into reinforced for certain actions for a
play when clients’ attitudes and assumptions get limited amount of time
in the way of positive behavior changes. (approximately 5 min)
Grounding Grounding is a disciplinary technique
Interventions to Modify Behavior Patterns used primarily with adolescents. They
are removed from stimuli to limit their
The interventions in this category can be summa- reinforcement from the environment
rized into two main sections: operant conditioning Job card Job card grounding is a behavior
and contracting and skills training. They have the grounding modification technique that is used
common characteristics of being operationally with adolescents. In this procedure,
definable, precise, and measurable. They are usu- parents make a list of small jobs that
take 15–20 min to complete and are
ally applied in combination so that family mem- not a part of the adolescent’s regular
bers learn individually and collectively how to chores. When a problem behavior
give recognition and approval for desired behav- begins, the adolescent is given one of
the jobs to complete and is grounded
iors instead of rewarding maladaptive ones. These
until the job is finished successfully
fundamental behavioral concepts can lead to sig-
nificant change in a short period of time (Gladding
2019).
Operant conditioning is used most effectively change and which might not be a priority.
in parent-child relationships where the aim is to “Charting” is a skill whereby families are taught
increase desirable behavior patterns of children by to keep an accurate record of the children’s prob-
modifying the contingencies of reinforcement lematic behavior. They are taught how to specially
coming from the adults (Table 1). define the behavior and in what quantity it should
There are several examples of operant condi- be recorded such as every day or every time it
tioning interventions. Contingency contracting is happens. This can be used when parents want to
a specific, usually written schedule or contract establish a baseline of the occurrence of targeted
describing the terms for the exchange of behaviors behavior before and after the intervention in order
and reinforcers between family members. One to assess it across time. It should be noted here that
action is contingent, or dependent, on another. charting is both a tool of assessment and the
For example, parents might use a point system intervention because the charting itself often
or “token economy” to reward children for spe- changes behaviors without other intervention
cific behaviors such as doing chores or speaking being necessary. Another example of an operant
nicely. The parents also work with the children to behavioral technique is based on the “Premack
decide which behaviors should be a focus of principle” whereby family members must first do
less pleasant tasks before they are allowed to wearing a coat in colder weather), more important
engage in pleasurable activities. Here, the more behavioral changes are more likely to be incorpo-
pleasant tasks serve as positive reinforcers for the rated. Here, the therapist begins by defining a
less pleasant ones. Finally, in order to apply these specific problem behavior and monitoring it in
operant techniques to the level of the family, regard to its antecedents and consequences. The
“behavior-change agreements” are used. Here, parents are then trained in social learning theory
each family member learns that when they engage with verbal and performance training methods. C
in a specific behavior, another family member will Verbal methods involve didactic instruction, as
be prompted to engage in a different behavior and well as written materials, with the aim of influenc-
so on. Rather than setting this up as a “tit for tat” ing thoughts and messages. Performance training
negotiation, it is used to delineate how each per- methods may involve role-playing, modeling,
son’s behavior affects and is affected by the engaging in behavioral rehearsal, and prompting,
behaviors of the other members of the family with the focus on improving parent-child interac-
(Gladding 2019; Nichols 2017). tions that are easily understood by the children,
The most commonly used skill trainings are given their current level of development. Regard-
communication training, problem-solving train- less of the form of the training, parents are asked
ing, and parenting skills training. Communication to chart the problem behavior over the course of
training improves skills for expressing thoughts treatment. Successful efforts are rewarded
and emotions, as well as for listening effectively through encouragement and compliments by the
to others. Therapists begin by presenting instruc- therapist (Dattilio and Epstein 2016; Goldenberg
tions to family members about specific behaviors et al. 2017).
involved in each type of expressive and listening
skill with the assistance of handouts describing Interventions to Modify Distorted and Extreme
the communication guidelines. They then coach Cognitions
the families during session and often model good Generally speaking, this category of interventions
skills for them. Session skills are then practiced as includes (1) cognitive restructuring techniques,
homework in order to increase and maintain which aim to help family members better monitor
improvement. In problem-solving training, thera- the validity (how accurate one’s thoughts are) and
pists use verbal and written instructions, model- the appropriateness (the utility of one’s beliefs) of
ing, and behavioral rehearsal and coaching to their cognitions, and (2) self-monitoring skills, by
facilitate effective problem-solving with family which therapists teach family members how to
members. The steps include achieving a clear actively and consciously assess and intervene
specific definition of the problem, generating spe- their cognitions in any given situation.
cific behavioral solutions to the problem, evaluat- Specifically, in order to restructure the cogni-
ing the advantages and disadvantages of each tions, therapists can teach older family members
alternative solution, and selecting and agreeing to identify automatic thoughts and associated
on implementing one solution. Finally, the main emotions and behaviors and identify cognitive
aim of parenting skills training is to change par- distortions and label them. Children can also be
ents’ responses to children by educating parents taught to identify and express their emotions
about operant learning principles, developing appropriately. Then, therapists can test and chal-
their ability to observe children’s behavior sys- lenge the automatic thoughts and reinterpret them
tematically, and coaching them in using develop- by considering alternative explanations. In this
mentally appropriate skills to set constructive process, some specific techniques are commonly
limits on children’s behavior and reinforce posi- used. For example, “behavioral experiments,”
tive behaviors. As parents learn better ways to ask where families are encouraged to test their pre-
for good behavior, children learn better ways of dictions that particular actions will lead to certain
behaving. Parents are also taught that if they give responses from other members, can provide first-
up focusing on less important behaviors (e.g., hand evidence in order to reduce one’s negative
expectancies. When family members attempt to family support system designed to prevent and
identify their thoughts and responses that treat behavioral and emotional problems in chil-
occurred in past incidents and have difficulty dren and teenagers and create family environ-
recalling pertinent information, imagery or role- ments that encourage children to realize their
playing techniques can be helpful to recollect the potential. The sophistication of this program is
past interactions. Furthermore, the “downward that it has been used in a number of different
arrow” technique can be used to track the associ- formats including work with individual parents,
ations among one’s automatic thoughts and to groups of parents, agencies working with parents,
identify the underlying core beliefs beneath and even government agencies states responsible
one’s automatic thoughts (Dattilio 2009; Dattilio for the dissemination of parenting guidelines
and Epstein 2016). (Sanders and Turner 2017).
Self-instructional training is a form of self-
management that focuses on people instructing
themselves. It is assumed that problems may be
based on maladaptive self-statements and self- Research About the Model
instruction affects behavior and behavioral
change. In self-instructional training, a self- Research on the effectiveness of CBFT is exten-
statement can serve as a practical clue in recalling sive in terms of individual outcomes but lean in
a desirable behavioral sequence, or it can interrupt terms of family outcomes. The outcome studies
automatic behaviors or thought chains and have focused mostly on the effectiveness of
thereby encourage more adaptive coping strate- behaviorally oriented family interventions in
gies. In families, it is more often employed in treatment of major mental disorders in individual
helping impulsive children modulate their impul- members, such as the psychoeducation and train-
sivity through deliberate and task-oriented “self- ing in communication and problem-solving skills
talk” (Gladding 2019). (Mueser and Glynn 1999), rather than on allevi-
In conclusion, CBFT uses behavioral and cog- ating general conflict and distress within the fam-
nitive interventions to both assess behavior across ily. For example, some studies have demonstrated
time and change it for more adaptive family inter- the efficacy of training parents in behavioral inter-
actions. Most commonly, behavioral components ventions for conduct disorders (Forgatch and
play a larger role than cognitive ones, but both Patterson 2010). Other studies provide empirical
categories provide the therapist with a large “tool support for behavioral family therapy for child-
box” of possible interventions for different fami- hood ADHD (Kaslow et al. 2012). There is also
lies, presenting problems, and pathology. strong evidence for the effectiveness of family-
based/family-focused CBT in the treatment of
Intervention Models childhood anxiety disorders (Kaslow et al.
There are a number of specific types of therapy 2012), adolescent eating disorder (Le Grange
based on the general principles of CBFT. For et al. 2015), pediatric bipolar disorder (West
example, parent-child interaction therapy (PCIT) et al. 2014), pediatric OCD (Selles et al. 2018),
addresses child behavioral problems with a two- trauma symptoms (Kameoka et al. 2015), and
stage intervention model including a relationship prevention of suicide attempts (Asarnow
enhancement phase and a discipline phase et al. 2017).
(Galanter et al. 2012). Similarly, functional family Little research has been conducted on CBFT
therapy (FFT) is a family-based, empirically for difficulties in the family as a whole, either in
supported treatment for behavioral problems, adapting to developmental life-stage changes or in
especially with adolescents (Alexander and Rob- coping with external stressors affecting the family
bins 2018). Perhaps the best known and most (Dattilio and Epstein 2016). However, CBFT
adaptable program is the “Triple P (positive par- principles and methods have been adapted to the
enting program).” Triple P is a parenting and treatment of a variety of problems that families
face in coping with forms of dysfunction in indi- each person why they were here, only Jane spoke.
vidual members and have demonstrated their Both Jenny and Davonti said they had no idea.
effectiveness, such as estrangement in family of The therapist then educated the family on how
origin (Dattilio and Nichols 2011). Another exam- family therapy can be helpful in terms of improv-
ple is that, a psychoeducational parenting pro- ing communication and relationships. Davonti
gram, rooted in cognitive-behavioral principles, indicated that they got along just fine. At this
has been found to be especially effective as an point, Jenny looked at her mother and squirmed C
intervention for at-risk parenting behavior, such as in her chair. When the therapist directed a question
child abuse (Nicholson et al. 2002). to Jenny about how she thought they all got along,
she said that nobody really talked to each other,
but that was fine with her. Jane then interjected
that she tries to get Jenny to come out of her room
Case Example and takes away her screen time when she refuses.
The therapist then asked Jane about her feelings
This is an adoptive, multiracial family. Jane is a about all the separateness at home. She said that
51-year-old Caucasian female. She was born in she values privacy because she grew up in a house
the United States and works as an IT engineer. that was very small with her and her two sisters
Davonti is a 49-year-old African-American male sharing a bedroom and having no personal space
who is a stay-at-home father, having been let go or place in the home to keep any possessions. She
from his job as an adjuster for an insurance com- also noted that Davonti is really the one who
pany. They define themselves as middle class spends all of his time in their room, sleeping
which is important to them, given that Jane was most of the day. Davonti then was able to interject
raised in a working/lower-class family that strug- that he is sick of hearing how poor Jane was
gled with money, while Davonti comes from an growing up. At this point, Jenny pulled out her
upper middle-class family where his mother was a headphones and put them on.
lawyer and his father was a university professor. While Davonti seemed indifferent to this
The two struggled with infertility for about behavior, Jane reached over, grabbed the head-
10 years before adopting Jenny, a 10-year-old phones, and told Jenny that the headphones were
girl from China, 6 years ago. Jane was very insis- “going away for a long time.” From this point on,
tent on having children and took the lead in both Jenny refused to speak. The therapist asked the
fertility treatment and in the adoption process. family if it would be ok to talk to Jenny alone. All
Davonti was less sure about adding a child to the agreed. He asked Jenny when her parents left the
family given that they had a history of financial room if this family interaction was typical. She
difficulties due to neither of them paying attention said yes, that her father let her do pretty much
to a family budget. They presented for therapy whatever she wanted and her mother didn’t under-
after finding out that Jenny was caught stand her at all. She also said she was sick of
stealing lunches out of lockers at school and hearing how poor her mother had been and how
lying to her teachers and parents about it. Jane lucky she should feel now.
wanted therapy because she wanted to understand When the therapist brought everybody back
why Jenny stole the lunches. Davonti believes that together, he made a few observations. First, he
this was a child “being a child” and that Jane and gently wondered aloud if Davonti might be
the teachers were overreacting to a minor depressed (individual psychopathology). He also
infraction. asked the parents if they had ever talked to Jenny
The therapy began with the therapist assessing about her early years (communication). They both
the nonverbal behaviors of the family members. indicated that they assumed she would not want to
He noted that each person in the family sat apart reflect on such a painful time (cognitive distor-
from the rest, with both Davonti and Jenny tion). At this point, Jenny burst into tears saying
appearing sullen. When the therapist then asked that all they cared about was money and that they
assumed that she didn’t want to talk about China Cross-References

on the idea that she had been raised in a poor
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others wanted to see changed and what they each Therapy
wanted as a reward for making their own changes ▶ Patterson, Gerald
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treatment plan, the therapist was careful to ask for ▶ Schemas in Families
understanding and agreement from each family ▶ Token Economy in Couple and Family Therapy
member before proceeding to the next interven- ▶ Triple P – Positive Parenting Program System
tion idea (partnering). At the end, he noted that he
would like to meet with each person alone over
the next few weeks for part of the sessions in order
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Lucksted, A., McFarlane, W., Downing, D., Dixon, L., & Building upon the work of Dr. Salvador
Adams, C. (2012). Recent developments in family Minuchin, Jorge Colapinto has had a unique
psychoeducation as an evidence-based practice. impact on family systems theory and practice
McCubbin, H. I., Larsen, A., & Olsen, D. (1996). Family through his application of Structural Family
coping coherence index (FCCI). In H. I. McCubbin, Therapy (SFT) to marginalized families and the
A. I. Thompson, & M. A. McCubbin (Eds.), Family larger systems that serve them.
assessment resiliency coping and adaptation invento-
ries for research and practice (pp. 703–712). Madison:
University of Wisconsin.
Moos, R. H., & Moos, B. H. (1986). Family environment Career
scale manual (2nd ed.). Palo Alto: Consulting
Psychologists Press. Colapinto received his Licentiate in Psychology
Mueser, K. T., & Glynn, S. M. (1999). Behavioral family
therapy for psychiatric disorders. Boston: Allyn and from the University of Buenos Aires in 1967.
Bacon. He moved to the United States in 1976 to
506 Colapinto, Jorge
train and work with Dr. Salvador Minuchin at affect them. In Working with Families of the Poor
the Philadelphia Child Guidance Clinic. There, (2007), Colapinto and his co-authors Patricia and
he served as an outpatient therapist and a faculty Salvador Minuchin articulated the application of
member in the Extern Program in SFT. When SFT to the field of child welfare, foster care,
Dr. Minuchin moved to New York and founded protective services, and mental health, and sub-
the Family Studies institute in the mid-1980s, stance abuse treatment. His writings highlight
Colapinto joined his consulting team. The how larger systems, despite their goal of helping
team applied SFT concepts and techniques in children and families, can sometimes dilute the
their work with the foster care system. Between very processes they are attempting to support
2000 and 2004, Colapinto consulted with the (1995). This can happen when larger systems
New York Administration for Children Services assume the decision-making function within fam-
on a family-focused approach to permanency and ilies and link individual family members to sepa-
between 2005 and 2008, on the implementation of rate services, thus decreasing the family’s
family team conferences for safety decision- cohesiveness, connectedness, and access to natu-
making. He also served as a member of the ral resources.
New York City Child Welfare Advisory panel Whether as a therapist, supervisor, consultant,
between 2002 and 2003. or trainer, Colapinto assumes a socially responsi-
Colapinto taught in the University of ble stance towards his work with families that
Pennsylvania School of Education from 1982 to have lost or surrendered autonomy to the larger
1989, and in the Drexel University Couple and system (1998). He directs and encourages family
Family Therapy program from 2009 to 2015. members to actualize alternative ways of relating
He has presented frequently on families, family to one another and to the institutions that impact
therapy, family therapy training, and interventions them, with the goal of helping them regain control
with larger systems, at workshops and confer- over their lives. These actions are based on his
ences in the United States and abroad. belief that family members are multifaceted and
Currently he is the Coordinator of Training possess the latent competence and resources they
and Supervision for the Minuchin Center for the need to function more effectively and autono-
Family, where he also directs a grant-supported mously. A nurturer of family processes, Colapinto
project for the development of an evidence-based focuses not on what relational issue contributes to
Structural Family Therapy model for the preven- the problem but rather on what latent “missing
tion of child maltreatment. pattern” within the family can be encouraged
and supported to bring about change. As part of
a larger effort to transform the service delivery
system toward a more family friendly approach,
Contributions to Profession his consultations typically take place on-site in
social agencies and institutions where the family
Colapinto’s writings provide a clear exposition of is receiving services.
SFT and its application to supervision, training, In recognition of his contributions, The
and particularly to understanding and intervening American Family Therapy Academy honored
on the context of larger systems that impact on Colapinto in 2012 with its Distinguished Contri-
families (1988, 2016). Continuing and expanding bution to Social Justice Award.
upon the initiatives of Salvador Minuchin,
Colapinto devoted his career to the application
of the theory and practice of SFT to the work Cross-References
with families involved with the child welfare sys-
tem. This is an endeavor to change not only the ▶ Minuchin, Salvador
families but also the policies and procedures that ▶ Structural Family Therapy
Collaboration with Clients in Couple and Family Therapy 507
References Harry Goolishian developed Collaborative ther-

apy, a framework that encourages therapists to co-
Colapinto, J. (1988). The structural way. In H. Liddle, create the therapy process with families through
D. Breulin, & R. Schwartz (Eds.), Handbook of family
dialogue (Anderson 2007). Therapeutic conversa-
therapy training and supervision. New York: Guilford
Press. tions integrate values around therapist-family
Colapinto, J. (1995). Dilution of family process in social co-equality, therapist attunement to clients’
services. Implications’ for treatment of neglectful worldviews, and reinforcement of clients’ agency C
families. Family Process, 34, 59–74.
in hypothesizing, reframing, and feedback. In col-
Colapinto, J. (1998). Structural family therapy and social
responsibility. In Paper presented at the X world family laborative couple therapy, the therapist works
therapy conference. Dusseldorf. http://colapinto.com/ with each partner collaboratively to improve the
files/SocialResponsibility.doc. capacity of each to work similarly with each other
Colapinto, J. (2016). Structural family therapy.
(Wile 2011). In multisystemic and other empiri-
In T. Sexton & J. Lebow (Eds.), Handbook of family
therapy. New York: Routledge. cally-based therapies, as both stance and strategy,
Minuchin, P., Colapinto, J., & Minuchin, S. (2007). collaboration is a common factor linked to client
Working with families of the poor (2nd ed.). outcomes (Kazantzis and Kellis 2012).
New York: Guildford.
Collaboration with Clients in In collaborative therapy, clinicians regard knowl-

Couple and Family Therapy edge and ideas as socially constructed and not
universal truths (Anderson 2007). Like family
Donna Baptiste, Trang Nguyen and Kesha Burch systems, therapy systems generate meaning and
The Family Institute at Northwestern University, solutions through conversations or language – a
Evanston, IL, USA means to engage the social world and gain insight
into problems and solutions. In this approach,
language plays a crucial role in improving family
Name of Concept outcomes and contributes to therapists’ growth
and learning. Clients’ deconstruction of their con-
Collaboration in couple and family therapy cerns is also just as valuable as therapists’ expert
knowledge.
Multisystemic and other evidenced-based fam-
Introduction ily psychotherapists endorse a collaborative
approach for problem youth and resistant or dis-
In psychotherapy, collaboration refers to a philo- engaged families (Tuerk et al. 2012).
sophical stance or framework as well as a broad Therapist–family partnerships are crucial to
range of strategies that therapists use to build work with youth in contexts of their helping sys-
alliances, engender trust, converse with clients, tems that affect their everyday lives. Multi-
and engage them in their recovery (Kazantzis systemic therapists engage families through the
and Kellis 2012). In couple and family therapy, lens of strengths by helping them to understand
collaboration involves forging alliances with each the therapy process and to see it as useful.
member of the dyad or family, and with the whole Therapists create partnerships through reflective
system, while respecting developmental hierar- listening, empathy, authenticity, and flexibility
chies and boundaries. Collaboration can be con- with therapy setbacks. Therapists amplify family
sidered to be a framework guiding therapy as well inputs as significant and accommodate
as a common therapeutic factor. For example, family expectations and goals in forging
postmodern scholars Harlene Anderson and solutions.
508 Collaboration with Clients in Couple and Family Therapy
In collaborative couple therapy, Wile (2011) Application of Concept in Couple and

suggests that therapists engage partners as consul- Family Therapy
tants to guide the process in which conflicts are
reframed as an inability to communicate heartfelt Sundet’s (2011) study of what therapists and cli-
hurts and disappointments. When partners cannot ents value in collaborating highlights three
express their exact thoughts and feelings, they use domains that undergird approaches discussed
adversarial or avoidant “fallback” strategies that above. The three domains are conversations, par-
create gridlock. Wile (2011) believed that couple ticipation, and relationships. Conversation refers
dynamics can be improved by encouraging them to verbal processes that include exploratory and
to attend to how they communicate around con- focused questions to understand families’ world-
flicts and how they show compassion for them- views, dynamics, and goals. Therapists are
selves and each other. encouraged to give both positive and
negative feedback, with negative feedback per-
Description ceived by families as safe and tolerable when the
therapy environment is helpful and supportive.
In collaborative therapy, Anderson (2007) recom- Families also value therapists’ hypotheses and
mends synchronicity with clients through the use reframing, based on their knowledge, to enlarge
of cooperative language, respectful listening, perspectives, action steps, and experiences.
exploratory questions, a capacity to simulta- A goal of the conversation is to offer families
neously hold multiple and competing ideas, and corrective experiences through respect and
conversing in the family’s style with respect for support.
their sociocultural dynamics and worldviews. In Participation involves therapists’ application
multisystemic family therapy, Tuerk et al. (2012) of expert knowledge in ways that do not under-
suggest highlighting family strengths throughout mine a family’s sense of their problems, culture,
treatment, reflective listening, reframing, empa- and values. Participation also suggests a deep
thy, and perspective taking. These strategies con- capacity for therapists to join with families
vey an understanding of suffering, encourage through authentic styles and affect attunement
trust, counteract the family’s negative experiences and to bond over everyday life struggles. Sundet
with larger systems (e.g., child welfare). Thera- (2011) indicated that in collaborating, families do
pists must remain hopeful about families and ener- not want to be merely objects of scrutiny, and
gize them to keep trying towards self-efficacy, therapists do not want families to take them for
even when they feel discouraged. Authenticity in granted.
communication with families and flexibility with Relationship implies “to be where people are”
therapy setbacks are also crucial. Therapists and “to get a taste of it” (Sundet 2011, p. 240)
should also advocate for families with larger sys- through listening, taking disclosures seriously,
tems that denigrate and marginalize. and believing families. It also implies
In collaborative couple therapy, Wile (2011) establishing and following the families’ preferred
encourages therapists to use their triggers or reac- goals and expectations, using expert knowledge
tions as clues to what partners are thinking and as an enhancement. Therapists’ generosity in
feeling or how they may be using adversarial or giving of themselves and willingness to foster
avoidant strategies. In a collaborative mode, ther- human connections strengthens such relation-
apists can amplify the inner struggles of each ships. Productive working relationships with
person in the union and steer dyads towards inti- families may mean mediating with other
mate and authentic relating. This strategy involves systems, and this can help families to regain
exchanging heartfelt concerns and showing com- a sense of honor and dignity in accessing
passion for self and the other. resources.
Collaboration with Clients in Couple and Family Therapy 509
Clinical Example closely with the psychiatrist and Byron’s foster

mother to help them understand medication
Byron, a 13-year-old teenager, started therapy due requirements and regimens. Setbacks during the
to problems at school. He was in the care of a 3 years of treatment included caseworker changes,
63-year-old woman with over 20 years of experi- family discouragement, and disengagement due to
ence raising foster children. She was raising three sibling difficulties. Byron had inconsistent aca-
other foster children and two of her grandchildren demic achievement although behavior at school C
when Byron entered the home. Before this, Byron improved. Byron also ran away to search for his
had six failed foster care and there were significant first foster family, requiring crisis services. With
ambiguities and gaps in his clinical records and each nuance in treatment, the therapist convened
diagnoses, suggesting his case should be updated. parts of the family and helping system as needed.
The new family therapist convened a meeting Over 3 years, the family-adolescent attachment
with Byron and his foster mother, and a separate improved, and Byron embarked on a vocational
meeting with the caseworker. track with interest in media production and acting.
The therapist encountered an engaging young Five years later, the therapist learned that Byron,
man, slightly introverted, with interests in social now 19, still lived in the same home, worked at a
media, music, and acting. However, Byron had a restaurant, had a committed relationship, and was
quirky disposition and chaotic personal bound- active as usual on social media. He was in therapy
aries, which explained poor school adjustment. and still on stimulant medications. Byron had
He talked out of turn, invaded personal space, setbacks, but he seemed to be achieving appropri-
and seemed overly inquisitive. His peers liked ate developmental milestones.
him, but his unusual manner created arguments The keys to successful collaboration, in this
and peer rejection in school. Byron’s foster case, were the therapist’s positive regard for
mother was anxious about his potential to be Byron and the foster family, optimism about
expelled from school. The therapist built rapport Byron’s future, advocacy for Byron within sys-
with Byron’s foster mother and sensed that she felt tems of care, and resilience with treatment set-
unsupported by other systems. backs. Seeing Byron’s strengths created new path-
The therapist suggested three goals: to clarify ways to clarify his diagnosis and treatment. While
Byron’s mental health profile, to work collabo- Bryon’s needs were paramount, the therapist also
ratively with his other systems of care, and to conveyed deep empathy for the needs of the foster
stabilize the current placement. Byron’s diag- parent and siblings and tried to address those
noses of schizophrenia, bipolar disorder, psy- needs as well.
chosis, and autism were ruled out based on a
neuropsychological assessment. Byron received Cross-References
a diagnosis of ADHD, was averagely intelli-
gent, and had poor social skills and features of ▶ Alliance in Family Relationships
disorganized attachment. The therapist also ▶ Alliance Scales in Couple and Family Therapy
connected Byron with a psychiatrist to begin ▶ Collaborative and Dialogic Therapy with Cou-
stimulant medication. The psychiatrist also col- ples and Families
laborated with Byron and the foster family on ▶ Collaborative Couple Therapy
attunement, attachment, and social skills. ▶ Postmodernism in Couple and Family Therapy
Additionally, the psychiatrist worked with the ▶ Split Alliance in Couple and Family Therapy
caseworker, foster mother, and school staff to ▶ Therapeutic Alliance in Couple and Family
design individual educational and 504 plans for Therapy
classroom behavior, academic compliance, and ▶ Using Collaborative Helping Maps to Organize
school-based group support. The therapist worked Therapeutic Conversations with Couples
510 Collaborative and Dialogic Therapy with Couples and Families
References therapist, or other helper, using this approach,

engages clients from a non-knowing stance or
Anderson, H. (2007). The heart and spirit of collaborative position of a curious and respectful learner; the
therapy: The philosophical stance – “A way of being”
client(s) is the expert on their own concerns,
in relationship and conversation. In H. Anderson &
D. Gehart (Eds.), Collaborative therapy: Relationships struggles, goals, and preferred outcomes.
and conversations that make a difference (pp. 43–59).
New York: Routledge. Introduction
Kazantzis, N., & Kellis, E. (2012). A special feature on
Collaborative and dialogic therapy is used at the
collaboration in psychotherapy. Journal of Clinical
Psychology, 68(2), 133–135. Houston Galveston Institute (HGI), a counseling
Sundet, R. (2011). Collaboration: Family and therapist and training center currently located in Houston,
perspectives of helpful therapy. Journal of Marital TX. The institute was founded in Galveston,
and Family Therapy, 37(2), 236–224.
Texas, by Harry Goolishian, Harlene Anderson,
Tuerk, E. H., McCart, M. R., & Henggeler, S. W. (2012).
Collaboration in family therapy. Journal of Clinical and several of their contemporaries who had
Psychology, 68(2), 168–178. https://doi.org/10.1002/ begun to experiment working with the families
jclp.21833. of their clients in a medical school setting where
Wile, D. B. (2011). Collaborative couple therapy. In D. K.
family therapy was not being practiced (Anderson
Carson & M. Casado-Kehoe (Eds.), Case studies in
couples therapy: Theory-based approaches et al. 1986). They began including more people’s
(pp. 303–316). New York: Routledge. voices in the therapeutic treatment of people who
were hospitalized and struggling with chronic
mental health. Working with the individual and
his or her family members, Goolishian, Anderson,
Collaborative and Dialogic and their colleagues noticed that the perspective
Therapy with Couples and offered to them about their clients’ contexts was
Families much broader and often provided valuable inter-
actions creating possibilities for change and
Sue Levin1,2 and Adriana Gil-Wilkerson1 opportunities for members of the system to
1
Adjunct Faculty, Our Lady of the Lake change their perspective or perception of the con-
University, Houston, TX, USA text in a way that provided relief or a dissolving of
2
The Taos Institute, Chagrin Falls, OH, USA a problem. In collaborative and dialogic practices,
a client and the therapist are engaged in conver-
sation where they are mutually learning from each
Synonyms other and creating, through dialogue, ways of
exploring the topics and concerns the client is
CLS (collaborative language systems); Collabo- identifying or has previously identified. In collab-
rative; Collaborative practices; Conversational orative and dialogic practices, a therapist and cli-
therapy; Dialogical; Not knowing; Problem- ent are conversational partners that equally
determined system; Postmodern approaches; engage in dialogue about the client’s concerns
Relational therapy; Social constructionist theories and then decide together about the direction of
therapy.
Therapy Strategies and Interventions Theoretical Framework

(e.g., “This is utilized most in X models and
Name of the Strategy or Intervention Y theories.”)
Collaborative and dialogic therapy does not use Collaborative* and dialogic* therapy is a post-
particular strategies or interventions; rather, it modern approach to therapy and has evolved from
demonstrates a philosophical stance in the way interdisciplinary studies in hermeneutics, physics,
that therapeutic conversations and dialogues are philosophy, linguistics, and poststructural and post-
conducted (Anderson 1997, 2000, 2001). The positivist theories that emphasize the subjective and
Collaborative and Dialogic Therapy with Couples and Families 511
socially constructed nature of reality. It is often helpful. Rather than create a list of interventions
categorized with other postmodern approaches or strategies, our philosophy is grounded in the
such as narrative and solution-focused therapies. tenets of providing a respectful, conversational
experience for the participants. We begin each
Rationale for the Strategy or Intervention client meeting with an intentionality of walking
The collaborative* and dialogic* therapy with them and addressing them with the focus of
approach developed out of the modernist, medical hosting a dialogical conversation in the moment C
model of therapy, including in family therapy, in as opposed to the intention of solving a problem.
which the therapist is viewed as the expert in Anderson (2007) describes how to enhance dia-
diagnosing the client/family and determining the logue by means of skills that are integral to being a
most effective treatment interventions. Collabora- responsive listener in a conversation and to having
tive practices* grew from studies in quantum a relational presence in a conversation where the
physics, postmodernism, hermeneutics, and speakers are able to have a dialogical exchange
other areas of study that emphasize the subjective back and forth – with the therapist engaged in
nature of reality. This translates into a focus on the conversation with genuine curiosity about the cli-
clients’ viewpoints, the need to engage the client ent’s thoughts and ideas and whereby the client
more fully, and the belief that the clients’ voice feels heard and safe to express him or herself.
(s) and their story must lead in a relational and One of the practices we invite clients to work
dialogic exploration of the problem description with is reflecting teams (Andersen 1991, 1992;
and the solution. Anderson and Jensen 2007). At HGI, clients are
given the option of seeing their therapist with a
Description of the Strategy or Intervention reflecting team present. The reflecting team con-
Collaborative and dialogic therapy is rooted in a sists of other therapists who are at different levels
philosophical stance and practices that are rela- of experience, some are students, some supervi-
tional in nature. Collaborative and dialogic ther- sors, and others are newly licensed therapists. The
apy is most commonly described as a way of way we organize the therapy session allows for
being as opposed to a theoretical framework or the therapist and client to have a conversation that
orientation (Anderson 1997, 2001, 2007). This is at least half of the hour where the reflecting
implies that each practitioner has expertise in pro- team members are in a listening role and not
viding a space for the client to explore their rea- commenting or asking questions, and when that
sons for coming to therapy and in conversational conversation is at a stopping point, the therapist
skills that are not usually intended to be evaluated checks in with the client to find out whether it
or quantified. This idea provides a challenge for a would be a good time to transition the conversa-
postmodernist – to speak about the active part of tion from the therapist and client to the reflecting
our work without identifying and labeling it as a team. Once the client and therapist agree that it is a
strategy or intervention as we usually identify good time for that transition, the reflecting team
each context as part of the relational experience members are instructed to have a conversation
that leads to the co-creation of knowledge. Some with each other to discuss ideas that they had
indicate that our strategy or intervention is the while listening to the conversation. The team
actual conversation while others might venture members then ask questions that are intended to
to say that the interventions or strategies used in expand the conversation and generate possibilities
collaborative therapy are the questions the thera- for the clients present. Once the reflecting team
pist asks. Thus a challenge arises in attempting to has had a conversation about the session conver-
describe a collaborative therapist’s work, in that sation, the clients are offered an opportunity to
using the language of intervention and strategies discuss anything that the team brought up or into
we unintentionally create standards that are not further conversation with their therapist. The
universal, but were created for a particular client reflecting team then takes on a listening role
or situation where the ideas and interactions were again and the client chooses to respond, reflect,
512 Collaborative and Dialogic Therapy with Couples and Families
or continue their conversation with the therapist. thoughts and feelings about specific events and
Sometimes, in the moment, clients do not respond relational difficulties she had experienced. Her
to reflections offered by the team members but challenges lately seemed to stem from not know-
come back weeks later to reference an idea or a ing what her role was in the family as she had
comment one of the reflecting team members always been the supporting wife/mother figure
brought up. and her children were now young adults and did
not need her as much while her husband was
Case Example working and thinking about what direction his
At the Houston Galveston Institute, we work with career would take. The therapist asked questions
couples of all kinds. When working with couples that were formed from her curiosity about the
in collaborative and dialogic practices, we offer to situation and about the details that were being
see them with reflecting teams as a way to expand discussed during the sessions. The clients were
our possibilities, perspectives, and ways of able to respond and clarify their points of view
looking at the situation. The therapist or during a dialogic process that invited their opin-
co-therapy team engages the couple in conversa- ions and ideas about their experience. In our reg-
tions about their experiences, especially those ular meetings, when the therapist and clients had
which have led them to seek our help. From the their conversations, the therapist then asked for
time we have a phone conversation with a poten- space/time for the team to have their reflecting
tial client until we are having a termination con- conversation. Shauna and Rick listened to the
versation or session, we engage in conversations ideas and conversations that happened on
that are intended to include the client in decision- the team, and they regularly would indicate that
making about their experience in therapy with the ideas that were brought up had been helpful, or
us. We work together with our clients to arrange they would choose one or two comments to con-
the details of their attending therapy. For example, tinue a conversation from the reflections. Rick
one of our clients that came in as a couple knew once told us that he had been reluctant to attend
they wanted to use a reflecting team due to a therapy to begin with. He indicated that in his
previous experience some of their family mem- context, he was taught to not trust outsiders and
bers had at HGI. Our arrangements with them that he had to be guarded and careful. Rick stated
were made based on their needs. The wife, that the reflecting team process and the conversa-
Shauna*, scheduled a few appointments with tions he and his wife had with the therapist, as a
one of our therapists and then informed her that result, usually left him with questions about how
she would like to bring her husband, Rick*, in for he saw and made sense of the world. He also
couple counseling to discuss some of the chal- expressed gratitude to the team for bringing ques-
lenges they had been facing lately. The therapist tions up in a way that allowed him and Shauna to
asked Shauna if she would like to work with a decline a comment or invited them into a careful
co-therapist and a reflecting team for when her conversation about a topic that might be difficult.
husband was to come. The client indicated that The therapist’s skills were factors that provided an
she did not mind that arrangement and that she experience with which the client felt comfortable
needed to let her husband know what the sessions to have conversations that Rick and Shauna indi-
were going to look like and what to expect. The cated had made a difference. During the process of
therapist agreed to speak with him to provide him 3 months during which we worked with this cou-
with information about how we work. Once the ple, the focus was on providing them with a space
clients had agreed to meet with a reflecting team for their conversations about the changes that
present, we began our work with the clients. They were happening in their life together. We have
discussed their relationship of over 18 years. not provided many details about the content of
Through several sessions and conversations their situation as they are different for most of our
about Shauna’s struggle to make sense of her clients. Additionally, this helps us to emphasize
role in the family, she was able to discuss her that when working with clients, collaborative and
Collaborative Couple Therapy 513
dialogic therapists focus on the relationship and conversations that make a difference (pp. 7–19).
conversations that are formed with each client, New York: Routledge.
Anderson, H., & Jensen, P. (Eds.). (2007). Innovations in
couple, or family. The ways in which we ask a the reflecting process: The influence of Tom Andersen.
question or the information which we take into London: Karnac.
account in conversation with a client as well as the Anderson, H., Goolishian, H., Pulliam, G., & Winderman,
negotiation that happens between all the people L. (1986). The Galveston family institute: A personal
present in the therapeutic conversation are what
and historical perspective. In D. Efron (Ed.), Journeys:
Expansions of the strategic systemic therapies
C
allows us to create change with a client, family, or (pp. 97–122). New York: Bruner/Mazel.
couple. Each time we engage in conversation with
the same clients, we arrive at crucial moments
when decisions about therapy have to be made
and the responsibility about making those deci- Collaborative Couple Therapy
sions is shared by everyone involved, even though
the voices of the clients will be the ones to ulti- Daniel B. Wile
mately inform the process in the most significant Oakland, CA, USA
way as they are the ones who decide whether or
not to return to therapy.
Name of Model
Cross-References Collaborative Couple Therapy
▶ Anderson, Harlene
▶ Andersen, Tom Synonyms
▶ Gergen, Kenneth
▶ Goolishian, Harry Ego Analytic Couple Therapy
▶ Houston Galveston Institute
▶ Reflecting Team in Couple and Family Therapy
Introduction
References In Collaborative Couple Therapy (CCT; Wile

1981, 1993, 2002, 2008, 2011), the therapist
Andersen, T. (1991). The reflecting team: Dialogues and relates to the partners collaboratively with the
dialogues about the dialogues. New York: WW goal of improving their ability to relate collabora-
Norton & Co.
Andersen, T. (1992). Relationship, language and pre-
tively with each other.
understanding in the reflecting processes. Australian and “Relating to the partners collaboratively”
New Zealand Journal of Family Therapy, 13(2), 87–91. means appealing to the couple as consultants
Anderson, H. (1997). Conversation, language and possi- in guiding the therapy. “Improving the partners’
Basic Books.
ability to relate collaboratively” means recog-
Anderson, H. (2000). Becoming a postmodern collabora- nizing that the particular content of the couple’s
tive therapist: A clinical and theoretical journey, part conflicts – money, sex, childrearing practices,
I. Journal of the Texas Association for Marriage and amount of time spent together, and so on – is
only part of the problem. The additional and
Anderson, H. (2001). Becoming a postmodern collabora-
tive therapist: A clinical and theoretical journey, part often more important part is how partners
II. Journal of the Texas Association for Marriage and talk – or do not talk – about these conflicts.
Family Therapy, 6(1), 4–22. They fight or withdraw. Collaborative Couple
Anderson, H. (2007). A postmodern umbrella: Language
and knowledge as relational and generative, and inher-
Therapy is founded on the assumption that part-
ently transforming. In H. Anderson & D. Gehart (Eds.), ners in a problematic exchange are in need of a
Collaborative therapy: Relationships and conversation – a conversation of reconciliation
514 Collaborative Couple Therapy
in the case of fighting or of reconnection in the If Betty were to confide these feelings and
case of withdrawal. Once partners are collabo- Joyce were to experience her confiding as an act
rating rather than fighting or withdrawing, they of intimacy, Betty would feel an immediate sense
are in a position to work together to come up of relief and both partners would feel closer. But
with whatever solutions, compromises, accom- Betty cannot confide these feelings. She is too
modations, and understandings might be ashamed of them. She worries that Joyce will
possible. think of her as needy and jealous. She feels
unentitled to her experience. She is left, accord-
ingly, without a good way to handle the situation.
Prominent Associated Figures When people are unable to obtain the relief that
can come from bringing their concerns out into the
Collaborative Couple Therapy, developed by Dan open – rather than leaving them festering within –
Wile, is built on ego analysis, a form of psycho- they resort to fallback measures that typically
dynamic reasoning developed by Bernard make matters worse.
Apfelbaum. In ego analysis, psychological prob- Fallback measures are substitutes; they are
lems are viewed as developing principally out of replacements. They are what people are stuck with
clients feeling unentitled to their experience when they are unable to express what they need
(Apfelbaum and Gill 1989; Wile 1985). to say.
This focus on fallback measures gives CCT
much of its collaborative feel. If you attribute
Theoretical Framework clients’ symptomatic behavior to such measures –
what they resort to because a better alternative is
Collaborative couple therapists attribute couple unavailable to them – you will see yourself work-
conflict to loss of voice – the inability by one or ing collaboratively to help clients express what
both partners to pin down and confide their they need to say (Wile 1984). If, on the other hand,
leading-edge feeling – what is “alive” for them you attribute clients’ symptomatic behavior to
at the moment, to use Marshall Rosenberg’s term. primitive impulses, for example, or character
If Betty were to confide what is alive for her at the defenses, need to control, or to the unconscious
moment, she would say to her partner, Joyce, “I’m gratification clients might be getting out of their
embarrassed to say I got jealous just now seeing symptoms – if some such notion is your central
you text your ex. I don’t know if I have reason to organizing principle – you will see yourself to
worry or it’s just my insecurity popping up again.” some extent in an adversarial relationship with
Few people are able to talk about their feelings clients, whom you see as resisting your efforts to
in such a fair-minded and nondefensive way. To improve their lives.
do so requires what Apfelbaum calls a “sense of In couple relationships, there are two major types
entitlement” to these feelings – which means, for of fallback measures: the adversarial and avoidant
Betty, that she feels sufficiently self-accepting shifts of everyday life. In the avoidant shift, partners
regarding her embarrassment, jealousy, and inse- take a feeling that makes them uneasy and sweep it
curity to be able to talk about them in a straight- under the rug. Betty keeps her feelings to herself and
forward manner and without putting the blame on talks about something else. Then she escapes to the
Joyce. It requires what collaborative couple ther- bedroom to be alone, soothes herself by writing in
apists call “speaking from the platform” – an her diary, and distracts herself by logging onto
ability to step back from the intensity of the Facebook. In the adversarial shift, partners take a
moment and view oneself in a compassionate feeling that makes them uneasy and turn it into
way. It requires, in addition, that Betty and Joyce something their partners are doing wrong. Betty
share the belief that confiding vulnerable feelings bursts into the kitchen and blurts out, “If you’re so
is a contribution to the relationship and an act of fascinated with Cecile, why don’t you just go back
intimacy. to her tonight and get it over with!”
If partners are unable to confide what they need Betty: I get pretty insecure sometimes.
to say – if they lose their voice – they are stuck as a Joyce: You wouldn’t if you saw the kind of
fallback measure attacking (“If you’re so fasci- thing she texts. Her cat didn’t come home at the
nated with Cecile, why don’t you just go back to usual time. I was reassuring her.
her tonight and get it over with”) and/or avoiding Betty: Oh, the cat. I should have known it
(talking about something else, leaving the room, would be something like that.
and trying to soothe and distract herself), Joyce: You know, I don’t like Cecile’s texting C
Each of these responses – confiding, attacking, me all the time. I’ve got to talk to her about that.
and avoiding – has its own particular effect on the Of course, Betty and Joyce would not have
relationship. Attacking can turn partners into ene- such a sweet conversation if Joyce were still
mies and trigger an adversarial cycle. Avoiding romantically interested in Cecile.
can turn partners into strangers and trigger a with- Partners typically come to a therapy session in
drawn cycle. Confiding can turn partners into some form of an adversarial or withdrawn state. In
allies and trigger a collaborative cycle. some cases, one partner is in adversarial mode and
In an adversarial cycle, each partner attacks the other in withdrawal mode. The focus in Col-
and/or defends in response to the other doing the laborative Couple Therapy is not on the problem
same: the partners are raising but the manner in which
Betty: Make up your mind – it’s Cecile or me. they relate to each other about this problem: they
Joyce: What are you talking about? fight or, in an attempt not to fight, they withdraw.
Betty: I saw you texting her a few minutes ago. The therapeutic task is to turn this fighting or
Joyce: Why is it any of your business who withdrawing into intimate relating: to get the part-
I text? ners on the same team, working together, talking
Betty: You’re still in love with her. That’s how in a more heartfelt way about the problem – which
it’s my business. puts them in place to come up with whatever
Joyce (sarcastically): I’m glad you’re so good solutions might be possible. The task, in other
at telling me how I feel. Anything else you’d like words, is to solve the moment rather than solve
to clue me in on? the problem – which is the CCT way ultimately to
Betty: Don’t change the subject. solve the problem.
Joyce: Someone needs to. You’re talking The quality of life in a relationship depends on
crazy. the partners’ ability to deal with what comes up
In a withdrawn or avoidant cycle, each partner moment to moment in the relationship. The ulti-
disengages in response to the other doing the mate goal of CCT is to improve the partners’
same: ability to deal with moments: to function as joint
Betty (trying to hide her reaction to seeing experts in turning fights into conversations and
Joyce text Cecile): How was work today? problems into opportunities for intimacy.
Since Betty is not engaged in what she’s say- To get in position to help the partners solve the
ing, her tone is flat. moment – which means helping them shift from
Joyce (taking Betty’s hollow tone to mean an adversarial or withdrawn cycle to a collabora-
she’s not really interested): Same as usual. tive one – therapists need to be in a collaborative
Betty (discouraged by Joyce’s hollow tone): state themselves. Therapists pass through all the
Well, I think I’ll go check my email. states the couples do. At certain moments, they are
In a collaborative cycle, each partner confides in a collaborative state, feeling engaged, at times
or comforts the other in response to the other even moved, by what the partners are saying. At
doing the same. other moments, they are in a withdrawn state,
Betty: I’m embarrassed to say I got jealous just feeling unengaged, their minds wandering. At
now seeing you text your ex. still other moments, they’re in an adversarial
Joyce: Jealous? That’s so sweet. It makes me state, feeling put off by or disapproving of one
feel really loved. or both partners.
CCT requires an active appreciation of each particularly useful for this purpose: “doubling”
partner’s inner struggle, an appreciation that is and the “how much, how much” question. These
possible only when therapists are in the collabo- two can be thought of as the signature methods
rative mode. It also recognizes that the therapist of CCT.
will frequently become noncollaborative. It is In doubling, which was originated by Jacob
hard to avoid privately siding at times with one Moreno for use in Psychodrama, the therapist
of the partners and, at such times, losing the ability speaks as if s/he were one of the partners talking
to appreciate fully the other partner’s point of to the other. Doubling allows the therapist to
view. An important part of the couple therapist’s translate a partner’s fight-inducing or withdrawal-
task, accordingly, is to become skilled in noticing inducing statement into a conversation-inducing
and recovering from these noncollaborative one.
moments. Betty: I saw you texting Cecile just now.
Ideally, therapists can use their reactions as Joyce: Why is it any of your business who
countertransference clues. They can use their feel- I text?
ings of withdrawal as a sign that the partners Betty: You’re still in love with her. That’s how
themselves are disengaged and it is the therapist’s it’s my business.
job to revitalize the situation. They can use their Therapist (doubling for Betty): Here, I’ll be
feelings of disapproval as a sign that the person you, Betty, talking to Joyce, and for you I’d say,
toward whom they feel disapproving is doing a “Joyce, I could be wrong. I hope I am. But when
poor job representing her or his point of view and I saw you texting Cecile, I got scared that you
it is the therapist’s job to help. might leave me and go back to her. And you know
me – my fear comes out as anger.”
In an attempt to reshape Betty’s fight-inducing
Populations in Focus statement into a conversation-inducing one, the
therapist replaced Betty’s harsh tone with a gentle
CCT is designed for working with pairs of people: one, recast her complaint as a fear, added a tem-
couples (LGBTQ or straight, married or not), porizing “I could be wrong,” and reported rather
family members (siblings, parent-child, etc.), than unloaded her anger (“You know me – my fear
coworkers, and so on. This approach can also be comes out as anger”). Intimacy can be just a
used in family therapy, group therapy, and sentence away and the therapist helps the couple
mediation. come up with that sentence.
Turning to Betty, the therapist says, “Where am
I right and where am I wrong in my speculation
Strategies and Techniques used in about how you feel?” After speaking for a partner,
Model the collaborative couple therapist checks it out
with that partner. If the partner says some version
To turn fighting or withdrawing into intimate of “You got it wrong,” that’s okay, since the ther-
talking, the therapist goes within to uncover apist can then go on to say, “How should I have
what each partner needs to say in this conversa- put it?” or “What is the more accurate way to say
tion, between to keep it a conversation, and above it?”
to raise the partners up on a platform from which The “how much, how much” question enables
they can talk collaboratively about impasses in the therapists to ask potentially threatening questions
conversation. by pairing them with benign alternatives. If the
Each of these three – going within, between, therapist were to ask Betty, “Do you see yourself
and above – can be accomplished through tradi- as a jealous person?” or “Has jealousy been an
tional psychotherapeutic methods such as asking issue in your life?” Betty might be upset at the
questions, reflecting, reframing, interpreting, and implication that the problem is her jealousy rather
externalizing the problem. Two techniques are than Joyce’s behavior. The therapist avoids this
implication by pairing the question with a benign Betty: Don’t play the innocent. I saw you
alternative. texting Cecile.
Therapist: How much do you see yourself as Joyce: You don’t even know what I said.
having an issue with jealousy and how much as Betty: I don’t need to know. Why do you have
having a finely tuned ability to scope out dangers to text her anything?
that are there? Joyce: Why do you always have to get so
The “how much, how much” question allows paranoid? There’s nothing happening. C
therapists to inquire into delicate, sensitive, and Each partner feels too unheard to listen – which
vulnerable areas without arousing partners’ defen- is what propels the fight. Turning the fight into a
siveness or sense of shame – to make it safe for conversation requires, before anything else, provid-
Betty to acknowledge that she might be prone to ing each partner a hearing. The collaborative couple
jealousy. And it enables the therapist to explore therapist typically provides such a hearing by
whether a partner has at least some appreciation of doubling – repeating a version of what each partner
the other partner’s experience. says so that person feels heard, at least by the
Therapist: Joyce, how much do you see therapist. The therapist’s goal is to reshape each
Betty’s distress as coming totally out of nowhere partner’s statement to make it more satisfying to
and how much as at least a little bit the partner being spoken for and easier for the
understandable? other partner to hear.
The “how much, how much” question enables Therapist (bringing the partners in on what he
therapists to peer into a partner’s inner workings, is planning to do): Okay, let’s see if I can say
raise difficult issues in a nonthreatening way, something here that might sort things out a little.
explore the nuances of each partner’s thinking, I’ll be you, Betty, talking to Joyce.
and suggest that it is normal to have simultaneous The risk in doubling for a partner when tension
contradictory feelings about an issue. is high is that the other partner, feeling their point
isn’t being represented, will interrupt. In other
words, each partner needs to be heard first.
Research about the Model A good way to deal with this problem is to speak
on behalf of one partner but begin by acknowl-
There are no known research studies specifically edging the other partner’s point of view.
devoted to Collaborative Couple Therapy. Therapist: Here I’m you, Betty, speaking to
Joyce, and for you, I’d say, “Okay Joyce, I see
what you’re saying. You felt attacked out of
Case Example nowhere by me, just when you were doing some-
thing nice by making dinner for us.”
The CCT task is to take the fight or withdrawal Joyce: Exactly!
occurring right there in the session, or that the Since Joyce’s point of view is being
couple reports from the past week (or earlier), represented, she relaxes. She’s now in position to
and turn it into an intimate conversation. In the listen, at least for a short period. Since Betty’s
following session, a composite, the therapist point of view isn’t being represented, there’s a
engages in a long string of interventions in his chance she might interrupt. To prevent this from
struggle to create the needed conversation. happening, the therapist has wheeled his chair
The couple is Betty and Joyce. Although Joyce over next to Betty and is delivering his comments
doesn’t want to go back to Cecile, she does want from there, giving physical representation to
to keep Cecile as a good friend. Joyce is reluctant being on her side. Also, Betty doesn’t have to
to express this wish, however, in fear that Betty wait long before the therapist presents her point
would get upset. of view.
Joyce: I’m minding my business, mixing a Therapist (continuing to speak for Betty): “I
salad, and you go into your volcano routine. wish I could get you to see how a person could
understandably worry about a threat from a previ- Therapist: Okay, Joyce, let me make up some-
ous relationship.” thing for you and see what you think. I give it
Betty nods her head in agreement, which about a 30% chance of capturing how you feel.
encourages the therapist to develop the point fur- By acknowledging that he is speculating, the
ther, building his statement out of feelings that she therapist makes his comment easier for Joyce to
expressed in previous sessions. reject, which emboldens him to speculate more
Therapist: “We haven’t been together long, freely.
but you’re precious to me. I feel closer to you Therapist: Joyce, I’m you talking to Betty and
than I’ve ever felt toward anyone. So I hope you for you, I’d say, “Cecile was part of my life for
can understand how I might get upset at the many years and so I can understand how you
thought of losing you.” might wonder how I feel about her now.”
Betty: Yeah! The therapist begins his comment for Joyce by
Betty appreciates how the therapist makes her acknowledging Betty’s position. He now goes on
position sound reasonable. She had worried that to state Joyce’s own position.
the way she had put it sounded too much like a Therapist: “Still, I’m frustrated with my
childish tantrum. Her enthusiastic “Yeah” makes inability to reassure you that there’s nothing
it unnecessary for the therapist to add the usual there that threatens our relationship.”
“Where am I right and where am I wrong in what Turning to Joyce, the therapist says, “Where
I just said for you?” Joyce is not pleased, however. am I right and where am I wrong in this statement
Joyce (to Betty): Do you expect me to give up I just made for you?”
all my friends? Joyce: You were right when you said she was
Betty: I’m not talking about all your friends. part of my life for many years. (to Betty): Certain
Just Cecile. roots set in when you’ve known a person a
Joyce: Now you’re telling me who can be my long time.
friends and who can’t. Joyce takes advantage of what she feels is the
Betty: No, I’m just— relative safety of therapy to press her wish to keep
Joyce: Why do you always have to be so Cecile as a good friend.
insecure and needy? Betty (upset): Roots? What do you mean
The therapist is put off by Joyce’s harsh judg- roots? How deep are these roots?
mental words and demeaning tone. He is reacting, Joyce (immediately sorry she said “roots”):
which means that he has temporarily lost the ability Now don’t get like this.
to look at the situation from her point of view. He’s Betty: How did you expect me to get?
momentarily out of position to do CCT – a condition Joyce: I don’t know – just not like this.
that can occur at various points in any given session. Betty: You know I’m not the one who—.
Recognizing that he has shifted out of thera- Therapist: Okay Betty, so you’re saying,
peutic mode and into judgmental mode, the ther- “Joyce, as you can see, the word “roots” really
apist employs the CCT remedial measure, which gets to me.”
is to become spokesperson for the partner – here The therapist jumps in to rescue the conversa-
Joyce – whom at the moment he finds himself tion. He does this by developing what Betty is
privately siding against. Becoming a spokesper- saying rather than by challenging or countering it.
son requires first finding a way to appreciate that Betty (sarcastically): You could say that.
partner’s point of view. The therapist thinks, Therapist (continuing to speak as Betty
“What must Joyce be feeling and thinking – talking to Joyce): “I hope when you say ‘roots’
what is her inner struggle – that would lead her you mean deep feelings a person has toward, say,
to say what she just said?” When reacting to a sister or old high school friend. I’m scared,
Joyce, as he did a moment ago, he temporarily however, that you mean romantic feelings.
lost the ability to appreciate her struggle, or even The therapist is putting words to what appears
recognize that she had one. to be Betty’s fear. He asks, “Where am I right and
where am I wrong in this guess about how you Therapist (to Betty): Yes, let’s ask her about
feel?” that. (to Joyce): What did you mean about
Betty (turning the therapist’s comment into “roots?”
ammunition against Joyce): I’ve seen you with Betty (appreciating the therapist’s pressing
your sister. That’s not at all how you are with Joyce on this matter): Yes, how about that?
Cecile. Joyce (appreciating the opportunity to explain
Joyce: I don’t get along with my sister! You herself): I feel better about Cecile now that I don’t C
know that. It’s not a fair comparison. have to deal with her morning, noon, and night.
Betty: It’s not fair, all right. You’re totally I’d never want to go back to her – never. That was
enthralled with Cecile. a total nightmare. But I’d still like to keep her as a
Joyce: Cecile was an important part of my life, friend.
but there’s nothing there. I don’t want you to feel Betty:(suspiciously) What kind of a friend?
bad about it. Joyce: As a kind of sister – one I like. Not like
Betty (upset): Oh, do I have something to feel Franny.
bad about? Betty: Why didn’t you say that in the first
Joyce (to the therapist): This isn’t going well. place?
The therapist is reacting to Betty’s tone – he’s Joyce: Because I was afraid you’d blow it out
put off by it – which he deals with in the usual of proportion – like you’ve been doing this
CCT way by speaking on her behalf. whole hour.
Therapist: I’ll be you, Betty, speaking to Betty: Only because you didn’t tell me about
Joyce, and for you I’d say, “As you can see, the sister thing – although, to tell you the truth,
Joyce, I’m terrified that you’re still caught up I’m not so happy about that either. How do I know
with Cecile. I’m beside myself. I don’t know that you’re not going to go off to love land with
what to do.” her again? How do I know you’re not doing it
Turning to Betty, the therapist says, “Or am already?
I stating this too strongly.” Joyce: That ship has sailed.
Betty: Not strongly enough. Betty: It could sail back. Why do you have to
Therapist (continuing to double for Betty): see her at all? Why is it so hard to give her up?
“I’m totally devastated. I feel like a lost little This argument is going too fast for the therapist
child no one wants. I don’t remember the last so he shifts to the overview level.
time I felt this bad.” Therapist (asking a version of the “how much,
The therapist wants to ask Betty whether jeal- how much” question): In what ways is this argu-
ousy has been an issue in her life. He fears, how- ment useful and in what ways is it not so useful?
ever, that she would hear it as, “Your jealousy is The therapist creates a platform from which
irrational. It isn’t about Joyce. It’s about your Betty and Joyce can talk collaboratively about
childhood.” The therapist uses the image of “a their argument.
lost little child” in hopes that it might lead Betty Betty: I don’t know.
to bring up any such early experience. It does not. Joyce: It’s frustrating.
Betty: I’ve never felt this bad. Therapist: Yes, it’s tough to be at odds with
Joyce: Listen, Betty. I’m glad I left Cecile – the person you most need to feel understands you.
I should have done it much earlier. I’m just saying So I want to give you an experience of such
that I don’t want to exclude her entirely from my life. understanding. I’m going to make up stuff based
Betty: I knew it. I should never have moved in on what you’ve said today and other times.
with you. (To the therapist): How can I believe Betty and Joyce seem intrigued. They wonder
her? You heard what she said about “roots.” what the therapist is going to say.
Betty is too riled up to pursue her point effec- Therapist: In this conversation, Betty, you’d
tively. Part of the therapist’s job is to help each say, “Joyce, it was a great relief to hear about
partner make their point. ‘morning, noon, and night’ and about ‘total
nightmare.’ For a brief moment I felt that maybe making acknowledgments rather than accusa-
you didn’t want to go back to her.” tions; reporting anger rather than unloading it;
Betty: A very brief moment. confiding vulnerable feelings and, in particular,
Therapist (incorporating Betty’s correction): replacing complaints with wishes and fears; and
“Yes, a very brief moment – because then stepping back to create a platform from which to
I thought, “Why didn’t you tell me earlier about talk collaboratively about the couple predicament.
the sister thing.” Then, Joyce, you’d say, “Well The situation would be different if Joyce were
yes, I can see why you might wonder about that. to want to return to Cecile. The therapist would,
I was worried you’d get upset, which you kind of however, proceed in the same way, working with
did.” Then, Betty, you’d say, “I know. I’m an what each partner said in an effort to create the
emotional person. But I thought you liked that.” best conversation possible given the situation.
Then, Joyce, you’d say, “Well, I do like that – a In Collaborative Couple Therapy, the therapist
lot. I’ve never met anyone like you. You’re the solves the moment by turning the struggle of the
first woman I’ve been with who doesn’t bore me. I moment into the best conversation possible. The
have trouble, however, when you’re angry at me. I goal is (1) to enable partners to become better
get afraid to talk.” witnesses and reporters of the thoughts and feel-
Therapist (concerned that he’s speculating too ings coursing through them and (2) to help cou-
wildly): What do you think so far about this ples to become better joint managers of their
exchange I’m making up? recurrent adversarial and withdrawn states.
Betty (to Joyce, softly): Are you really afraid
to talk to me?
Joyce: Sometimes. Cross-References
Betty: I don’t want you to be afraid to talk.
For a moment, Betty and Joyce are talking ▶ Bids and Turning Toward in Gottman Method
collaboratively. It doesn’t last long. Couple Therapy
Betty (stiffening): That’s how I get sometimes. ▶ Collaboration with clients in couple and family
You should know me well enough by now not to therapy
take it so seriously. ▶ Collaborative and Dialogic Therapy with
Therapist (jumping in to rescue the conversa- Couples and Families
tion): I want to go back a moment to that sweet ▶ Countertransference in Couples Therapy
exchange you just had – you know, Betty, when ▶ Doubling in couple and family therapy
you said, “Are you really afraid to talk to me?” It ▶ Emotionally focused couple therapy
had such a different feel from almost everything ▶ Gottman Method Couples Therapy
else in the session. Do you both see it that way, ▶ Psychodrama in Family Therapy
and how did it feel when you were saying it? ▶ Wile, Daniel
The session continues primarily in battle mode
with occasional whiffs of a collaborative
exchange. The therapist asks the usual CCT References
end-of-the-session question, “What are you taking
away from this session that’s useful, if anything, Apfelbaum, B., & Gill, M. M. (1989). Ego analysis and the
and what’s been disappointing about it?” relativity of defense: Technical implications of the
structural theory. Journal of the American Psychoana-
Joyce: This is good. We’re able to talk here. lytic Association, 37, 1071–1096.
Betty: Your interruptions allow a longer dis- Wile, D. B. (1981). Couples therapy: A nontraditional
cussion than we have at home. approach. New York: Wiley.
Joyce: The way you restate what we say opens Wile, D. B. (1984). Kohut, Kernberg, and accusatory inter-
pretations. Psychotherapy: Theory, Research, Practice,
my heart. and Training, 21(3), 353–364.
The therapist shows by demonstration a differ- Wile, D. B. (1985). Psychotherapy by precedent:
ent way to have a relationship, characterized by Unexamined legacies from pre-1920 psychoanalysis.
Collusion in Family Systems Theory 521
Psychotherapy: Theory, Research, Practice, and Train- needs (Simon et al. 1985). The new ways of
ing, 22(4), 793–802. relating to one another over time in the dyadic
Wile, D. B. (1993). After the fight: Using your disagree-
ments to build a stronger relationship. New York: relationship are experienced as burdensome, and
Guilford. the partners become polarized within the context
Wile, D. B. (2002). Collaborative couple therapy. In of jointly repressed conflicts between one another.
A. S. Gurman & N. S. Jacobson (Eds.), Clinical hand- The repressed needs and wishes that each partner
book of couple therapy (3rd ed., pp. 281–307).
New York: Guilford. delegated onto the other become increasingly C
Wile, D. B. (2008). After the honeymoon: How conflict can threatening, and the partner, who served as the
improve your relationship, revised edition. Oakland: embodiment, must be vigorously opposed
Collaborative Couple Therapy Books. (Simon et al. 1985).
Wile, D. B. (2011). Collaborative couple therapy. In
D. K. Carson & M. Casado-Kehoe (Eds.), Case studies
in couples therapy: Theory-based approaches
(pp. 303–316). New York: Routledge. Prominent Associated Figures
Melanie Klein (1936) introduced the concept of

projective identification in relation to how her
Collusion in Family Systems patients appeared to project onto other aspects of
Theory themselves that were unbearable to face by one-
self. This projection process can be extended to
Dawn M. Wirick and Lee A. Teufel-Prida relational issues in couples where, in projective
The Family Institute at Northwestern University, identification, one partner carries projected
Evanston, IL, USA aspects of the other. Therefore, one partner may
assume the aggression from the other partner, and
the partner, who projects the aggression, assumes
Name of Theory pacifistic traits.
Henry Dicks (1967) initially outlined the con-
Collusion in family systems theory cept of collusion in relation to ego boundaries, in
his book, Marital tensions: clinical studies
towards a psychological theory of interaction.
Introduction He described deeper unconscious bonds within
the couple’s relationship, which he labeled as
In the formation of a dyadic relationship, each joint ego boundaries drawn around the dyad. He
partner discovers in the other past and/or further described the unconscious attribution of
repressed parts of self. These aspects of self may shared feelings onto one another as a collusive
be regarded as representations of needs and process.
wishes repressed via defense mechanisms. Jurg Willi, in his books Couples in Collusion
A partner’s attraction is often based on the extent (1982) and Dynamics of couples therapy (1984),
to which the partner is viewed as embodying the described progressive and regressive roles in the
parts of self that have been repressed (Simon et al. dyadic relationship as they relate to collusive
1985). Consequently, the concept of collusion in dynamics in dyadic relationships. One partner
family systems theory is derived from projective assumes a progressive role, while the other partner
identification. assumes a regressive role.
Over the course of the relationship, what was
viewed as initially attractive becomes an eventual
source of conflict, and interpersonal strife Description
emerges. Choosing a partner permits one the
opportunity to complete one’s self, but also sets Collusion is an unconscious act undertaken by
the stage for renewed conflicting wishes and partners in an attempt to master their fears and
522 Collusion in Family Systems Theory
conflicts (Simon et al. 1985). To handle conflicts The application of the concept of collusion
that originate from the individual’s personal his- implies that there is always either conscious or
tory, the members of the couple assign to one unconscious agreement within the dyadic rela-
another the task of embodying components tionship, despite the presence of apparent irrecon-
of ambivalence that otherwise would be too pain- cilable differences. The agreement is reinforced
ful for them to bear as individuals (Simon through shared fantasy when both partners con-
et al. 1985). clude together that, for example, males are to
The concept of collusion derives from projec- behave in a detached manner to demonstrate that
tive identification in that the recipient of the split- they are strong. While the male partner denies that
off part of the partner does not disown the projec- he detaches from the female partner, he also indi-
tion, but rather acts upon the unconscious mes- cates, at the same time, that he must detach from
sage. For example, a need for a more engaged time to time to uphold the notion of being strong.
partner to gratify the needs of a less engaged Because of his fantasy of what it means to be a
partner requires that both partners agree to the strong male (e.g., I am not able to be strong unless
assigned roles (Stewart et al. 1975). One partner detached), in essence, he agrees with the woman’s
receives praise for being engaged, while the less accusations. As such, both partners in the relation-
engaged partner receives protection from the more ship possess the same fantasy as to what com-
engaged partner. At times, collusion is explicit prises a strong male (Stewart et al. 1975). The
and may be neither problematic nor pathologic therapist must be aware of how gender norms
(Stewart et al. 1975). However, when the assigned within one’s culture are practiced and if notions
roles have changed, couples can experience dis- of traditional gender norms are upheld or set aside
comfort or symptom formation. by the couple.
Engagement in overfunctioning behaviors,
from one partner, determines the extent of
underfunctioning behaviors in relation to the part Clinical Example of Theory
of the other partner. For example, an extremely
helpful partner determines the level of helpless- Maria and Juan are a child-free couple who have
ness in the other partner. The more helpful one been married for 12 years. They entered couples
partner becomes, the more helpless the other part- therapy because Juan suddenly resigned at his
ner becomes. Similarly, progressive behavior such job after 10 years of employment, and Maria
as overcompensation on the part of one partner reported not knowing about Juan’s resignation
leads to regressive behavior such as irresponsibil- until after it occurred. Maria indicated her con-
ity on the part of the other partner. cerns about their acute financial crisis. As a
result, Maria stated taking on two additional
part-time jobs to make up for the loss of Juan’s
Relevance to Couple and Family Therapy income and to prevent the loss of their home.
Juan countered by stating that Maria wanted to
The difficulty within the therapeutic context arises control every item in the household and that he
when the couple denies collusion, exaggerates quit his job, because he was certain Maria would
differences, and employs multifaceted attempts immediately react to and see him as a failure she
to prevent the therapist from unveiling collusion saw him as being. In response, Maria stated
(Stewart et al. 1975). These tactics, on the part of seeing Juan as completely helpless, while Juan
the couple, can lead to increasing the level of stated that he saw Maria as being too helpful to
confusion for the therapist in relation to how the everyone in her life, including his needs. Juan
couple can live together and why they remain in reported that he was typically attracted to
the relationship despite the overt disagreement women who were strong, independent, and will-
around meeting one another’s needs (Bagarozzi ing to take care of his needs. Maria stated that
2011). she was attracted to men who needed her help
Collusion in Family Systems Theory 523
and care and recognized her prior patterns in yet in a way that Juan would not experience as
abandoning relationships when she did not feel intrusive or controlling.
needed. To further facilitate the spouse’s independent
The couples therapist explored the central functioning, the therapist asked Juan to attend a
themes to highlight the personal mythologies pre- social skills training workshop so that Juan could
sented by each partner. A central theme in Maria’s enhance his job interviewing skills. The rationale
personal mythology was her fear that she would offered for this suggestion was that since Juan’s C
be rejected and abandoned by Juan. In reflection problematic behavior, at his last job, was partially
about her family of origin, Maria had shared that responsible for his departure, social skills training
her biological father left her mother for a par- might provide some value. Juan’s involvement in
amour when Maria was 6 years of age. As such, social skills training proved freeing for Maria, and
Maria had developed a self-image of one who was she began to feel less responsible for constantly
defective, incomplete, and unworthy of a man’s monitoring and correcting her spouse.
love. It became apparent that Maria had selected Maria’s feelings of low self-worth and the
Juan for a husband, because she viewed Juan’s depressive episodes that occurred as a result were
high level of dependence as an assurance that he rooted in her ambivalent relationship with her father.
would never leave her. For Juan, Maria The therapist helped Maria work through her ambiv-
represented a sense of safety. He defined her as alent feelings toward her father, and because Maria’s
force who helped him to stay consistently father lived close, the therapist suggested inviting
employed and away from trouble. According to him to a future session. Maria indicated that she
Juan, Maria also urged him to withdraw from believed that she could work through her feelings
those in his past who encouraged him to return without her father attending.
to criminal activity. Maria structured Juan’s daily
activities, enacted rules designed to decrease his
engagement with past persons and places, and
Cross-References
consistently enforced the rules that she created
without Juan’s consent. Over time, Juan began to
▶ Object Relations Couple Therapy
resent Maria for taking on more of a “parent role
▶ Projective Identification in Psychoanalytic
within their dyadic relationship,” while Maria
Couple and Family Therapy
began to resent Juan for “acting like a child.”
▶ Psychoanalytic Couple and Family Therapy
Maria and Juan acknowledged and agreed that
the way their lives had been structured no longer
was functional or desired and that a change was
References
necessary. Both agreed with the therapist’s interpre-
tation that Maria’s attempts to assist Juan had Bagarozzi, D. A. (2011). A closer look at couple collusion:
become weighty for her and that Juan interpreted Protecting the self and preserving the system. The
her help as intrusive and controlling. The therapeutic American Journal of Family Therapy, 39(5), 390–403.
Dicks, H. V. (1967). Marital tensions: Clinical studies
issue became how to change the established pattern
toward a psychological theory of integration.
in a manner that would account for each partner’s New York: Basic Books.
unique personal issues (e.g., Maria’s fear of aban- Klein, M. (1936). The psychoanalysis of children. London:
donment and feeling unworthy of a man’s love) and Hogarth Press.
Simon, B. F., Stierlin, H., & Wynne, L. C. (1985). The
Juan’s need for external structure (e.g., Juan being language of family therapy: A systemic vocabulary and
unable to establish his own sense of safety via his sourcebook. New York: Family Process Press.
own rule construction). The process began by Stewart, R. H., Peters, T. C., Marsh, S., & Peters, M. J.
assisting the couple to develop a cooperative strat- (1975). Family Process, 14, 161–178.
Willi, J. (1982). Couples in collusion. New York: Jason
egy that would permit Juan to explore his environ-
Aronson.
ment (places and persons) and also permit Maria to Willi, J. (1984). Dynamics of couple therapy. New York:
participate in the process that was acceptable to her, Jason Aronson.
524 Combs, Gene
narrative therapy in the Chicago area, and he is a

Combs, Gene founding member of the University of Chicago
affiliated Chicago Center for Family Health.
Irma Rodríguez With his partner Jill Freedman, Gene received
Grupo Campos Elíseos, Mexico City, Mexico the American Family Therapy Academy’s award
for Innovative Contribution to Family Therapy in
2009. The American Association for Marriage
Name and Family Therapy awarded him for the Out-
standing Contributions and Leadership to the
Gene Combs, MD (1946–) Association in 2004.
Introduction Contributions to Profession
Gene Combs is internationally recognized for his In addition to his writing about and teaching nar-
advances in narrative theory and training. He has rative therapy, Gene has served on the Committee
been involved for the last quarter century in the on Accreditation in Marriage and Family Therapy
development of narrative therapy as a distinct Education (COAMFTE) and on the board of the
approach to individual therapy, family therapy, American Family Therapy Academy (AFTA). He
and community work. In his current day-to-day is an active member of the editorial review boards
work, he is developing ways to help primary care for Family Process, the Journal of Marriage and
physicians become more skilled at understanding Family Therapy, and the Journal of Systemic
and working with the particular hopes and fears of Therapy.
the people who consult with them. With his part- In his work with young physicians, Gene
ner Jill Freedman, Gene has practiced, studied, strives to help them preserve a human, interper-
taught, and written about narrative therapy for sonal, and reflective focus in the face of corporate
over two decades. pressures toward pills, procedures, and
“productivity.”
Career
Cross-References
Gene received an MD from the University of
Kentucky College of Medicine in 1972, which ▶ Family Therapy
he followed with a Psychiatry Residency, at the ▶ Narrative Couple Therapy
same institution. He specialized in Family Ther- ▶ Narrative Family Therapy
apy through live supervision with Jay Haley and
Cloe Madanes, residential workshops and super-
visory experiences in Italy with Luigi Boscolo and References
Gianfranco Cecchin, and live case consultations
with Michael White. Books
Gene is an associate professor in the Depart- Combs, G., & Freedman, J. (1990). Symbol, story, and
ceremony: Using metaphor in individual and family
ment of Family Medicine at NorthShore Univer- therapy. New York: Norton.
sity HealthSystem, where he is Director of Freedman, J., & Combs, G. (1996). Narrative therapy: The
Behavioral Science Education for the University social construction of preferred realities. New York:
of Chicago affiliated Family Medicine Residency Norton. (Also in Russian, Taiwanese, Korean, Chinese,
Czech, and Serbian Translations).
Program. He also serves as Codirector of the
Freedman, J., & Combs, G. (2002). Narrative therapy with
Evanston Family Therapy Center, an independent couples. . . and a whole lot more! Adelaide: Dulwich
postgraduate training center dedicated to teaching Centre Publications. (Also in Korean Translation).
Common Factors in Couple and Family Therapy 525
Articles therapist is thought to be healing, regardless of

Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, the theoretical approach used. Common factors
T., & Trepper, T. S. (2012). From Ericksonian roots to
theorists believe that regardless of their source,
postmodern futures. Part I: Finding postmodernism.
Journal of Systemic Therapies, 31(4), 63–76. identifying the core and unifying elements of
Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, effective CFT may lead to more efficient training
T., & Trepper, T. S. (2013). From Ericksonian roots to and ultimately better clinical outcomes. As such
postmodern futures. Part II: Shaping the future. Journal
the common factors paradigm is not a model of C
of Systemic Therapies, 32(2), 35–45.
Combs, G., & Freedman, J. (2002). Relationships not bound- therapy per se, but a principle-based meta-model,
aries. Theoretical Medicine and Bioethics, 23(3), or “model of models.”
203–217.
Combs, G., & Freedman, J. (2012). Narrative, post-
ructuralism, and social justice: Current practices in
narrative therapy. Counseling Psychologist, 40(7), Prominent Associated Figures
1033–1060. https://doi.org/10.1177/0011000012460662.
Combs, G., & Freedman, J. (2016). Narrative therapy’s rela- The common factors paradigm is new to CFT, so
tional understanding of identity. Family Process, 55(2),
the list of prominent scholars is relatively small.
211–224.
Freedman, J., & Combs, G. (2000). Therapy relationships Douglas Sprenkle, Adrian Blow, Sean Davis, and
that open up possibilities for us all. Dulwich Centre Eli Karam are the most prominent CFT common
Journal, 1 & 2, 17–20. factors scholars. The first article explicitly
Freedman, J., & Combs, G. (2001). Facilitating a narrative
addressing common factors in CFT was a book
culture in a school. Journal of Systemic Therapies, 20(3),
49–59. chapter written by Sprenkle et al. (1999), followed
Freedman, J., & Combs, G. (2009). Narrative ideas for con- by an article by Blow and Sprenkle (2001) in the
sulting with communities and organizations: Ripples Journal of Marital and Family Therapy (JMFT).
from the gatherings. Family Process, 48(3), 347–362.
Sprenkle and Blow (2004) had an oft-cited debate
with Thomas Sexton in the JMFT over the merits
of common factors versus a traditional model-
Common Factors in Couple driven paradigm. A few years later Sean Davis
and Family Therapy and Fred Piercy published two articles identifying
common factors in the practices of prominent
Sean D. Davis CFT model developers and their students (Davis
California School of Professional Psychology, and Piercy 2007a, b). Around this time Sprenkle
Alliant International University, Sacramento, et al. wrote several foundational articles outlining
CA, USA key principles of common factors in CFT (Blow
et al. 2007, 2012). Douglas Sprenkle, Sean Davis,
and Jay Lebow wrote Common Factors in Couple
Introduction and Family Therapy: The Overlooked Foundation
of Effective Practice, the field’s first text devoted
The study of common factors focuses on identify- to common factors in CFT (2009). More recently,
ing core elements of effective couple and family Eli Karam has applied many common factors
therapy (CFT). Proponents of common factors principles to training, practice, and supervision
claim that once model-specific language is (Karam et al. 2014, 2015).
removed, most CFT theories orient the therapist
to similar patterns of dysfunction and help them
guide the family towards similar patterns of Description
health. Much of what makes therapy effective is
also inherent in the structure of therapy itself. For Principles of a Moderate Common Factors
example, the alliance created by confidentially Approach
disclosing vulnerabilities to and seeking guidance The contemporary, moderate common factors
from a nonjudgmental, caring, empathetic approach (Sprenkle and Blow 2004; Sprenkle
526 Common Factors in Couple and Family Therapy
et al. 2009) rests on several foundational princi- their best to tailor their approach to the client and
ples. The first principle states that change is due to foster a healthy alliance, but at the end of the day
common mechanisms that cut across different clients either take whatever is given to them and
models. This principle is often misconstrued as make it work or not. Some clients will take some-
meaning that models are not important. To the thing meaningful from the most average of ther-
contrary, common factors proponents believe apy, whereas other clients will choose to not
that a coherent model of CFT is an essential com- benefit from the best of therapy. Therapists ulti-
ponent of therapy, but not because of any unique mately only have so much control over the out-
contributions of one particular model. Rather, come of therapy. Of course there are limits to
models are thought to be useful because they this – unethical treatment is likely to do harm no
provide an order and structure that allows the matter what. Furthermore, a skilled therapist may
therapist and clients to feel calm and confident, be able to motivate a seemingly unmotivated cli-
and they provide a coherent set of rituals for ent, and an unskilled therapist may thwart the
healing. As long as the model is structured and most proactive of clients. Generally speaking,
coherent, is based on sound systemic principles, is however, the client is the most important variable
credible to the therapist and client, and is a good fit in therapy.
with the client’s worldview, it will likely work.
The second principle of a contemporary com- Generic Common Factors
mon factors approach is that qualities “surround- In addition to the principles described above,
ing” treatment (e.g., the therapeutic alliance, many common factors of effective CFT are shared
therapist credibility, client motivation) are more with psychotherapy designed for individuals.
important than the unique aspects of a particular These include the therapeutic alliance, expec-
treatment. Again, that is not to say that these tancy/hope, and allegiance effects.
surrounding qualities such as the alliance are The therapeutic alliance (i.e., the clinical rela-
both necessary and sufficient for effective therapy, tionship between the therapist and client(s)) is the
as is sometimes claimed. Rather it is to say that a common factor with the most empirical support.
treatment model is inseparably connected to con- A strong alliance has repeatedly been shown to be
textual elements that are every bit as or more associated with positive outcomes. This is partic-
important to treatment as the model. ularly true in the beginning of therapy, when the
The third principle states that the qualities of clients are deciding whether the therapist is a good
the therapist offering the treatment are more fit. A poor initial alliance is positively correlated
important than the treatment itself. Indeed, treat- with treatment dropout, whereas a strong initial
ment cannot be separated from the therapist deliv- alliance is associated with later treatment success
ering the treatment. Though research has failed to (Sprenkle et al. 2009).
show significant differences in effectiveness The therapeutic alliance is a dynamic mix of
between treatment models, some of those same client and therapist attributes. The client must
studies show significant differences between ther- be at least somewhat willing to engage in ther-
apists (Blow et al. 2007). Without the therapist apy. The therapist must have enough emotional
giving them life, models are just words in a book. intelligence to be able to “read” the client in
The treatment either comes alive or dies through order to adapt his or her approach. An approach
the therapist’s manifestation of the treatment that is too directive will likely unnecessarily
model. offend or overwhelm clients, whereas an
The fourth principle states that above all else, approach that is too passive will likely not lead
the client is the primary agent of change. If a to any meaningful movement. Both stances are
person goes to the gym, does it matter whether likely to lead to dropout, and depend on the
he or she uses the treadmill or the stair climber, or therapist’s ability to read clients (and/or get
does it matter that they got themselves off the their direct feedback) and moderate his or her
couch and down to the gym? A therapist can do approach accordingly.
The therapeutic alliance has been said to wants them to be gone and will do things to
consist of tasks, bonds, and goals. It is impor- subtly get them off his or her caseload.
tant that both the therapist and client agree on Maintaining an I-thou attitude towards clients
the goals of therapy. This becomes more com- is viewed as crucial to maintaining positive
plicated with the competing goals often pre- outcomes.
sented in couple or family therapy, but it is Expectancy and hope are also important com-
nevertheless usually still possible to find at mon factors. Simply put, therapy is more likely to C
least some common ground. Once goals are go well if a client thinks it will. The same can be
established, it is important that everyone agrees true for a therapist. It is important that a therapist
that the tasks (i.e., interventions) being utilized believes in his or her approach. A therapist that
will help the clients reach their goals. “Bonds” believes in what he or she is doing presents him or
refer to the emotional connection, respect, and herself more convincingly, and his or her passion
positive regard between the therapist and cli- can spread through the system. Similarly, if a
ents. It is possible that one or two of these client believes that therapy will go well, he or
elements can be going well, but the alliance is she is more likely to take what is given to them
overall still struggling due to the third element and make it work.
being off. A client’s expectancy is affected by many
Therapist factors are another important com- things, including the referral source, the degree
mon factor. In general, effective therapists are of fit between the therapist and clients in the early
warm, compassionate, genuine, empathetic, and stages of therapy, and whether they experience
nonjudgmental. They also are able to walk the fine any success, especially early on. If clients are
line between remaining true to themselves and referred to a therapist via a trusted friend or family
adapting their style to their clients. Each of the member, they are more likely to assume that what-
above-mentioned traits can look different with ever the therapist is doing is helpful. Clients in this
different clients. For example, the same therapist situation are often more likely to try things out and
may be more assertive and stern with an overbear- be open to therapy. Regardless of the referral
ing husband yet warm and understanding with the source, if the things the therapist says resonates
exhausted wife. Yet if the therapist manages with clients early on, they are likely to be hopeful
things well, both clients will likely describe him that change can be achieved. This is especially
or her as caring, compassionate, and competent. true if they experience symptom relief early on in
So much of being a good therapist comes down to therapy.
being able to read and adapt to the needs of the Allegiance effects are similar to hope and
specific situation. expectancy. Allegiance effects occur in research
Recent common factors literature proposes a when the researcher believes in one of the vari-
therapist’s “way of being” as a common factor ables he or she is studying and that belief alone
(Fife et al. 2014). A therapist’s way of being sways the results of the study. For example, if a
refers to his or her in the moment attitude researcher loves strategic therapy, it is likely
towards his or her clients. A therapist with an that any studies he or she conducts will show
“I-thou” attitude towards others views them as that strategic therapy works well. That may be
having needs that are as legitimate and valuable because strategic therapy does indeed work, but
as those of the therapist. As a result, the thera- it will be difficult to tell how much of that
pist will treat his or her clients as real people as outcome is due to the researcher wanting it to
deserving of respect as the therapist. Con- work. Allegiance effects are problematic in
versely, a therapist with an “I-it” attitude views research, but they can be a good thing in ther-
his or her clients as objects that will either make apy. A similar dynamic happens in therapy
life easier or more difficult. If the clients will when a therapist really believes in what he or
make life easier the therapist likes them, but if she is doing. The mere belief alone makes the
they may make life more difficult the therapist therapist more likely to be effective.
CFT Common Factors Research and Training common factor in and of itself), but they would
Much of the rationale for common factors came learn the theories in terms of their commonalities
from meta-analytic reviews of comparative effi- with each other so they could move smoothly
cacy studies. These reviews consistently demon- between theories as client needs dictate. This is
strate that CFT is effective, but no one theoretical different from the current approach to training,
approach is more effective than another (Shadish which typically focuses on having students briefly
and Baldwin 2002). This finding is replicated in overview several theories and then pick their
psychology, and for a time many in that field “favorite” to learn in depth.
claimed that there was no more need for more Given that therapist attributes are a common
comparative efficacy studies. The contemporary factor, training should focus more on the develop-
moderate common factors approach, however, ment of certain character traits in a therapist –
claims that comparative efficacy studies are still compassion, empathy, boundaries, and so forth,
useful – they just need to include measures of as future research dictates. A similar shift could
common factors in order to provide a more occur in terms of focusing on clients, since they
nuanced view of why therapy works, not just are such a major factor. Training could focus on
whether therapy works. helping therapists learn to help differently moti-
Common factors researchers are concerned vated clients, how to gauge client satisfaction with
with why therapy works. What makes therapy therapy progress and the alliance, and so forth.
effective? Consequently, process research meth-
odologies are particularly well suited for the study
of common factors. Qualitative process research Relevance to Couple and Family Therapy
focuses on inductively discovering specific
variables (i.e., processes) that may be common Several common factors have been proposed as
to effective therapy. This is commonly being unique to CFT (Sprenkle and Blow 2004;
achieved through interviewing therapists and cli- Sprenkle et al. 2009). These include conceptual-
ents regarding what made therapy effective, izing difficulties in relational terms, disrupting
conducting thematic reviews of videotaped ses- dysfunctional relational patterns, working with
sions, and so forth. Quantitative process research an expanded direct treatment system, and manag-
focuses on deductively testing whether certain ing the complexities of an expanded therapeutic
processes are indeed related to outcome. Exam- alliance.
ples include coding videotapes of therapy, deter- Conceptualizing difficulties in relational terms
mining whether the presence or absence of certain is a hallmark of systemic therapy. Many symp-
processes correlates with outcomes, and so forth. toms become understandable responses to unten-
Common factors research faces several chal- able circumstances when a therapist steps back
lenges, the biggest of which is that most of the and views the broader context in which the symp-
common factors are interrelated. For example, the toms occur. For example, a husband is likely not
therapeutic alliance is affected by therapist and withdrawing because he is a jerk, but rather
client variables, as well as expectancy/hope fac- because he does not know how to adequately
tors and allegiance effects, and vice versa. Where respond to his wife’s nagging. The wife is likely
one begins and the other ends is not clear, so not nagging because she is by nature overbearing,
teasing out the effects of only one variable is but because she does not know how to get her
difficult. husband to be more open and accessible. Each
The common factors paradigm has several person’s response brings about that of the other.
implications for training. Training could be Conceptualizing difficulties systemically pro-
greatly streamlined and focused if a core set of vides a foundation for successful therapy. Sys-
principles were identified for working with differ- temic conceptualization allows the therapist to
ent presenting problems. Students could still learn view each partner as trying their best to solve a
theory (since having a structured approach is a problem. This can lower client defensiveness, as
the therapist is not treating one or both of them as with as many people as possible. If working with
inherently problematic. If each person is seen as just the husband in the above example, a therapist
trying their best, clients typically respond well to would likely end up subtly siding with the hus-
having that validated and brought forth in a way band and demonizing the wife. This would, of
that their partner can understand. If the problem is course, frustrate treatment progress and in some
seen as largely between people (i.e., their commu- cases may even lead to an otherwise avoidable
nication) rather than solely within them (i.e., their divorce. C
personal issues, resistance, etc.), then solutions Managing the complexities of an expanded
tend to emerge more readily as opposed to if therapeutic alliance is another common factor of
someone is told the problem is all them. systemic therapy. The alliance becomes more
If conceptualizing problems in relational terms complicated in systemic therapy, as family mem-
is a common factor of systemic therapy, it follows bers often have varying goals and agendas.
that disrupting those same relational patterns is A therapist must validate each person without
also a common factor. Clinicians using different alienating or unnecessarily siding with one family
systemic models typically focus on changing cog- member at the expense of others. This is easier
nitive, affective, and behavioral aspects of cou- said than done. A therapist must also try to find
ple’s communication cycles (Davis and Piercy common ground with goals of therapy – also not
2007a, b). For example, a wife thinks her husband an easy task for a family that is likely already
does not care about her when he watches TV at divided. The therapeutic alliance can be managed,
night rather than help get the kids in bed though, with careful attention to those dynamics.
(cognition), so she gets angry (affect) and calls
him a lazy slob (behavior). The husband thinks his
wife is too controlling and bossy when he helps Clinical Example of Application of
her (cognition), so he feels small (affect) and tries Theory in Couples and Families
to avoid her by watching TV instead (behavior).
One spouse’s interactional stance invites the Raul and Sara came to therapy seeking help for
other’s interactional stance. A therapist has six their teenage son, Sam, whose grades had recently
different points of entry into this cycle, each of started to slip around the same time he had been
which could shift the entire dance. For example, if caught smoking marijuana. Raul and Sara’s ther-
the husband saw his wife as overwhelmed and in apist, Michelle, had come highly recommended
need of help, his feelings towards her may soften by a close friend, so they were optimistic they
and he may push past her bossiness to help her could be helped. Michelle had a lot of experience
anyway. Doing so may invite the wife to see working with families in this situation and had
her husband as more involved, which may soften gone through similar experiences both as a child
her feelings towards him which may in turn lead and parent, so she was confident she would be
her to expressions of gratitude rather than frustra- able to help as well (hope/expectancy effects). At
tion. Any of these changes could bring about the the first meeting Michelle correctly guessed that
others. Each systemic model focuses on this cycle Sam would not want to be there, so she would
but emphasizes different points of entry into the need to build more “emotional capital” with him
cycle. Common factors suggest that the point of than with his parents, who already trusted her.
entry should be determined by what resonates for As a result, when they all met for the first
the client, not which model the therapist prefers. session (expanded direct treatment system) she
Working with an expanded direct treatment intentionally joined with Sam by asking about
system – those directly receiving treatment – is his interests, etc., prior to asking about the behav-
another hallmark of systemic therapy. Generally, ioral issues. When asking about his behavioral
the more relevant people in the room the better. issues, she focused on what function they might
A therapist is more likely to hold a balanced, be serving in his life (systemic conceptualization)
complete view of the problem if he or she works rather than on lecturing him or trying to get him to
stop. Once Michelle believed Sam felt validated, At the end of treatment there was still a funda-
she repeated the same process with Sam’s parents, mental disagreement about what was acceptable
focusing on validating their concerns and fears for behavior, but Sam at least understood that his
Sam (managing the expanded therapeutic alli- parents were coming from a place of love and
ance). Each family member left having had a concern rather than vindictiveness. He reluctantly
new, calmer experience with each other. They accepted his increased restrictions, and Raul and
were beginning to see each other in ways they Sara felt validated in their desire to stick to rules
had not before. Sam, Raul, and Sara trusted that that reflected their family values. At the same
Michelle would be able to help them (therapist time, they had a newfound respect for the emo-
factors, therapeutic alliance, hope/expectancy). tional complexities of Sam’s life, and they
As treatment progressed, Michelle highlighted redoubled their efforts to genuinely connect with
and helped magnify each family member’s strengths him and help him find healthy coping mechanisms
and attempts to connect (client factors). There were for his stress. They all felt closer to each other.
stark disagreements between Sam and his parents Everyone had a respect for Michelle’s fairness and
about what was acceptable behavior. Michelle han- commitment to helping each of them be under-
dled this by helping them slow down their interac- stood. Throughout treatment, Michelle con-
tions and hear each other’s concerns. She helped sciously employed several principles of common
each person express their concerns directly and in a factors to help ensure the family was successful in
way that was easier to hear. Several times through- therapy.
out treatment one of the two dyads (i.e., Sam or his
parents) would feel invalidated by Michelle. Since
Michelle used a brief three-item questionnaire about Cross-References
client satisfaction that she’d designed to gather feed-
back after each session, she was able to catch this ▶ Blow, Adrian John
and address it at the next session. Healing the rup- ▶ Davis, Sean
tured alliance in this way modeled crucial attributes ▶ Integration in Couple and Family Therapy
such as humility and assertiveness (therapist ▶ Sprenkle, Douglas
attributes). ▶ Therapeutic Alliance in Couple and Family
Throughout treatment, Michelle used different Therapy
treatment approaches based on what seemed to
resonate with the family’s personality and goals.
In the early stages she realized that the hierarchy References
was out of balance – Sam was running the show at
Blow, A. J., & Sprenkle, D. H. (2001). Common factors
home, and the parents felt helpless. She used across theories of marriage and family therapy:
structural therapy to help put the parents back in A modified Delphi study. Journal of Marital and
charge of setting rules. Mixed in with this Family Therapy, 27, 385–401.
approach were elements of experiential therapy, Blow, A. J., Sprenkle, D. S., & Davis, S. D. (2007). Is who
delivers the treatment more important than the treat-
as she used sculpting to help each of them see how ment itself?: The role of the therapist in common fac-
the family was structured and help them clarify tors. Journal of Marital and Family Therapy, 33,
how they would like it to be structured (clarifying 298–317.
goals, using different models to the same end). Blow, A. J., Davis, S. D., & Sprenkle, D. H. (2012).
Therapist–worldview matching: Not as important as
Once that structural shift was achieved, and even matching to clients. Journal of Marital and Family
while it was being achieved, Michelle relied Therapy, 38, 13–17. https://doi.org/10.1111/j.1752-
heavily on narrative therapy dialogue to help 0606.2012.00311.x.
each family member understand the larger socio- Davis, S. D., & Piercy, F. P. (2007a). What clients of MFT
model developers and their former students say about
political pressures they were operating under. This change, Part I: Model dependent common factors
dialogue helped each family member have com- across three models. Journal of Marital and Family
passion for each other. Therapy, 33, 318–343.
Communication in Couples and Families 531
Davis, S. D., & Piercy, F. P. (2007b). What clients of MFT Synonyms

change, Part II: Model independent common factors
and an integrative framework. Journal of Marital and Interaction; Message
Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014).
The therapeutic pyramid: A common factors synthesis Introduction
of techniques, alliance, and way of being. Journal of
Marital and Family Therapy, 40, 20–33. https://doi.
C
org/10.1111/jmft.12041. Communication is the process of sharing informa-
Karam, E. A., Sprenkle, D. H., & Davis, S. D. (2014). tion. It goes beyond the content of the information
Targeting threats to the therapeutic alliance: A primer being shared to encompass the way the information
for marriage and family therapy training. Journal of
Marital and Family Therapy, 41, 389–400. https://doi. is being shared between people. Communication
org/10.1111/jmft.12097. also reveals information about how people connect
Karam, E. A., Blow, A. J., Sprenkle, D. H., & Davis, and the relationships between people. The process
S. D. (2015). Strengthening the systemic ties that of communicating includes thinking, expressing,
bind: Integrating common factors into marriage and
family therapy curricula. Journal of Marital and listening, interpreting, understanding, and
Family Therapy, 41, 136–149. https://doi.org/ responding (Koerner and Fitzpatrick 2002). Almost
10.1111/jmft.12096. everything is a form of communication, including
Shadish, W. R., & Baldwin, S. A. (2002). Meta-analysis of spoken words, sounds, body posture, text, and even
MFT interventions. In D. H. Sprenkle (Ed.), Effective-
ness research in marriage and family therapy silence. Even not speaking is a form of communi-
(pp. 339–370). Alexandria: American Association of cating, as it can also hold meaning and value and
Marriage and Family Therapy. conveys information in itself (Watzlawick et al.
Sprenkle, D. H., & Blow, A. J. (2004). Common factors 1967). For example, a teenage daughter falls silent
and our sacred models. Journal of Marital and Family
Therapy, 30, 113–130. and casts her eyes down towards the floor while her
Sprenkle, D. H., Blow, A. J., & Dickey, M. H. (1999). parents are fighting. This act of silence might con-
Common factors and other nontechnique variables in vey some important information about family
marriage and family therapy. In M. A. Hubble, B. L. dynamics and how the daughter is feeling, such as,
Duncan, & S. D. Miller (Eds.), The heart and soul of
change: What works in therapy (pp. 329–359). “Please leave me out of this. It scares me when you
Washington, DC: American Psychological fight and I feel like shutting down.”
Association. Communication in couples and families is a
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). prominent focus of clinical work. Communication
Common factors in couple and family therapy: The
overlooked foundation for effective practice. New plays a role in the problems couples and families
York: Guilford. come into therapy with, and a major role in the
change process that allows them to terminate therapy
successfully. It is important during the initial assess-
ment stage to explore families’ communication styles
and to use communication during stages of interven-
Communication in Couples tion as a way to create change within the couple or
and Families family unit. One way to use communication as a
change agent might be to teach and encourage a
Rebecca Bokoch family to use “I-statements” when speaking to one
Couple and Family Therapy, CSPP Alliant another. “I-statements” are messages that are about
International University, Los Angeles, the speaker’s beliefs, feelings, or values. “I-
CA, USA statements” are in contrast to “you-messages,”
which are about the person to whom the speaker
is speaking. Helping couples and families to use
Name of Theory “I-statements” is a practice used by many thera-
pists to create change in communication patterns
Communication in Couples and Families and to decrease conflict (Gordon 2000).
532 Communication in Couples and Families
Prominent Associated Figures families to move out of their stable state. Negative
feedback loops are communication patterns that
Gregory Bateson, the father of cybernetics, is an maintain stability while minimizing change, and
important figure in communication in couples and positive feedback loops are communication pat-
families. Cybernetics is a multidisciplinary field terns that facilitate change, moving the family
of study regarding communication and control in towards making progress or falling apart. Unless
humans and robotic systems (Bateson 1972). All an intervention is specifically used to disrupt
systemic theories of family therapy originally homeostasis, families will most likely take any
stemmed from the cybernetic paradigm, as it interaction and respond to it in a way that will
refers to a growing body of knowledge about allow them to find their way back to homeostasis.
systems of information processing. First-order Perpetuating a state of homeostasis can either
cybernetics provides therapists with the perspec- propagate dysfunctional communication within
tive to see families as information processing the system, or maintain equilibrium despite chal-
machines with growing and changing bodies of lenges faced (Watzlawick et al. 1967).
knowledge. Second-order cybernetics was the Understanding theories of communication in
second wave of the cybernetic paradigm, which couples and families also requires a different
allowed therapists to view themselves as part of an lens, where the theorist can balance family mem-
evolving family information processing system bers’ expectations, dynamics, relationships, and
and led to a more collaborative and non- rules, along with the family structure and context.
pathological approach to family therapy There are several theories of family communica-
(Freedman and Combs 1996). The idea that fam- tion that highlight different interaction patterns,
ilies are systems of information processing and including the McMaster model of family function-
interaction supports the idea that change within ing (Epstein et al. 1982), the family communica-
couples and families can be achieved through tion theory of cohesion and change (Galvin et al.
communication. 2016), and the theory of family communication of
conformity and conversation (Koerner and
Fitzpatrick 2002). The McMaster model of family
Description functioning operates from an underlying belief
that different styles of family functioning can
Families and couples act as systems of interaction. lead to contrasting styles of communication,
They have certain internal variables that are some- such as: instrumental fact-based communication
what constant, like individuals’ personalities or vs. affective expression about emotion, clear and
relational dynamics within the family, and other easily understood messages vs. masked or unclear
variables that are always changing around them, communication, and indirect interaction
like their environments and current life situations. expressed in a roundabout way vs. direct commu-
Each communication, message*, or interaction* nication delivered to the person for which it was
received by the family system is acted upon and intended (Epstein et al. 1982). The McMaster
modified within the family system and given feed- model suggests that the healthiest and most func-
back from the family system (Watzlawick et al. tional style of communication is when couples
1967). Because families are interaction systems, it and family members can be both clear and direct
is important for families to develop functional with one another (Epstein et al. 1982). According
communication skills and experience healing to the family communication theory of cohesion
through the use of effective communication, and change (Galvin et al. 2016), the two main
which can be supported through couple and fam- spectrums of family communication are: cohe-
ily therapy. sion, which allows families to be both indepen-
Families and couples tend to remain in a state dent and interconnected, and adaptability, which
of homeostasis until some sort of communication allows families to be flexible throughout changes
or interaction occurs, like feedback loops, forcing in family relationships, roles, and rules. Strong
communication skills allow families to express communication skills are not known or are not
themselves within healthy ranges of the cohesive- being practiced, or negative facial expressions,
ness and adaptability spectrums (Galvin et al. vocal qualities, and body language are conveyed
2016). Koerner and Fitzpatrick’s (2002) theory (Goldberg 2017). In addition, miscommunication
of family communication identifies different fam- occurs when people contradict themselves, there
ily communication patterns, such as conformity are inconsistencies in conversation, someone
orientation, meaning that family members should changes the subject or goes on a tangent, or infor- C
all have the same values, attitudes, and beliefs, mation is misunderstood or misinterpreted
and conversation style, which means family mem- (Watzlawick et al. 1967). Therapists have also
bers are open to expressing their own varied identified that lack of perspective-taking abilities,
thoughts, values, and beliefs. Members of couples criticizing, and blaming are among the most det-
and families may have the same or different com- rimental communication problems for couples
munication patterns from one another, which may and families (Galvin et al. 2016).
lead to various levels of conflict and relationship Disagreements over content and the way that
satisfaction within the system. This theory sug- things are communicated are also dysfunctional
gests that conversational and open families are communication patterns that can contribute to
most capable of functional communication conflict in couples and families. For example, if
(Koerner and Fitzpatrick 2002). a child went to a friend’s house after school with-
Dysfunctional communication. Despite the out asking his or her parents, the family could
theory or model being used to explore communi- disagree based on the content: the fact that the
cation in couples and families, it is apparent that parent did not approve of the child going to the
there are some styles, patterns, and techniques that friend’s house, as they would have preferred that
are functional and others that are dysfunctional. they went home first and finished their homework.
Dysfunctional communication often leads to con- However, the family could also be in disagree-
flict and dissatisfaction in couples and families ment based on the way things were communi-
and can obstruct therapeutic growth. One of the cated: if the child did not consult with the parent
most common examples of dysfunctional family first, even though the parent was fine with them
communication is the double bind. Double binds going (Watzlawick et al. 1967).
occur when conflicting messages are received that Also, couples and families dealing with
discount one another, are mutually exclusive, and stressors or crises may resort to dysfunctional
often lead to emotional distress (Bateson 1972). communication styles, as they are reacting to a
For example, if a partner says to his significant situation that they do not know how to cope with
other, “Be spontaneous, for once!” This statement as a family. For example, when a mother is diag-
serves as a double bind for this couple, because if nosed with breast cancer, a father may fall silent,
the other partner responds by doing something and a child may start acting out. This crisis situa-
spontaneous, it is not really spontaneous because tion shifts family dynamics and communication
she was told to do so, but if the partner responds patterns in a way that is not supportive of close
by doing nothing, she is also not being spontane- family relationships or therapeutic processing
ous. This double bind allows for two conflicting, (Galvin et al. 2016). Couples and families may
mutually exclusive messages to be received, also use their symptom as a method of communi-
which is difficult for the partner to respond to cation, which is another form of dysfunctional
successfully and will most likely lead to emo- communication. For example, “I want to talk to
tional conflict and distress for the couple. you, but I’m too anxious right now.” This state-
Problems also often arise when intentions and ment allows clients to give the symptom power
perceptions get confused, there is a lack of empa- over themselves, which can lead to problems in
thy, there is a mismatch of methods of the relationship (Watzlawick et al. 1967).
communication, there is a challenging topic Functional communication. Functional com-
being communicated, verbal and non-verbal munication is when couples and families are able
to share information about thoughts, feelings, Spatial relationships refer to the distance between
needs, and wants in a way that others can under- people when they communicate. It is valuable for
stand. Couples and families may take a personal couples and families to pay attention to their own
approach to improve their communication, or seek and each other’s body language. When body lan-
therapy. Personal approaches might include seek- guage is congruent with what is being spoken, it
ing education (i.e., reading books or blogs about enhances the message; however, when body lan-
improving communication skills), negotiating, guage is incongruent with what is being commu-
spending time together, and accessing support. nicated verbally, it might undermine or alter the
Therapists can also work with couples and fami- message (McKay et al. 2009). For example, one
lies to develop functional communication as a partner might remark to a therapist in couple’s
therapeutic strategy across all systemic theories therapy, “Yeah, my partner’s a really considerate
and approaches. Some of the most valuable com- person. He’s always looking out for me and my
munication skills include: listening, expressing, needs.” If the speaker said this with a soft tone and
and body language (McKay et al. 2009). a smile, the message is congruent with the body
Listening skills involve more than just hearing language, and we can gather that the speaker is
what is being said. Active listening involves sending a positive message about her partner.
acknowledging and respecting other peoples’ However, if the speaker said this with a sarcastic
points of view, even if you do not agree with tone while rolling her eyes and with a flat expres-
them. This can be achieved through reflecting sion on her face, the message would be incongru-
statements, which involves restating the speaker’s ent with the body language, and we might
feelings and words. Reflective statements show interpret the meaning behind what was being
the speaker that you are trying to perceive the said as a negative description of her partner.
world as they see it, you are doing your best to Family relationships and communication are
understand their messages, and you encourage closely related to family mental health (Galvin
them to continue talking. Clarifying language is et al. 2016). Building communication skills can
a way to enhance listening skills. Clarifying lan- be particularly important to improving relation-
guage might involve asking questions or restating ship satisfaction and creating positive change
things that were said, in order to make sure that an within couples and families. Families that practice
individual understands the other’s experience and functional communication are better at problem-
is interpreting his or her message accurately solving and tend to have more relationship satis-
(McKay et al. 2009). faction (Lavner et al. 2016). Research also sup-
Expressing is when individuals share “whole ports that clear, open, frequent, and direct
messages” about their experience. Whole mes- communication leads to greater relationship satis-
sages” include information about observations, faction (Epstein et al. 1982). It is important to note
thoughts, feelings, and needs. When expressing that while research supports the correlational rela-
these “whole messages,” the speaker should be tionship between relationship satisfaction and
aware of the self, the other person with whom they quality of communication, most studies’ findings
are communicating, and the environment in which do not suggest cause and effect (Lavner et al.
they are communicating, in order to communicate 2016); therefore, more research needs to be done
most effectively. “Whole messages” can help cou- to explore this relationship.
ples and families to better understand one another
and support functional communication and thera-
peutic growth within the relationship (McKay Relevance to Couple and Family Therapy
et al. 2009).
Body language is an important aspect of non- Communication is also relevant to couple and
verbal communication, including body movement family therapy, as it is a focus of several systemic
and spatial relationships. Body movements con- theories, including strategic family therapy,
sist of gestures, facial expressions, and posture. Satir’s human validation process model,
emotionally focused couple therapy (EFT), the or discomfort, including the blamer, placater,
Gottman method of couple therapy, and narrative irrelevant, and super reasonable. These dysfunc-
family therapy. tional stances prevent families from practicing
In strategic family therapy, therapists use a frequent, open, and clear communication, which
directive approach and paradoxical interventions negatively impacts self-esteem and relational con-
to create second-order change (Hayley and nection. The blamer blames others for their
Richeport-Haley 2003). Paradoxical interventions distressing feelings and family conflict. The pla- C
are specific linguistic strategies used by therapists cater avoids and hides from uncomfortable situa-
to encourage families to unknowingly create tions. The irrelevant communicator deflects and
change through prescribing the symptom, ordeals, distracts from conflict and stress. Lastly, the
or restraining, and can be referred to as therapeutic supperreasonable relies on logic and discredits
double binds (Watzlawick et al. 1967). In pre- emotion. Satir’s theory also suggests a fifth com-
scribing the symptom, the therapist advises the munication stance, congruent communication,
client to enact the symptom, and may even order where people can share their thoughts and feelings
the client to enact this behavior during a particular without projecting them onto others or worrying
time period, thus removing all spontaneity and about them being misinterpreted. As theorized,
allowing the client to see that they actually do these communication stances suggest that those
have control over their symptoms and the ability who can communicate congruently, even through
to create change (Hayley and Richeport-Haley uncertainty and conflict, will have the most effec-
2003). For example, if a family complains of tive communication, and thus, the most satisfac-
disconnect and isolation with no success in previ- tory relationships. For example, a couple may
ous attempts to spend time together, a therapist present in treatment where the wife acts as the
might use a paradoxical intervention by blamer, blaming her husband for their relationship
suggesting to the family: “Because it seems you problems, and the husband presents as the pla-
all have a desire to be alone, let’s schedule a set cater, avoiding and hiding from the relationship
time to be alone. Let’s agree to spend time alone in problems. With this case, the therapist might try to
your own rooms for at least 3 hours from 5 to 8 pm move the couple from their incongruent commu-
each night.” In this example, the therapist used nication styles to a congruent communication
paradoxical language to purposefully put the cli- style, by supporting them in communicating
ent in a double bind. The family does not want to openly, clearly, and directly through their rela-
be alone, yet the therapist is explaining to them tional issues (Satir 1972).
that they do want to be alone based on what they Communication is also a core aspect of EFT,
are telling her, and demanding that they spend at which suggests that developing healthier inter-
least 3 h alone each night. The family may action patterns is crucial for the change process.
respond in the moment by saying there’s no way In the earlier stages of treatment, Johnson
they will do such a thing as this is not what they (2004) suggests that the therapist helps couples
want, or they may come to the next session and to identify their negative interaction cycle that
share that they were unable to be alone for that reinforces a dysfunctional feedback loop within
long every night. In both scenarios the therapist’s the relationship. In addition to understanding a
use of paradoxical language in prescribing the couple’s interactional pattern, EFT also supports
symptom ultimately led to a shift in thinking and the couple in accessing and expressing primary
change in behavior. emotions to one another, sharing their underly-
Virginia Satir’s Human Validation Process ing attachment needs, and creating a new way of
Model focuses on communication styles as a interacting based on a new, shared understand-
way to assess family relationships, roles of each ing of one another (Johnson 2004). For exam-
member, and the overall family system. Satir iden- ple, if a couple identifies a negative interaction
tified four incongruent communication styles pattern of pursuing-distancing, the therapist
that people resort to in times of distress, conflict, would first guide the couple towards identifying
and expressing the underlying emotions of the the person. The therapist also attempts to person-
cycle, like feeling scared or inadequate. ify the problem, to further externalize it from
The Gottman method also highlights the specific family members, and to empower the
importance of identifying negative communica- family to see that they have power over the prob-
tion methods during conflicts, as their research lem (White 2007). For example, instead of talking
has found that these negative methods of commu- about “mom’s depression,” the family can rename
nication can detrimentally impact intimate rela- it “the sticky sadness,” and the therapist can ask:
tionships, lead to couple dissatisfaction, and “What can you do to get the sticky sadness to
even predict divorce for couples in the United become unstuck in the family?” Deconstructive
States (Gottman 1994). Gottman (1994) also iden- questioning helps clients unpack their stories,
tifies the most destructive methods of communi- with the intent of understanding how they have
cation, which he refers to as the “four horsemen of been constructed and maintained. By unpacking
the apocalypse”: criticism, defensiveness, con- the story, families are able to see the story from a
tempt, and stonewalling. Criticism is when a part- different perspective, free from the obstruction
ner implies that there is something wrong with the and subjugation of dominant social discourses
other partner. Defensiveness is responding to a (White 2007). For example, the therapists can
perceived attack with an attack. Contempt is facilitate the meaning-making process by asking:
when one partner perceives himself or herself to “What is the significance for your family that you
be better than the other and expresses this percep- are here together talking about this new perspec-
tion verbally or non-verbally. Stonewalling is tive on the anger?” Relative influence questions
when one partner withdraws from the conversa- enrich the description of the problem by mapping
tion and shuts down. The Gottman method sug- its influence on various domains such as behav-
gests that healthy alternatives to these negative ioral, emotional, physical, cognitive, relational,
communication techniques involve soothing, lis- and spiritual (Freedman and Combs 1996). For
tening, and validating (Gottman 1994). For exam- example, to explore the influence of the problem
ple, if a couple struggles with criticism, the on behavior, a therapist might ask, “What does the
therapist would help the couple to learn to express anger get you to do that is against your better
complaints and listen to concerns, without criti- judgment?”
cizing his or her partner.
Narrative family therapy also emphasizes the
importance of communication by focusing on and Clinical Example of Application of
using language as an agent of change, to create Theory in Couples and Families
and express the subjective meaning of experi-
ences. Narrative therapists embrace the subjectiv- Emotion-focused couple therapy and couple
ity of experiences through the use of linguistic communication. Jada and Theo have been mar-
techniques that are designed to explore clients’ ried for 3 years and dating for 7 years. Jada initi-
meaning-making process and create change, ated therapy with an emotion-focused couple
including narrative metaphor, externalizing con- therapist. Jada’s husband, Theo, was reluctant to
versations, deconstruction, and relative influence attend because he did not feel comfortable
questioning (White 2007). Narrative metaphors discussing their issues with a “stranger.” Jada
are used to help clients re-author their problem- expressed that she felt as if Theo never supported
saturated narrative to a preferred narrative, by her or took initiative in planning events for them
allowing the therapist to talk about the problem as a couple or advancing his career. Theo shared
in a specific way that can change the family’s view that when Jada asked him to do things, he often
and relationship with the problem (Freedman and didn’t follow through, because he felt like she was
Combs 1996). For example, “How can you turn too demanding.
your back on the problem together?” Externaliz- After identifying the main conflict that the
ing language is used to separate the problem from couple is struggling with, the therapist helps the
couple to identify the negative interaction cycle in see. So underneath the conflict, where you usu-
which their conflict was expressed. Together, the ally get angry and start to yell, there are other
couple and therapist identify and describe the feelings of fear of loss, sadness, loneliness, and
couple’s pattern of pursuing-withdrawing. Jada a need for an emotionally available partner.”
shares, “Whenever I try to go to him and talk to “Yes, exactly,” replies a tearful Jada. “How
him about things, I just feel like he pulls away, like about for you, Theo? What are you experiencing
he doesn’t want anything to do with me.” Theo emotionally when Jada pursues you?” asks the C
adds, “It’s not that I don’t want to be around you, therapist. “Well, I feel annoyed most of the time.
I just feel like I can’t win. I never please you or Because I feel like I never can get it right with
respond in a way you seem to like, so why even her. I feel bad about myself. Like, I’m not a good
try?” The therapist responds, “It seems like you husband, or a good man. So, I guess that leads
two are in a common pattern of Jada pursuing and me to feel somewhat hopeless,” Theo shares.
Theo distancing.” “That sounds about right,” The therapist asks: “And when you are feeling
replies Jada. “And when does this pattern usually that hopelessness, what is it that you need in that
come out?” asks the therapist. “Usually when I get moment? Is there any need that isn’t being
home from work, I get bombarded with all of met?” Theo responds, “Hmm. Yeah, I guess. It
this,” states Theo. “Well, I’ve been waiting all makes me wish I had a partner who could build
day to talk to you in person about what needs to me up instead of always tearing me down,”
get done. And I’m usually annoyed when I get Theo shares. “It sounds like you are needing
home from work, and nothing we’ve talked about some validation, some support, in order to
earlier in the day has gotten done,” says Jada. “It build some confidence in yourself. Does that
sounds like you both want to be what the other sound right to you?” asks the therapist. “Yes.
person needs and wants, it’s just this negative I know that’s a need I should work on for myself
cycle of pursuing and withdrawing that gets in too. I know I’ve lost a lot of confidence over the
the way,” states the therapist. “What do you years. But I need some support and encourage-
mean?” asks Theo. “Well, for example, when ment from her too. It would help give me a
Jada pursues you when you get home from chance to get better,” Theo states.
work, and you feel ‘bombarded’ and withdraw In the next session, moving into the later
from Jada, you’re not able to be the partner that stage of treatment the therapist promotes change
feels secure with himself and takes initiative. by working with the underlying feelings and
Does that make sense? Does that sound right?” needs that have been expressed and promoting
asks the therapist. “Yeah,” says Theo, “That partner acceptance and the continued expres-
makes a lot of sense.” sion of needs and wants. The therapist facili-
In a later phase of treatment, the therapist tated the expression and acceptance of partner
attempts to guide the couple towards accessing experiences by working in the here and now and
unacknowledged emotions and underlying using an enactment to soften the pursuer, Jada,
needs. “Now that we’ve figured out the com- and reengage the withdrawer, Theo. At one
mon, negative pattern that has been interfering point in the session, when Jada sees Theo get-
in your relationship, I want to get more infor- ting frustrated, she reaches out and squeezes
mation about how you are experiencing this Theo’s hand. The therapist brings attention to
cycle. Jada, when you feel like Theo pulls this nonverbal interaction. “I notice you just
away, what emotion are you feeling in that squeezed Theo’s hand. I wonder what you are
moment?” Jada replies, “I’m feeling sad, lonely. wanting to express to him now. Can you turn to
I need a partner, not a child that I need to scold Theo and tell him what it means when you
or tell what to do. I’m scared that he’s going to squeezed his hand?” Jada softly says, “I believe
leave me when he shuts down like that. It’s like in you. I love you.” Theo smiles at Jada. “And
he’s already checked out.” The therapist encour- Theo, can you continue looking at Jada, and tell
ages this identification of underlying needs, “I her what it meant to you that she has shared this
with you?” prompted the therapist. “Yes, that explore the externalized problem in more depth,
means the world to me. I feel like a worthy by asking: “What makes the tornado bigger or
person when you say that. I feel like I’m smaller?” “School,” says Matthew, “I hate
enough. I feel supported. I love you too,” Theo school!” “Oh,” says the therapist, “How does
responds sincerely. Jada smiles and leans on school make the tornado bigger?” Matthew
Theo, and the couple hugs. responds: “When I’m at school, I don’t under-
The therapist begins termination by continu- stand what the teacher is saying, and I feel stu-
ing to foster new solutions to old problems and pid. I feel like all the kids in my class think I’m
solidify new positive interaction patterns. stupid. So then I get mad when I have to do
Understanding their dysfunctional communica- school at home. And that’s when I start throwing
tion patterns and working toward more func- things and pushing people. That’s when the
tional communication helped this couple to tornado gets bigger.” Matthew’s response helps
change their experience and understanding of the family to gain a greater understanding of the
each other and their relational problems. Their problem narrative by mapping the influence of
shift in perspective also allowed the couple to the problem. The therapist also explores the
create a new, more positive interaction pattern family’s preferred narrative, so that the family
that embodied clear, frequent, and open com- can know what they would like to work toward,
munication of feelings and needs. by asking: “And what is it that you would like
Family communication and narrative fam- your family life to look like, if not this stormy
ily therapy. Matthew, an 8-year-old child dealing tornado?” “I would just like for our family to
with anxiety and attention problems, was brought have some peace and quiet,” shares the father.
to therapy by his parents based on his teacher’s “Yes, for our family to be at peace, happy, and
recommendation. Matthew’s teacher reported that calm and getting along,” agrees Jan. “Okay, so it
he was very active in the classroom, had a hard seems like we have a clear picture of moving
time focusing, and sometimes became so over- from an angry, stormy family that does not
whelmed that he cried in class. Matthew’s parents, get along, to a happy, calm family that does
Jan and Gary, reported that he fought with his get along,” restates the therapist.
younger brother Jon (age 6), and was disobedient Next, the therapist aims to identify unique
and violent at home, especially during homework outcomes. “So last week we learned about this
time. “Overall, he’s just a bad boy, and we don’t tornado problem that keeps coming up in the
know what to do with him. Can you help us?” family and that school makes the tornado big-
asked Jan. ger. I wonder if you could tell me about times
The narrative family therapist first addresses when the tornado is not there at all?” Jan
this problem with the family by using linguistic responds, “Well, I think when we have our fam-
techniques to externalize the problem from Mat- ily time on Friday nights, it’s less likely that a
thew and change the family’s perspective of the tornado will come. We usually watch a movie,
problem, so that they could unite as a family read a book aloud together, or play a board
system to work against the problem. The thera- game, and then Matthew, Jon, and everyone
pist responds to the family by stating, “This really seem to be happy.” “Yes, those are nights
fighting and being very active, what should we we get some peace and quiet,” states the father.
call that?” Gary replies with a chuckle, “Well, “I like family night,” says Jon. “Wow, it sounds
sometimes we call it the tornado. Like when he like all of you really enjoy family night on
starts to get upset we joke, ‘uh oh, there’s a Fridays. How do you think we could get that
storm coming.’” With the help of the therapist’s same feeling of peace and happiness to happen
use of externalizing language, the family starts more often?” asks the therapist. “Maybe if we
to shift their communication about the problem could just watch movies more instead of doing
from Matthew to the problem itself. The thera- homework?” suggests Matthew. “I mean, yes,
pist also uses relative influence questioning to that would be great if we could just relax,
Matthew. But we can’t just watch movies all the ▶ Positive Feedback in Family Systems Theory
time. We have to go to school,” says Jan. The ▶ Prescribing the Symptom in Couple and Family
therapist uses questioning to expand on pre- Therapy
ferred narratives and thicken the plot of the ▶ Satir Model of Transformational Systemic
preferred narrative. “What I’m hearing is being Therapy
able to relax more with family would feel better ▶ Second-Order Cybernetics in Family Systems
than having to do homework. I wonder if there’s Theory C
a way to make homework time feel more like ▶ Strategic Family Therapy
relaxing family time?” says the therapist.
“Maybe if mommy and daddy didn’t yell at me
when I get upset when I’m trying to do it. . .” References
suggested Matthew. “Um, yes, sometimes we
get frustrated Matthew, because you get so Bateson, G. (1972). Steps to an ecology of mind.
upset,” Gary says. “Maybe if we took breaks?
Epstein, N. B., Bishop, D. S., & Baldwin, L. M. (1982).
Maybe then it would help us calm down before McMaster model of family functioning. In F. Walsh
we get to yelling. I know sometimes that’s help- (Ed.), Normal family processes (pp. 115–141).
ful for me,” suggests Jan. In the final stage of New York: Guilford Press.
Freedman, J., & Combs, G. (1996). Narrative therapy: The
treatment, the therapist continues to work with
social construction of preferred realities. New York:
the family to solidify the preferred narrative by Norton.
asking if taking breaks works, and continuing to Galvin, K. M., Braithwaite, D. O., & Bylund, C. L. (2016).
find unique outcomes and expanding on them, Family communication: Cohesion and change
(9th ed.). New York: Routledge.
until the family is able to live out their preferred
Goldberg, R. M. (2017). Communication errors/problems
narrative. in couples and families. In J. Carlson & S. B. Dermer
(Eds.), The SAGE encyclopedia of marriage, family,
and couples counseling (pp. 300–302). Thousand
Oaks: SAGE Publications.
Cross-References Gordon, T. (2000). Parent effectiveness training: The
proven program for raising responsible children.
▶ Blamer Stance in Couples and Families Gottman, J. M. (1994). What predicts divorce? Hillsdale:
▶ Communication Theory Lawrence Erlbaum Associates.
Hayley, J., & Richeport-Haley, M. (2003). The art of stra-
▶ Communication Training in Couple and Family
tegic therapy. New York: Brunner-Routledge.
Therapy Johnson, S. M. (2004). The practice of emotionally focused
▶ Double Bind Theory of Family System couple therapy: Creating connection. New York:
▶ Externalizing in Narrative Therapy with Cou- Brunner-Routledge.
Koerner, A. F., & Fitzpatrick, M. A. (2002). Toward a
ples and Families
theory of communication. Communication Theory,
▶ Feedback in Family Systems Theory 12(1), 70–91. https://doi.org/10.1093/ct/12.1.70.
▶ Four Horsemen in Couple and Family Therapy Lavner, J. A., Karney, B. R., & Bradbury, T. N. (2016).
▶ Gottman Method Couples Therapy Does couples’ communication predict marital satisfac-
tion, or does marital satisfaction predict communica-
▶ Homeostasis in Family Systems Theory
tion? Journal of Marriage and Family, 78(3), 680–694.
▶ Listening in Couple and Family Therapy https://doi.org/10.1111/jomf.12301.
▶ McMaster Family Therapy McKay, M., Davis, M., & Fanning, P. (2009). Messages:
▶ Metacommunication in Couple and Family The communication skills book. Oakland: New Harbin-
ger Publications.
Therapy
Satir, V. (1972). Peoplemaking. Palo Alto: Science and
▶ Narrative Family Therapy Behavior Books.
▶ Negative Feedback in Family Systems Theory Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D.
▶ Paradox in Strategic Couple and Family (1967). Pragmatics of human communication: A study
of interactional patterns, pathologies, and paradoxes.
Therapy
New York: W. W. Norton & Company.
▶ Paradoxical Directive in Couple and Family White, M. (2007). Maps of narrative practice. New York:
Therapy Norton.
540 Communication Theory
perceptual processes and relational processes.

Communication Theory Those theories that fall under the message/percep-
tual processes emphasize what, how, and why a
Jason Cencirulo1 and Kathleen A. Eldridge2 message is being communicated and the subse-
1
Los Angeles, CA, USA quent perceptual processes involved, while rela-
2
Graduate School of Education and Psychology, tional processes examine how communication
Pepperdine University, Los Angeles, CA, USA begins, sustains, or dissolves a relationship.
Name of Theory Prominent Associated Figures
Communication theory Communication theory relies heavily on cognitive

science, which, in turn, is influenced by numerous
fields, including linguistics, psychology, sociol-
Synonyms ogy, and philosophy. This creates a rich multi-
disciplinary intersection whose contributors are
Communication privacy management; Communi- too numerous to thoroughly credit. However,
cation boundary management prominent figures for the communication theories
covered in this entry include Sandra Petronio,
who is credited with fully articulating communi-
Introduction cation privacy management theory; Chris
Kramarae and Robin Lakoff, early feminist theo-
Communication permeates every dimension of rists who studied gendered communication styles;
life. Scholars from numerous fields have Rajeswari Sunder Rajan and Audre Lorde, post-
attempted to examine various aspects of commu- colonial feminists who have examined the
nication, from what is being communicated to intersectional influences of gender, class, nation,
how it is being perceived and what impact it has and colonialism on women and relationships;
on internal, interpersonal, and system-level vari- Howard Giles, who helped establish communica-
ables. Communication is especially integral to the tion accommodation theory; Dalmas Taylor, Irwin
development, maintenance, and dissolution of Altman, and others who proposed social penetra-
couples and family systems. As such, numerous tion theory; Barbara Montgomery and Leslie Bax-
frameworks have been created to help practi- ter who, inspired by Mikhail Bakhtin, developed
tioners organize and understand the processes dialectical theory; and Mary Anne Fitzpatrick,
involved in communication and the mechanisms who was prominent in the creation and/or growth
of action specific to them. Within each frame- of both family communication patterns theory and
work, however, there rests an underlying assump- marital typologies.
tion that certain cognitive processes – or mental
activities – shape and direct the messages being
sent and influence how these messages are Description
understood.
This entry is by no means exhaustive, but Message/Perceptual Processes
rather serves as an overview of influential theories
that have shaped and continue to impact the field Feminist Theory
of communication. For the purposes of this entry, Feminist communication theory explores the
the body of knowledge that comprises the disci- intersection between gender, class, ethnicity, and
pline of communication will be viewed through race in women’s lives against historical structures
two main theoretical categories encompassing and communication styles that have traditionally
both couples and familial foci: message/ privileged men (Griffin 2009). Since its inception,
Communication Theory 541
feminist communication theory has examined a Feminist communication theory is relevant to

wide body of topics pertaining to ways in which couples and families, and the contributions of the
dominant cultural narratives are born and theory can be found in numerous relational
reinforced through language and the ways in dynamics. For example, within couples, scholars
which power differentials disproportionately mar- studying the demand-withdraw pattern of com-
ginalize women. Early theorists, including Chris munication, in which one partner criticizes or
Kramarae and Robin Lakoff, examined the ways complains and another partner forecloses conver- C
in which women’s communication styles were sation or physically exits, have examined the roles
modified by gender. For example, early feminist of gender and power in determining demanding
communication scholars proposed that gendered and withdrawing parties. While researchers first
communication expectations exist such that established the pattern as more prominent in
women are expected to hedge more frequently female-demand/male-withdraw pairings, emerg-
while communicating to others, apologize more, ing research in line with postcolonial feminist
and speak less often. Further, when a woman theory has demonstrated that the pattern manifests
violates these presupposed gendered expecta- differently cross-culturally and within same-sex
tions, she is rebuked. As such, early scholars dyads, pointing to an intersubjective space that is
contended that women subsisted in a double- more prominently influenced by the individual
bind position that dictates communication style within a couple seeking change.
and stifles personal, professional, and social
advancement. This is manifest in numerous Communication Accommodation Theory
realms, including the realm of politics, where Communication accommodation theory (CAT) is
early feminist theory explored oration differences a framework that merges sociolinguistic and
between genders and the notable absence of sociopsychological dynamics in order to explore
women’s speeches and speaking styles in histori- the movement of individuals toward and away
cal textbooks. from one other through adaptations in communi-
As feminist theory advanced, scholars cation (Gallois et al. 2005; Giles et al. 1991).
questioned the prominence of Western-centric Championed by Howard Giles and others, CAT
views of feminism, particularly regarding power delineates numerous forms of accommodation in
and subjectivity (Mohanty et al. 1991). For exam- communication. For example, shifting one’s lan-
ple, early inclusion of a binary of power guage toward another’s language is an accom-
vs. powerlessness when exploring differentials modation of convergence often intended to
between men and women privileged a Western minimize the social distance between two
view of women’s stylistic bind. As such, when individuals.
exploring women in relation to their counterparts Convergence can be upward or downward and
around the world, some early feminist communi- reciprocal (symmetrical) or nonreciprocal
cation theorists were criticized for defining and (asymmetrical) in nature. For instance, what one
advancing notions of power for all women as might call a couch among peers might be called a
opposed to just those who shared their view of sofa in the presence of a highly influential person
the ideal (Western) power structure. (if one assumes that sofa is a term better under-
For many scholars, these early theories ignored stood by the influential person with whom one is
a greater world lens of women’s issues, which seeking to connect). This example would be con-
therefore led to a body of postcolonial feminist sidered an upward convergence that, if recipro-
theory that focused on intersubjectivity and the cated, would be symmetrical. However, there are
reconstruction of women’s agency through a mul- degrees to which accommodations can alienate –
ticultural framework, including dialogues of race, as opposed to connect – others, as accommoda-
class, religion, sex, etc. Prominent contributors to tions that are too sweeping might appear mocking,
this field include Rajeswari Sunder Rajan and and accommodations that are too rapid might
Audre Lorde. appear disingenuous.
Power plays a prominent role in this theory, as The rule management process advanced by
researchers have found that those outside relative CPM contends that an individual must coordinate
social power work harder in order to accommo- his/her boundaries with others because informa-
date the norms of the dominant class, whereas this tion is often co-owned with others. To this end,
move is not reciprocated by the dominant class as CPM uses the term private disclosure when label-
readily. Here, divergence takes place, which can ing disclosure, as opposed to self-disclosure, in
increase social distance and forward pre-existing order to incorporate the numerous domains of
power structures. Within relationships, divergent disclosure, including through group or commu-
accommodations can be found within distressed nity means. Further, CPM posits that the coordi-
couples who consciously use the tactic as a means nation of boundaries is precipitated on a desire to
of emotionally distancing themselves from their exercise individual or collective control. When an
partner. Conversely, some level of convergent individual is unable to navigate his/her privacy
accommodation is normative in the formative and private disclosure, boundary turbulence
stages of a relationship and can be harnessed in occurs, and corrective action is needed.
therapy in order to build intimacy or The proliferation of social media and the avail-
understanding. ability of multiple channels of information that
might be used for private discourse present fertile
Communication Privacy Management ground for boundary turbulence within couples
Communication privacy management (CPM) and families. Concerns about what information
studies the realm of private disclosure (Petronio is shared, by whom, with whom, when, and for
2002). Specifically, CPM explores the relation- what purpose must therefore be navigated with a
ship between the messages an individual chooses greater degree of conscious consideration. Take,
to conceal and the messages an individual chooses for example, what information might be gleaned
to reveal. Privacy is central to this theory because about a couple’s health, well-being, or expendable
it is the foundation upon which perceived owner- income by the distribution of a picture on social
ship of personal information is derived. As such, channels or the unintended consequence of a “sta-
privacy protects an individual from the risks tus update” on the trajectory of a relationship. In
inherent in disclosure to others, whether due to these cases, CPM provides the therapist with a
the relation of too much private information to framework of understanding and action that
another, poor timing of a disclosure, or a disclo- might help to clarify or resolve concerns about
sure communicated to one who may do harm. disclosure.
However, privacy needs may deny a person of
the benefits of disclosure, as disclosure may con- Relational Processes
nect one to one’s shared humanity, relieve one of
undo burden, clarify feeling, or increase intimacy Dialectical Theory
within a partnership. Dialectical theory explores the contradictory ten-
Due to the risks and rewards inherent in both sions within relationships and throughout social
privacy and disclosure, CPM advances a rule-based functioning that help to order experience
approach that illuminates the ways in which one (Pawlowski 1998). Whereas family systems the-
might balance his/her needs. The theory offers five ory focuses on homeostasis as a state to which the
assumptions, including (1) the focus of a given family unit returns, regardless of the relative
decision is on private information, (2) private infor- health of that homeostasis, dialectical theory
mation and public relationships are demarcated eschews homeostasis in favor of change and
through the use of a boundary metaphor, (3) the flux. In short, according to dialectical theory, com-
desire for personal control fuels boundary manage- munication never resolves, but rather moves, and
ment, (4) rules aid in the regulation of boundaries, in moving, creates meaning. Developed by
and (5) disclosure and privacy are considered dia- Barbara Montgomery and Leslie Baxter and
lectical in nature. influenced by Mikhail Bakhtin, dialectical
theory’s central tenant is built off a contradiction: conventional norms, can operate interdependently
a unity of opposites (Baxter and Montgomery (yet maintain relative self-sufficiency), and can
1996; Baxter 2004). It includes three central, sym- manage conflict. Separates, however, maintain
bolic dialectical dimensions that shape interper- conventional norms, operate more independently
sonal relating, including stability-change, than interdependently, and desire to circumvent
expression-non-expression, and integration- conflict to a greater extent than all other types.
separation. These dialectics can occur both inter- Finally, traditionals maintain more conventional C
nally and externally, for example, between a cou- norms than all other types, operate
ple and between a couple and a couple’s greater interdependently, and can manage conflict, but
social sphere. Within a relationship, a partner may would prefer to circumvent it if possible. While
one moment desire physical distance, while these typologies describe couples that share a
moments later desire proximity. These opposing communication style, mixed-couple marital
desires are not inherently good or bad, as they are types are also possible, such as separate-
common to all relationships and managed traditionals and traditional-independents, and
throughout a relationship’s unfolding. However, occur in roughly 40% of all couplings. Overall,
it is through the negotiation of these tensions that the theory of marital types provided an important
the relative health and well-being of a relationship framework from which to understand couples’
is determined. As relationships change, so too do communication, but has declined as a focus of
the dialectics. Work with couples and families, research since its inception in lieu of theories
therefore, centers on the identification and rele- that favor emergent, dynamic qualities of couples’
vance of these co-occurring dialectics within a relationships.
particular place and time. While all three dialec-
tics can co-occur, a therapist might help a couple Family Communication Patterns Theory
identify which dialectics have more salience and Family communication patterns theory (FCPT)
therefore create a reference point from which to frames family functioning as a shared social real-
navigate flux. ity influenced by two primary communication
foci – conformity and conversation (Koerner
Marital Typology 2009). From these two communication foci, four
Typology – or classification based on different distinct family types emerge: consensual, plural-
types – has played an important role in the forma- istic, protective, and laissez-faire. Popularized by
tion of many relational communication theories, Mary Anne Fitzpatrick, Ascan Koerner, and
as it provides an accessible heuristic from which others, FCPT posits that each unique family
to base human behavior. Mary Anne Fitzpatrick style influences the manner by which a family
used a typological approach to develop a theory of expresses warmth, shares information, and main-
marital types and refine/popularize a theory of tains or resolves conflict (Koerner and Fitzpatrick
family communication styles (discussed in detail 2004).
below). Using self-report measures, Fitzpatrick One communication focus – a focus on con-
and colleagues categorized couples by five pri- versation between family members – helps par-
mary orientations based on their interaction pat- ents and children cocreate meaning of shared
terns: independents, separates, traditionals, symbols and understand each other’s social envi-
separate-traditionals, and traditional- ronment. Conversely, another communication
independents (Fitzpatrick 1988). Each orientation focus – conformity – creates a communication
maintains its own position with respect to the pattern between parents and children that is uni-
degree of freedom desired within a relationship, directional, such that parents ascribe meaning to
desired marital ideology, and manner of managing the symbols a family shares.
conflict. According to FCPT, families that are focused
Those with an independent marital type main- primarily on conversation between members are
tain a system of belief that is outside of classified as pluralistic and enjoy a greater degree
of member autonomy than other family types. Here, development (Knapp and Vangelisti 2005).
parents are clear about their beliefs, but do not These stages, which unfold separately, include
mandate that their children maintain the same initiating, experimenting, intensifying, integrat-
beliefs. Consensual families, on the other hand, ing, and bonding. In each stage, partner unifica-
while focused on conversation, equally value con- tion intensifies and deepens.
formity. Parents help their children navigate the The role that uncertainty plays in relationship
dialectics of exploration and hierarchy and provide development has also been studied, namely, by
a clear frame in which members operate. Families Charles Berger, Richard Calabrese, and others
with a consensual frame have been found to enjoy (Berger 2005). According to these theorists,
greater emotional health and well-being than other uncertainty plays a pivotal role in relationship
types. Protective families focus primarily on confor- development due to its unique ability to intensify
mity in lieu of conversation. Obedience is empha- emotions and polarize communication. While
sized within this structure, which establishes rules some theorists view uncertainty as inherently neg-
within the family unit, yet stifles children’s ability to ative in relationships, others such as Leslie Baxter
understand and trust their own decision-making view it as a vehicle for increased cooperation and
processes. Finally, a laissez-faire family places little an opportunity for couples to experience more
emphasis on both conformity and conversation. surprises that increase needed relational novelty.
Families with this focus maintain infrequent com- After the development of a given relationship,
munication with one another and demonstrate a certain behaviors contribute to its ideal mainte-
limited interest in a shared emotional processing as nance. Scholars such as Laura Stafford and Daniel
compared to other families. As such, children in this Canary have identified a number of behaviors that
family style are prone to place more emphasis on the help to maintain marital relationships in particular.
opinions of others in order to determine the meaning These behaviors include engaging in a positive
of information or calculate a given course of action. manner, remaining open in communication, send-
ing messages of assurance, sharing social net-
Relationship Development, Maintenance, and works, and sharing tasks. Other researchers have
Dissolution Theories identified salient behaviors that help to maintain
Communication plays a pivotal role in the develop- romantic relationships, including a focus on self-
ment, maintenance, and dissolution of romantic enhancing behaviors such as exercise and medi-
relationships. For example, the ability to communi- ated communication such as frequent phone
cate warmth, confidence, or ease through verbal and contact.
nonverbal channels has been shown to increase For each relationship that is developed and
attraction between strangers. Further, similarities in maintained, there is a likelihood of dissolution.
communication styles can result in increases in the Just as Mark Knapp described relationship devel-
attraction between individuals. A number of theories opment, he outlined a stepwise relationship disso-
seek to illuminate the process of relationship devel- lution process that includes the following stages:
opment through a stepwise model that predicts rela- differentiating, circumscribing, stagnation,
tionship development. Dalmas Taylor and Irwin avoiding, and terminating. Opportunities for inter-
Altman proposed a social penetration theory that vention exist in each stage, and as such, the dis-
examined the role of self-disclosure as a means to solution process is just as important to couples
deepen intimacy among individuals (Taylor and work as the development and maintenance stages.
Altman 1987). According to these theorists, as the For example, intervention in the circumscribing
breadth, depth, and frequency of disclosure phase might focus on communication boundaries
increases among individuals, so too does the inti- set up by one’s partner in order to limit the fre-
macy of individuals’ shared bond. quency and depth of conversation, whereas inter-
Borrowing from elements of the social pene- vention in the stagnation phase might focus on
tration theory, Mark Knapp proposed a stepwise communication gaps between the couple that pro-
model that included stages of relationship mote neglect.
Relevance to Couple and Family Therapy superficial disclosure (decreased intimacy). Work
with the couple would then focus on helping part-
The field of communication broadly seeks to ners develop the practical skills of effective personal
explore the ways in which messages comprise, disclosure (“I feel” statements, eye contact, etc.).
organize, or dissolve our personal, familial, and Still other theories offer a typology to explain
social relationships and the manner by which the impact that certain communication styles
these messages are transmitted or perceived might have on a couple and/or family. For exam- C
(Stamp and Shue 2004). As such, communication ple, family communication patterns theory
is central to all aspects of work in both couple and (FCPT) offers an understanding of the intersection
family therapy, from conceptualization of distress between family communication styles and behav-
to treatment planning and intervention. Some iors based on the level of conversation and con-
examples of the relevance of communication the- formity within a family. A therapist who
ory to couple and family therapy are provided in understands a family to be of a certain typology
this section, followed by additional case examples (e.g., consensual) might be able to better identify
in the next section. behaviors that correspond (e.g., a mandate for
One example is a therapist who might use a family dinners) and help the family to identify
feminist communication theory to understand a cou- how their communication style corresponds to
ple’s difficulties communicating as related to inter- their behaviors. While both communication styles
nalized gender norms that stifle intimacy, regardless and behaviors can change over time in a family,
of whether the couple is cross sex or same sex. the focus in therapy is on the multidimensional
Treatment, then, would focus on raising the couple’s functions they serve and their contribution to the
consciousness about the internalization of their gen- shared social reality of a family. Essentially, com-
der norms while investigating the exact ways in munication styles create meaning for a family, and
which these norms have manifest in their daily life. as meanings change, the therapist must work with
Further work might focus on resocializing the cou- the family to bridge the often tumultuous interac-
ple in order to liberate them from the oppressive tions that result. Using a FCPT framework, a
nature of their respective models. therapist might help family members understand
However, other conceptualizations might see dis- the impact their communication style has on their
tress as exclusively resulting from a communication family’s intersubjectivity, or shared meaning, and
skill and/or process deficit and would target treat- interactivity, or the interpersonal interactions
ment on buttressing these deficits For example, resulting from their communication style.
work from a social penetration theory frame might
focus on building self-disclosure skills. First, a ther-
apist would help a couple identify their current Clinical Example of Application of
communication pattern, including disclosures that Theory in Couples and Families
each partner believes to be personal in nature and
superficial in nature. A therapist might do this by, in Jennifer, a 43-year-old African-American female
part, paying attention to nonverbal cues that denote who identifies as agnostic and Daniel, a 41-year-
immediacy (forward lean, touching) and relaxation old Caucasian male who identifies as Christian,
(arm and leg symmetry), two nonverbal behaviors have one daughter together, a 13-year-old named
that have been associated with greater intimacy. By Shannon. The couple self-referred to therapy in
first identifying these behaviors based on observa- order to alleviate pent-up ill-will stemming from
tions in the therapeutic setting, a therapist might then differences in cultural expectations about the role
help each partner to identify these behaviors in one of gender and religion in their relationship, as well
another. Thereafter, a therapist could choose to help as to improve communication.
the couple understand the interpersonal rewards of Using self-report measures, the couple’s
increased personal disclosure (increased intimacy), therapist first develops a marital typology in
in addition to the costs of an overreliance on order to understand the ways in which the
couple relates to one another. She determines greater community. The decision-making matrix
that the couple operates more independently that Jennifer, the couple, and the family must go
than interdependently and that they desire to through according to CPM takes into consider-
circumvent conflict rather than address it head- ation Jennifer’s desire for control and her ability
on. She, therefore, believes that the couple falls to navigate vulnerability and includes a coordina-
into the typology of separates and hypothesizes tion of the family’s shared boundaries. The thera-
that work will focus, in part, on increasing pist has a pre-existing idea of the family’s
interdependence. boundaries because she has examined their com-
First, however, she seeks to better understand munication style and behavior over time and has
how the couple employs the skill of communi- determined that they operate from a pluralistic
cation with one another. She finds that the cou- typology. As such, the couple’s daughter has
ple is stuck in a communication pattern of been told about her parents’ beliefs, but has been
demand-withdraw, in which Jennifer is the with- free to choose her own beliefs about what and
drawing party and Daniel is the demanding when to communicate regarding her mother’s dis-
party. Utilizing a social penetration frame, she ease. While this family communication style has
sees this as a de-penetration of intimacy within benefitted the unit previously, the family’s new
the relationship that has impacted the couple’s context may require more conformity and conver-
ability and willingness to share their innermost sation in order that the family successfully navi-
thoughts and beliefs. She learns that these styles gate their newfound boundaries. As such, the
of communication have been formed because therapist works to make the family aware of the
Daniel seeks change in the relationship that benefit of a consensual communication pattern.
Jennifer is unwilling to accommodate. Daniel As the needs of the family change over time, so
desires that Jennifer spends more time at home too do the interventions and the conceptualization
with their daughter, but Jennifer believes her of distress, but within each change, the under-
current time at home is sufficient and hopes lying therapeutic focus on communication
that Daniel will be more accepting of their cur- predominates.
rent roles.
Using a feminist and postcolonial feminist the-
oretical framework, the therapist teases out the
Cross-References
historical influences impacting Daniel’s desire
for – and sense of entitlement to – traditional
▶ Cognition in Couple and Family Therapy
gender roles, including the intersection of his
▶ Communication in Couples and Families
race and religion. She then helps Jennifer identify ▶ Communication Training in Couple and Family
the communicative double bind she is placed in
Therapy
that leads to her withdrawing behavior. This
understanding helps the couple navigate the dia-
lectic of communication and non-communication
References
that they have struggled to integrate, and the
acceptance of this dialectic helps the couple find Baxter, L. A. (2004). A tale of two voices: Relational
moments of communicative convergence in line dialectics theory. Journal of Family Communication,
with communication accommodation theory 4(3), 181–192.
Baxter, L. A., & Montgomery, B. M. (1996). Relating:
(CAT). Dialogues and dialectics. New York: Guilford Press.
Over the course of treatment, Jennifer is diag- Berger, C. R. (2005). Interpersonal communication: Theo-
nosed with stage II breast cancer. The therapist retical perspectives, future prospects. Journal of Com-
then employs CPM’s rule-based approach to munication, 55(3), 415–447.
Fitzpatrick, M. A. (1988). Between husbands & wives:
decision-making in order to help the couple first
Communication in marriage. Newbury Park: Sage.
manage their disclosure of private health informa- Gallois, C., Ogay, T., & Giles, H. (2005). Communica-
tion to their daughter and subsequently to their tion accommodation theory: A look back and a look
Communication Training in Couple and Family Therapy 547
ahead. In W. Gudykunst (Ed.), Theorizing about Introduction

intercultural communication (pp. 121–148). Thou-
sand Oaks: Sage.
Giles, H., Coupland, N., & Coupland, J. (Eds.). (1991). The Communication skills training is among the most
contexts of accommodation. New York: Cambridge commonly used of the behavioral interventions in
University Press. couple and family therapy. It is used to improve
Griffin, C. (2009). Feminist communication theories. In the clarity with which members of relationships
S. W. Littlejohn & K. A. Foss (Eds.), Encyclopedia of
communication theory (Vol. 2, pp. 391–394). Thousand express their thoughts and emotions to each other C
Oaks: Sage. and the effectiveness with which they listen to and
Knapp, M. L., & Vangelisti, A. L. (2005). Interpersonal understand each other’s messages. Good commu-
communication and human relationships (5th ed.). nication involves one individual expressing
Boston: Allyn & Bacon.
Koerner, A. F. (2009). Family communication theories. In thoughts and emotions in a manner that is easy
S. W. Littlejohn & K. A. Foss (Eds.), Encyclopedia of to understand and another person setting aside
communication theory (Vol. 2, pp. 382–385). Thousand personal agendas to try to take the expresser’s
Oaks: Sage. perspective, understand the person’s subjective
Koerner, A. F., & Fitzpatrick, M. A. (2004). Communica-
tion in intact families. In A. Vangelisti (Ed.), Handbook experience, and reflect those thoughts and feelings
of family communication (pp. 177–195). Mahwah: back to the expresser to demonstrate empathy.
Lawrence Erlbaum. Guerney’s (1977) Relationship Enhancement
Mohanty, C. T., Russo, A., & Torres, L. (1991). Third World Program emphasized positive outcomes of family
women and the politics of feminism. Bloomington:
Indiana University Press. members’ psychological and emotional well-
Pawlowski, D. R. (1998). Dialectical tensions in marital being derived from the increased intimacy gained
partners’ accounts of their relationships. Communica- from improved expressive and empathic listening
tion Quarterly, 46(4), 396–416. skills. Similarly, Markman et al.’s (2010) Preven-
Petronio, S. S. (2002). Boundaries of privacy: Dialectics of
disclosure. Albany: State University of New York tion and Relationship Enhancement Program
Press. (PREP) applies expressive and listening skills,
Stamp, G., & Shue, C. (2004). Twenty years of family integrated with conflict resolution skills, to help
research published in communication journals. In couples weather the stresses of life together
A. Vangelisti (Ed.), Handbook of family communica-
tion (pp. 11–28). Mahwah: Lawrence Erlbaum. and prevent deterioration in the quality of their
Taylor, D., & Altman, I. (1987). Communication in interrelationships. For therapeutic interventions with
personal relationships: Social penetration processes. In distressed relationships, a core goal of communi-
M. E. Roloff & G. R. Miller (Eds.), Interpersonal cation skills training is to substitute positive
processes: New directions in communication research
(pp. 257–277). Newbury Park: Sage. expressive and listening skills for existing nega-
tive communication patterns such as criticism,
verbal aggression, defensiveness, and withdrawal.
Clear, constructive communication also is consid-
ered a prerequisite for effective problem-solving
Communication Training in skills (Epstein and Baucom 2002; Jacobson and
Couple and Family Therapy Margolin 1979).
Norman B. Epstein1 and Mariana K. Falconier2

1
University of Maryland, College Park, MD, USA Theoretical Framework
2
Virginia Polytechnic Institute and State
University, Falls Church, VA, USA Although forms of communication skills training
are used in a variety of couple and family therapy
theoretical models, they are associated most with
Name of Intervention behavioral and cognitive-behavioral models
based on social learning theory (Epstein and
Communication training in couple and family Baucom 2002). Social learning theory proposes
therapy that adults who form a couple relationship bring
548 Communication Training in Couple and Family Therapy
personal learning histories that shape how they effectively (e.g., be brief, be specific, describe
interact with each other. In their families of origin emotions as well as thoughts, when expressing
and other past relationships, they learned skills dissatisfaction with your partner’s behavior, first
and styles of communicating and relating to sig- say something positive or encouraging about the
nificant others, by observing parents, siblings, partner) and for active, empathic listening (e.g.,
etc., and by being reinforced for certain actions use good eye contact, reflect back the expresser’s
and punished for others. These learned behavioral thoughts and emotions); (b) modeling the expres-
patterns may differ considerably across cultures. sive and listening skills via demonstration, either
Parents model and explicitly teach their children live modeling by trainers/therapists or viewing of
expressive, listening and problem-solving skills. video recordings such as the video accompanying
Some parents model constructive skills, whereas the Markman et al. (2010) book; (c) clients repeat-
others model ineffective and even destructive edly practicing the skills; and (d) trainers/thera-
approaches. In a social learning and cognitive- pists providing the clients with specific feedback
behavioral theoretical model, it is assumed that on their behavior and coaching to shape more
individuals develop both positive and negative effective skill enactment. Typically, couples or
behavioral responses through these same learning families first are asked to practice using the skills
processes; consequently, learning procedures can with benign topics that do not elicit strong upset
be used to teach members of couples and families feelings that could interfere with developing the
more constructive communication skills. skills. As they exhibit greater ability to communi-
cate about significant upsetting relationship
issues, they are guided in using the skills for
Rationale for Communication Skills discussing areas of conflict.
Training
Research has demonstrated that negative forms of Case Example

communication are risk factors for relationship dis-
tress, deterioration, and divorce (Gottman 1994), Elizabeth and James sought premarital therapy
and communication training is a key component of because they found themselves feeling misunder-
cognitive-behavioral couple therapy that reduces stood by each other when they discussed their life
relationship distress (Epstein and Baucom 2002). priorities and their hopes for the future of their
Couples and family members commonly readily relationship. Their therapist assessed the couple’s
grasp the goals and structured methods of commu- current communication pattern by listening to
nication skills training, so the skills can be taught their descriptions of past upsetting discussions
and practiced easily in a variety of relationship and also by asking the couple to engage in a
enrichment groups (e.g., Markman et al. 2010) and discussion of life goals in front of the therapist.
couple therapy (e.g., Epstein and Baucom 2002). Both members of the couple seemed to focus more
on stating their own ideas than on listening and
understanding the other’s perspective, and when
Description of Communication Skills they expressed themselves, their messages tended
Training to be long and jump from one topic to another. The
therapist gave the couple feedback about this pat-
Procedures for teaching communication skills are tern and suggested that the three of them work
based on social learning principles, in which the together on improving their communication skills.
trainer or therapist’s role focuses on teaching and The therapist provided each partner a handout
guiding the members of couples or families. The with specific guidelines for the expresser role and
skills training components include (a) educating the empathic listener role and explained them to
the members regarding guidelines and methods the couple. The therapist then demonstrated first
for expressing one’s thoughts and emotions the expresser skills and then the listener skills, and
Complementarity in Structural Family Therapy 549
she answered Elizabeth and James’ questions

about them. Next, the couple selected a benign Complementarity in
topic to discuss (their reactions to new neighbors Structural Family Therapy
who seemed unfriendly). They decided that Eliz-
abeth would take the expresser role first, with Jorge Colapinto1 and Wai Yung Lee2,3
1
James providing empathic listening. Elizabeth ini- Minuchin Center for the Family, Woodbury, NJ,
tially only described her perceptions of the neigh- USA C
2
bors, so the therapist coached her in also Asian Academy of Family Therapy, Hong Kong,
mentioning her emotional responses to them. China
3
She also began to speak at length, so the therapist Aitia Family Institute, Shanghai, China
asked her to stop after a couple of minutes so
James could reflect back what he heard her saying,
and then she could express herself further. After Introduction
James did his reflecting, Elizabeth was able to
give him feedback that he accurately summarized Complementarity is the concordance of behaviors
most of her feelings but overlooked a particular and roles between family members.
point. He then reflected back his understanding of
that point, and Elizabeth confirmed that he had
done a good job of showing his empathic listen- Theoretical Context
ing. The therapist then asked the partners to
exchange roles, with James expressing his reac- The concept is central in structural family therapy,
tions to the neighbors and Elizabeth taking the underlying both the structural therapist’s chal-
empathic listener role. lenge to the family’s definition of the problem,
and her or his optimistic stance regarding the
possibilities of change.
Cross-References
▶ Cognitive Behavioral Couple Therapy Description

▶ Problem-Solving Family Therapy
Complementarity denotes the fit among the
▶ Social Learning Theory
behaviors and roles of individual members or
subsystems of a family. Although the notion
bears some resemblance to that of circular cau-
References
sality, there is an important difference between
Epstein, N. B., & Baucom, D. H. (2002). Enhanced the two. Circular causality designates a sequen-
cognitive-behavioral therapy for couples: tial pattern of behaviors, represented with a
A contextual approach. Washington, DC: American series of arrows (girl clings ➔ mother rejects
➔ girl clings), while complementarity looks at
Gottman, J. M. (1994). What predicts divorce? The rela-
tionship between marital processes and marital out- the same behaviors as pieces of a puzzle: the
comes. Hillsdale: Lawrence Erlbaum. girl’s clinginess and the mother’s rejection are
Guerney, B. G., Jr. (1977). Relationship enhancement: “shapes” that fit each other. The difference is not
Skills training programs for therapy, problem preven-
tion, and enrichment. San Francisco: Jossey-Bass.
trivial; it accounts for the structural therapist’s
Jacobson, N. S., & Margolin, G. (1979). Marital therapy: preference for addressing spatial arrangements
Strategies based on social learning and behavior (literal and metaphorical) among family mem-
exchange principles. New York: Brunner/Mazel. bers, rather than sequences of behavior.
Markman, H. J., Stanley, S. M., & Blumberg, S. L. (2010).
The visual representation of complementar-
Fighting for your marriage: Positive steps for pre-
venting divorce and preserving a lasting love ity is similar to that of the Chinese Yin and
(3rd ed.). San Francisco: Jossey-Bass. Yang, where all things exist as contradictory
550 Complementarity in Structural Family Therapy
but inseparable opposites. “When people see Application in Couple and Family
things as beautiful,” says the Tao Te Ching, Therapy
“ugliness is created. When people see things as
good, evil is created. Being and non-being By highlighting complementary patterns, the
produce each other. Difficult and easy comple- structural therapist challenges the family’s cer-
ment each other. Long and short define each tainty about the location of the problem, from
other. High and low oppose each other. Fore one individual to a relationship:
and aft follow each other” (Laozi and Mitchell, When [a client] starts a family therapy session with
1988, p. 2). In Chinese mythology, Yin and his wife by saying, “I am depressed,” the therapist’s
Yang’s ever-changing relationship is first question is not an acknowledgment (“You are
responsible for the constant flux of the universe depressed?”) but a challenge (“Is Pat depressing
you?”). Simplequestions like this challenge the
and life in general: as one pole increases, the way people experience reality. They introduce
other decreases. When there is too great an uncertainty. (Minuchin and Fishman, 1981, p. 195.
imbalance between Yin and Yang, catastrophes
Looking at behaviors as expressions of parts of the
can occur; a correct balance between the two
halves must be reached to achieve harmony self that are activated by specific complementary
patterns, rather than as the products of individual
and order.
psyches, allows the therapist to be optimistic
The similarity is not complete. In structural
family therapy harmony and order are not about the possibilities of change. An apparently
ineffective (or authoritarian) parent is seen as hav-
absolute values. Complementary patterns may
ing an efficient (or flexible) side, hidden from
sustain an unhealthy homeostasis through a
rigid distribution of roles, conflict avoidance, view but potentially accessible. A mother who
“loses it” and yells at her son may be described
and excessive mutual loyalty that stifle growth
by others and even herself as incapable of self-
and individuation. Disrupting long established
patterns is often the job of the structural control, but a structural therapist will assume that
her yelling is sustained by the complementary
therapist.
behavior of somebody else – maybe the son him-
Through years of mutual accommodation,
family members develop dyadic complemen- self, or a disqualifying grandmother, or both. The
target of therapy will then be the complementary
tary patterns that accentuate selected traits of
patterns, rather than the psychological makeup of
each individual and inhibit others, which subsist
in latent form and may manifest in a different the mother.
context. Thus the notion of complementarity is
consistent with that of the individual self as a Clinical Example
diversified structure. While the traditional psy-
chodynamic envisions a “core” identity typi- A 5-year-old girl runs in circles around the room,
cally originated in early experiences (“this followed by her 2-year old sister. The consultant,
mother cannot nurture her daughter because Salvador Minuchin, does not study the girl’s
she herself was not nurtured as a child,”) – the behavior but her interaction with the mother,
structural perspective regards being “non- who occasionally issues directives without much
nurturant” as only one of many possible ways conviction. He asks a relational question: “Is this
for the mother to be. She may be nurturant to a how the two of you live your life?.” The mother
different child or with the same daughter when answers, “Yes, it’s a continuous battle,” and the
nobody is looking. She is not unidimensional, session becomes an exploration of relationships
but a complex individual whose various possi- between the girl, the mother, and the father. It
ble ways of being are activated within different turns out that the 5-year old is “uncontrollable”
contexts and at different times. by the mother, but not by the father; and that the
Concurrent Therapy 551
mother/daughter relationship is itself

complemented by the allegedly super efficient Concurrent Therapy
father, who comes to mother’s “rescue” when
she is struggling with the daughter. William D. Ewing and Jessica Rohlfing Pryor
The family’s view is that the father’s interven- The Family Institute at Northwestern University,
tion is needed because the mother fails to manage Chicago, IL, USA
the girl. But if the mother’s and father’s contribu- C
tions are seen as complementary, it is possible to
reverse the direction of causality and say that the Name of Model
mother fails to manage the girl because the father
intervenes before she can succeed. To test this Concurrent Therapy
hypothesis, the consultant asks the mother how
she would like the situation in the room to change.
She says that the children should play with the Introduction
toys in one corner, so that the grownups can talk.
“Good, make it happen,” says the consultant. Concurrent therapy refers to when a therapist sees
The mother resumes her half-hearted efforts to each member of a couple separately, in two different
direct the girls. On cue, the father adds his own, individual sessions. This is contrasted to conjoint
more forceful voice. The consultant stops him: “Let therapy, seeing the couple together in the same
your wife do it. She does it when you are not home, session. While conjoint therapy is the community
right?.” The mother keeps trying, still from her standard for couple therapy, concurrent therapy can
chair, and still unsuccessfully. At times she appears be feasible and effective in particular situations
to give up and turn to the consultant, who invariably (Gurman and Burton 2014). Concurrent therapy
responds: “It’s not happening. What you wanted to commonly occurs during intake to learn each part-
happen is not happening.” After a few minutes of ner’s point of view separately or as a mediation tool
not being “rescued” by her husband nor by the when couples are not able to be in the same therapy
consultant, the mother does get up from her chair, session without fighting. Concurrent therapy is also
and in a gentle but decisive way organizes the two effective when the couple needs to overcome their
girls to play in a corner of the room. intrapersonal challenges in order to improve their
relationship (Gurman and Burton 2014; Hefner and
Prochaska 1984; Cookerly 1974). Other common
Cross-References prompts for concurrent therapy include one partner
refusing to participate in a conjoint session, one
▶ Family Development in Structural Family partner’s cognitive impairment or substance abuse,
Therapy or a lack of emotional and physical safety within the
▶ Family Function and Dysfunction in Structural relationship (Gurman and Burton 2014).
Family Therapy Conversely, conjoint therapy is most effective
▶ Individual in Structural Family Therapy for couples who are able to maintain order during
▶ Structural Family Therapy the session or need to improve their interpersonal
skills, such as communication or problem solving.
Conjoint therapy is the most common structure of
References couple therapy as it focuses primarily on the rela-
tional skills that are the hallmark of this treatment
Laozi, & Mitchell, S. (1988). Tao te ching: A new English
form, while concurrent therapy is more commonly
version (p. 2). New York: Harper & Row.
Minuchin, S., & Fishman, H. C. (1981). Family therapy used secondarily as a mediation tool (Hefner and
techniques. Cambridge, MA: Harvard University Press. Prochaska 1984; Cookerly 1973).
552 Concurrent Therapy
Concurrent therapy, for example, may be When the couple is separated, they may give
used in response to a particular couple therapy more accurate and level-headed information,
session when a topic becomes quite heated. In which subsequently allows the therapist to
this instance, the therapist would ask the indi- more fully understand the challenges the couple
viduals to meet with the therapist concurrently may face (Gurman et al. 2015). These individual
and then come back together conjointly to create sessions provide a space for each partner to
a resolution. Another common use of concurrent explore parts of their past that they may not be
therapy is when a couple needed to have several comfortable sharing with their partner and also
individual concurrent sessions in order to work review content which could not be fully exam-
on intrapersonal skills (e.g., emotion regulation) ined in a conjoint session due to high-conflict
before joining together again. When concurrent dynamics. While conjoint sessions tend to
therapy is needed, it often occurs alongside con- address interpersonal relational skills between
joint therapy (a therapist sees the couple members of a couple, concurrent therapy pro-
together in one session, and also meets with vides a space for each partner to work toward a
each member of the couple in individual ses- greater understanding of intrapersonal chal-
sions) to promote both individual and family lenges that may be affecting the marriage.
growth.
Concurrent therapy has a risk of creating com-
petition between intimate partners. Each partner
may compete to develop a closer relationship with
the therapist in an attempt to sway the therapist’s
Concurrent therapy is primarily utilized as a medi-
opinion or bias them in some way (Gurman et al.
ation tool for couples and families who would
2015). To this point, it is crucial to have an equal
benefit from individual time with the therapist or
number of concurrent sessions with each client
development of intrapersonal skills. While pri-
and establish which information shared privately
marily focused on couples, concurrent therapy
is appropriate to share in the conjoint session with
can also be used to mediate other relationships,
both partners present. Concurrent therapy serves
such as family members, business partners, or
as an adjunct supplement to enrich the main focus
roommates.
of the couple’s work, which is addressed most
appropriately when the couple is seen together
through conjoint therapy (Gurman and Burton
2014). Research About the Model
It has been found that couples who participated in

concurrent marital therapy had a significant
decrease in intrapersonal problems, such as anxi-
ety and depression (Cookerly 1974). A related
No one figure in this field is responsible for defin-
study suggested that those who took part in con-
ing or creating the therapy.
joint therapy had significant improvement in inter-
personal functioning than did participants who did
concurrent therapy (Cookerly 1973).
Theoretical Framework (Including Core However, a study by Hefner and Prochaska
Concepts of Model, Theory of Change, (1984) suggested that, while the effectiveness of
and Rationale for the Model) concurrent and conjoint therapy demonstrate sig-
nificant therapeutic results, the dropout rate for
When conjoint therapy is not possible, couples conjoint therapy in their study was twice that of
that refer to high-conflict threats, such as the dropout rate for concurrent therapy. Hefner
abuse or an affair, can be seen concurrently. et al. postulated that this may have been due to
Conduct Disorders in Couple and Family Therapy 553
scheduling conflicts between the couple or References

because the conflict was simply too high in the
conjoint sessions. Bennun, I. (1985). Behavioral marital therapy: An outcome
evaluation of conjoint, group and one-spouse treat-
Additionally, Bennun (1985) suggested that
ment. Scandinavian Journal of Behavior Therapy,
there were no significant outcome differences 14, 157–168.
between conjoint therapy and seeing one partner Bennun, I. (1997). Relationship interventions with one
alone; however, they found that couples in con- partner. In W. K. Halford & H. J. Markman (Eds.), C
Clinical handbook of marriage and couples interven-
joint therapy “solved their target problems more
tion (pp. 451–470). New York: Wiley.
rapidly” (Bennun 1985, p. 157). Over a decade Cookerly, J. (1973). The outcome of the six major forms of
later, Bennun (1997) encourages concurrent marriage counseling compared: A pilot study. Journal
therapy, much to the criticism of some contem- of Marriage and Family, 35(4), 608–611.
Cookerly, J. (1974). The reduction of psychopathology as
porary scholars. For example, Gurman and Bur-
measured by the MMPI clinical scales in three forms of
ton (2014) state that conjoint therapy should be marriage counseling. Journal of Marriage and Family,
the primary mode of couple therapy, as concur- 36(2), 332–335.
rent therapy has several major issues. They sug- Gurman, A. S., & Burton, M. (2014). Individual therapy
for couple problems: Perspectives and pitfalls. Journal
gest that choosing concurrent therapy over
of Marital & Family Therapy, 40(4), 470–483.
conjoint therapy can lead to therapist side- Gurman, A. S., Lebow, J., & Snyder, D. K. (2015). Clinical
taking, disruptions in the working therapeutic handbook of couple therapy (5th ed.). New York:
alliance, inaccurate individual client reports, Guilford Press.
Hefner, C., & Prochaska, J. (1984). Concurrent vs. conjoint
and many more issues.
marital therapy. Social Work, 29(3), 287–291.
Case Example
Conduct Disorders in Couple
Kevin and Mary came to therapy after 10 years
and Family Therapy
of marriage with concerns of emotional detach-
ment and frequent fights. During intake, con-
Scott W. Henggeler
joint therapy is not possible because the couple
Family Services Research Center, Medical
is fighting constantly. As a result, the therapist
University of South Carolina, Charleston, SC,
suggests working with the couple concurrently
USA
until they are able to collaboratively participate
in the same session. The therapist explains that
with concurrent therapy, she will see the hus-
Introduction
band and the wife individually in order to hear
both partners, as well as to work on their intra-
The primary aims of this chapter are to provide
personal factors that may be affecting their mar-
(a) an up-to-date overview of the research litera-
riage. Once they are able to attend the same
ture concluding that several family-based thera-
session, Kevin and Mary are able to see the
pies are the most extensively validated treatments
therapist together conjointly in order to work
of youths with serious conduct problems, (b) brief
together to address the issues that may be caus-
overviews of the clinical methods used in these
ing their marriage to dysfunction.
This manuscript was supported by grant R01DA34064

Cross-References from the National Institute on Drug Abuse.
Dr. Henggeler is a board member and stockholder of
MST Services LLC, the Medical University of South
▶ Conjoint Couple and Family Therapy Carolina-licensed organization that provides training in
▶ High Conflict Couples MST.
554 Conduct Disorders in Couple and Family Therapy
family-based treatments, and (c) a discussion of processing), family (e.g., poor parental supervi-
their commonalities – commonalities that have sion and monitoring, lack of warmth), peer (e.g.,
implications for the effectiveness of family ther- association with drug-using friends), school (e.g.,
apy approaches in general. lack of commitment to school, iatrogenic school
The content of the chapter is based largely on policies), and community (e.g., lack of prosocial
two recent and extensive reviews of the activities for youth) levels. These research find-
corresponding research literatures. McCart and ings are highly consistent with Bronfenbrenner’s
Sheidow (2016) evaluated 86 published studies (1979) theory of social ecology where behavior is
over a 48-year period that covered 50 unique viewed as largely the product of the reciprocal
treatment protocols. Based on criteria used by interplay between individual characteristics and
the American Psychological Association (APA) the proximal systems in which the individual is
Task Force on Psychological Interventions, embedded (i.e., family, peer, school, neighbor-
treatments were classified as either well hood) as well as the relations among these
established (e.g., at least two independent, systems.
well-designed studies demonstrating efficacy), Importantly, research on the determinants of
probably efficacious (e.g., possibly one well- conduct problems and the corresponding social-
designed study or at least two studies, though ecological theoretical framework have critical
not independent, demonstrating efficacy), pos- implications for the design of effective treat-
sibly efficacious (e.g., at least one well-designed ment interventions. First, to optimize the prob-
study demonstrating efficacy), experimental ability of effectiveness, treatments must be
(e.g., not tested with rigorous research), and comprehensive and have the capacity to address
questionable efficacy (e.g., research shows no a range of risk factors across the youth’s social
beneficial effects). The second review network. Second, in light of the many possible
(Henggeler 2016) examined much of the same targets for intervention, treatments must be indi-
literature, but was based on the more rigorous vidualized to address the key risk factors in a
evaluation criteria developed by the Blueprints youth and family as well as to build protective
for Violence Prevention at the University of factors. As discussed subsequently, the most
Colorado. Blueprints reviewed more than effective treatments based on APA and Blue-
1,000 programs that aim to reduce antisocial prints criteria are both comprehensive and
behavior in youths. Blueprints model programs individualized.
are well specified, have strong evidence of
effectiveness, achieved sustained outcomes for
at least a year, and have the capacity to be Effective Treatments of Conduct
disseminated to community settings with Problems
fidelity.
Family-based treatments are the only approaches
that meet the highest levels of effectiveness based
Theoretical Context on APA and Blueprints criteria. Multisystemic ther-
apy (MST; Henggeler et al. 2009) and Treatment
During the past several decades, thousands of Foster Care Oregon (TFCO, formerly Multi-
studies have examined the causes and correlates dimensional Treatment Foster Care; Chamberlain
of conduct problems, and leading researchers 2003) meet APA criteria for well established, and
have drawn clear and consistent conclusions. Functional Family Therapy (FFT; Alexander
Conduct problems in youth are multidetermined et al. 2013) meets criteria for probably efficacious.
from the interplay of key variables at individual Moreover, MST, TFCO, and FFT were the only
(e.g., biological vulnerabilities, basic cognitive interventions to meet Blueprints criteria for model
processes such as deficits in social information programs. It should be noted that two cognitive-
behavioral therapy approaches, Aggression savings for community stakeholders. Finally,

Replacement Training and Solution-Focused and importantly, several of the studies have
Group Program, also met APA criteria for probably demonstrated the importance of treatment fidel-
efficacious, but closer review reveals that the effec- ity in achieving desired clinical outcomes. That
tiveness of these interventions is not well supported is, youth and family outcomes improved as ther-
by the corresponding research. The former treatment apists adhered more closely to the respective
has only one successful evaluation with a very small treatment protocols. C
sample, three failed evaluations, one international
replication, and a variation that qualified for the
questionable efficacy category; and the latter inter- Clinical Procedures
vention has only one small international efficacy
study. On the other hand, the family-based Although each of the three evidence-based treat-
approaches have overwhelming support for their ments views the family as the primary change
effectiveness. agent, variations in clinical procedures are
Together, MST, FFT, and TFCO have been eval- evident.
uated in more than 30 controlled, published studies
with youths presenting conduct problems, often of a Multisystemic Therapy
very serious nature. Twenty of these studies evalu- As noted elsewhere in this encyclopedia, MST is
ated MST, and eight of those were conducted by delivered by master’s-level therapists working
investigators independent of the treatment devel- within programs that are usually located in private
opers. Likewise FFT has been evaluated in seven provider organizations and funded by public juve-
controlled studies including four by independent nile justice, child welfare, and mental health
investigators, and TFCO has been evaluated in authorities. Each MST team consists of two to
four controlled studies including one by indepen- four therapists, a half-time supervisor at mini-
dent investigators. Moreover, favorable results from mum, and administrative support. Each therapist
each of these models have been replicated in carries a caseload of four to six families, and the
published studies conducted in community settings average duration of treatment is approximately
as well as international sites. 4 months – with sessions occurring as frequently
Across these outcome studies, numerous as needed to achieve desired outcomes.
favorable results for these family-based treat- A home-based model of service delivery is
ments have been reported that are consistent used to remove barriers to service access (e.g.,
with the aforementioned causes and correlates transportation, appointments at convenient
of conduct problems in youth. Studies often times) and facilitate family engagement in ther-
showed improvements, relative to comparison apy. Indeed, more than 85% of families complete
youth and families, in key outcomes and risk a full course of MST treatment nationally. The
factors including decreased conduct problems, home-based approach also enables the collection
decreased caregiver symptomatology, improved of more ecologically valid assessment data from
parenting and family relations, less association which to design interventions as well as more
with deviant peers, and improved school perfor- accurate data reflecting the outcomes of planned
mance and attendance. Moreover, for example, interventions.
across clinical trials, MST has achieved median MST interventions are designed to adhere to
reductions of 39% and 53% in rearrests and nine treatment principles (Henggeler et al. 2009).
out-of-home placements, respectively. Indeed, Together, these principles shape the specifics of the
favorable outcomes have been sustained for interventions to be strength focused, action ori-
more than 20 years post treatment (Sawyer and ented, ecologically valid, and developmentally
Borduin 2011), and improved youth and family appropriate. Interventions are designed to require
functioning has produced considerable cost daily effort by family members, and the outcomes
556 Conduct Disorders in Couple and Family Therapy
of these efforts are monitored continuously, with approach to engage and align with each member
the therapist being ultimately accountable for of the family through active listening and empa-
achieving desired goals. Consistent with strategic thetic behaviors. Second, the therapist engenders
and structural models of family therapy, interven- hope and positive expectations among family
tions target sequences of behavior between the members through the use of reframing, avoiding
various interacting systems (e.g., family, peers, confrontation, and taking a nonblaming stance.
school, and community) that are hypothesized to Third, the therapist develops an understanding of
sustain the identified problems. Importantly, how- how the presenting problems are associated with
ever, evidence-based behavioral and cognitive- the family’s internal interactions and relations
behavioral strategies are integrated into the social- with extrafamilial systems. Here, the therapist
ecological approach as needed (e.g., teaching care- analyzes the family’s values and observed inter-
givers to provide cognitive-behavioral therapy actions to develop a plan for behavior change.
interventions to their child with an anxiety prob- Fourth, the primary aim of behavior change is to
lem, using contingency management to address establish new patterns of family interaction to
substance use), and evidence-based pharmacother- replace the less functional older patterns. Family
apy is incorporated when necessary as well. interactions are modified through the use of
Ongoing training and quality assurance are behavioral techniques such as modeling, commu-
critical components of MST programs nication training, teaching, and assigning home-
(Schoenwald 2016). The fundamental aim of the work. Finally, the generalization phase of
quality assurance system is to surround therapists treatment extends favorable gains to the family’s
with the support and resources needed to optimize social network and creates plans to address
the probability of achieving desired outcomes relapse prevention.
with the client families. As noted previously, sev-
eral studies have demonstrated significant associ- Treatment Foster Care Oregon
ations between therapist fidelity to MST treatment TFCO is a foster care program that serves as an
principles and favorable youth and family out- alternative to residential placement. Youth are
comes. Hence, the quality assurance system is placed in a TFCO foster home for 6–9 months,
designed to continuously assess and promote with one youth per home. The foster parents
treatment fidelity. receive extensive training in behavioral tech-
niques and have continuous access to a TFCO
Functional Family Therapy program supervisor. In addition, therapists and
FFT programs typically include a team of three to skills trainers work with the youth to improve
eight master’s-level therapists who carry case- social skills and meet with the biological/adoptive
loads of 12–15 families. Services are provided in family to facilitate reunification.
office, home, school, and community settings; and Clinically, TFCO is more explicitly behavioral
the duration of treatment is about 3–4 months. As than MST and FFT, but the model is clearly eco-
with MST, the implementation of FFT includes logical in nature and depends on family-based
strong training and quality assurance protocols, interventions for success. The foster parents
and research has demonstrated an association implement a highly structured behavioral plan
between treatment fidelity and youth outcomes. that specifies rewards and consequences for
Clinically, FFT is based on an integration of fam- desired and problem behavior at home, in school,
ily systems theory and behavioral approaches. and in the community. Youth behavior is closely
Conduct problems are viewed as symptoms of tracked, and the contingencies are implemented as
dysfunctional family relations, and interventions planned. The overriding purpose is to surround
aim to change patterns of family interactions in the youth with competent adults who are positive
ways that lead to symptom change. and encouraging and model responsible behavior.
The implementation of FFT includes five Finally, resources are devoted to enhancing the
phases. First, the therapist takes a strength-based parenting skills of the youth’s biological/adoptive
family – to generalize the gains made in foster perspectives of these family-based treatments.
placement to the home context. As with MST and Importantly, however, these linear behavioral
FFT, TFCO includes extensive training and ongo- interventions are delivered within a systemic
ing quality assurance to support favorable youth social-ecological context that includes the family
outcomes. in all aspects of behavior change across the social
ecology.
Fifth, MST, FFT, and TFCO implement rigor- C
Commonalties That Form the Bases ous quality assurance protocols. The primary aims
of Success of these protocols are to promote treatment fidelity
and maximize the probability of favorable youth
The three evidence-based treatments of conduct and family outcomes. Therapist and supervisor
problems have several commonalities that likely training are extensive and ongoing. Treatment
contribute to their success in comparison with the outcomes and program fidelity are monitored con-
numerous interventions that have not proven tinuously, and expert resources are available to
effective. support remediation as difficulties arise.
First and foremost, MST, FFT, and TFCO view In conclusion, the most effective treatments for
the family as the primary change agent. The conduct problems in youth are family based. The
majority of clinical resources are devoted to particular family-based approaches that have
empowering the family and modifying family proven effective include several key similarities
relations in ways that are less conducive to anti- that can inform the larger practice community.
social behavior and more supportive of prosocial Interventions should be pragmatic and goal ori-
behavior. Importantly, several quantitative and ented, aim to enhance parenting competence,
qualitative studies have verified that improved remove barriers to service access, and address
family relations, especially increased parenting aspects of the larger social ecology (i.e., peers,
competence, are the key mediator of favorable school, neighborhood) that present challenges in
youth and family outcomes. sustaining behavior change as well as opportuni-
Second, consistent with extant knowledge ties to enhance prosocial functioning.
concerning the correlates and causes of conduct
problems, these family-based treatments take a
social-ecological perspective of behavior. Hence, References
each devotes considerable attention to key social
systems in which the youth is embedded. With Alexander, J. F., Waldron, H. G., Robbins, M. S., & Nebb,
caregivers serving as the primary change agent, A. A. (2013). Functional family therapy for adolescent
behavior problems. Washington, DC: American Psy-
strategies are often developed to decrease youth chological Association.
association with deviant peers, increase youth Bronfenbrenner, U. (1979). The ecology of human devel-
involvement in prosocial activities, and enhance opment: Experiments by design and nature. Cam-
school or vocational performance. bridge, MA: Harvard University Press.
Chamberlain, P. (2003). Treating chronic juvenile
Third, interventions are delivered where prob- offenders: Advances made through the Oregon multi-
lems occur – in homes, schools, and community dimensional treatment foster care model. Washington,
settings. This strategy overcomes barriers to ser- DC: American Psychological Association.
vice access (i.e., youths with conduct problems Henggeler, S. W. (2016). Community-based interventions
for juvenile offenders. In K. Heilbrun, D. DeMatteo, &
and their families have very high dropout rates) N. E. S. Goldstein (Eds.), APA handbook of psychology
and supports the ecological validity of behavior and juvenile justice (pp. 575–595). Washington, DC:
change. APA Press.
Fourth, interventions are behavioral, individu- Henggeler, S. W., Schoenwald, S. K., Borduin, C. M.,
Rowland, M. D., & Cunningham, P. B. (2009).
alized, and comprehensive. Behavioral and Multisystemic therapy for antisocial behavior in chil-
cognitive-behavioral interventions are action and dren and adolescents (2nd ed.). New York: Guilford
goal oriented, which fits the problem-focused Press.
558 Conflict Tactics Scale-2
McCart, M. R., & Sheidow, A. J. (2016). Evidence-based focuses on the CTS as a measure of behaviors
psychosocial treatments for adolescents with disruptive between intimate partners, such as married,
behavior. Journal of Clinical Child & Adolescent Psy-
chology, 45, 529–563. cohabiting, or dating partners.
Sawyer, A. M., & Borduin, C. M. (2011). Effects of MST Assessment using the CTS exposed a startling
through midlife: A 21.9-year follow up to a randomized and unpleasant reality about American family life:
clinical trial with serious and violent juvenile offenders. husbands and wives engaged in physical aggression
Journal of Consulting and Clinical Psychology, 79,
643–652. against one another at very high rates, with 17.9% of
Schoenwald, S. K. (2016). The multisystemic therapy ® wives and 9.1% of husbands endorsing at least one
quality assurance/quality improvement system. In act of physical aggression, such as pushing, grab-
W. O’Donahue & A. Maragakis (Eds.), Quality bing, or hitting (Straus 1979). This finding
improvement in behavioral health (pp. 169–192). Swit-
zerland: Springer International Publishing AG contradicted popular wisdom at the time, which
Switzerland. held that married individuals did not typically
engage in physical aggression against each other,
and if they did, they would not disclose these unde-
sirable behaviors on a self-report survey. The high
rates of physical aggression by women also
Conflict Tactics Scale-2 contradicted a long-held belief that husbands were
the primary perpetrators of violence against wives.
Michele Cascardi1, Sarah Avery-Leaf2 and
Critics of the CTS charged that it lacked important
Michelle Rosselli1
1 contextual information, such as aggression used in
William Paterson University, Wayne, NJ, USA
2 self-defense, injury and fear resulting from aggres-
The Informatics Applications Group (tiag),
sion, and aggression used to coerce sex (Straus
Tacoma, WA, USA
1987). The basis for these criticisms was that
women were more likely to use aggression in self-
defense, to be injured at a higher rate, and to be
Name and Type of Measure
victimized by sexual aggression more often than
men. Thus, females were believed to be erroneously
Conflict Tactics Scale 2 is a self-report survey of
characterized as more aggressive relative to males.
positive and negative behaviors used in an inti-
In 1996, Straus and his colleagues revised
mate relationship.
the CTS to address several of these criticisms.
Specifically, they developed a new version of the
CTS, the Revised Conflict Tactics Scales (CTS2),
Synonyms
that increased the number of behaviors rep-
resenting more serious psychological aggression
CTS2; Revised Conflict Tactics Scales; Revised
(e.g., called fat or ugly) and physical assault (e.g.,
Conflict Tactics Scales 2
choked) and added scales for sexual coercion and
physical injury (Straus et al. 1996). Although this
broader coverage of aggressive behaviors and
Introduction consequences was advantageous, it still did not
distinguish aggression used in self-defense from
Murray Straus published the groundbreaking aggression used for other reasons. Straus et al.
measure called the Conflict Tactics Scale (1996) defended this decision, arguing that:
(CTS) in 1979. The CTS was designed to mea-
sure the frequency of specific positive tactics the CTS is not intended to measure attitudes about
(e.g., negotiation and reasoning) and negative conflict or violence nor the causes or consequences
of using different tactics. . .. These types of issues
tactics (e.g., psychological and physical aggres- are critical, but they must be investigated by includ-
sion) used to resolve conflicts, disagreements, ing measures of those explanatory, context, or con-
or disputes in family relationships. This entry sequence variables. (pp. 284–285)
Conflict Tactics Scale-2 559
That is, they firmly believed that a behavioral endorsement of items on the CTS2. One concern
measure provided an objective and standardized is a potential mismatch between the interpretation
method for quantifying specific acts taking of IPV by the practitioner and one or both mem-
place in an intimate relationship, which can be bers of the couple. For example, a therapist
supplemented with additional measures of might identify one partner as a perpetrator and
“cause, context, and consequence variables the other as a victim, even if neither individual
[that] are relevant for the study or the clinical self-identifies in this way. Additionally, a therapist C
situation” (p. 285). may assign victim and perpetrator roles even if
Use of CTS in Family and Couples’ Therapy. both partners endorse both having perpetrated acts
The CTS2 is arguably the most widely used of physical aggression against their partner and
assessment of intimate partner violence (IPV), also been a target of such acts. This role assign-
and in the context of family and dyadic treatment, ment may not align with the couple’s perception.
it is used as a screener for physical IPV. Research Thus, it may be difficult for a practitioner to main-
has also suggested that the CTS2 may be used to tain an objective, neutral stance when ascribing
evaluate the potential for future physical IPV “perpretrator” and “victim” labels to clients.
based on the frequency of psychological IPV There may also be discrepancies in interpreta-
(Salis et al. 2014). While there seems to be tion based on CTS2 item endorsement. For exam-
widespread agreement regarding the use of this ple, one tactic, “stomped out of the room or house
instrument (as opposed to alternative measures) or yard during a disagreement,” is categorized as
for this purpose, appropriate application of the “psychological aggression.” A common style dif-
data to intervention has been complicated by dis- ference among couples is observed when one
agreements of interpretation, pertaining both to partner prefers to continue any heated or intense
appropriateness of treatment modalities and defi- interaction, while the other wants a respite (“time-
nitional issues. out”). It is unclear whether the act of leaving a
Treatment appropriateness. Should a couple marital disagreement reflects an adaptive cool-
seeking conjoint therapy be accommodated down method or problematic behavior. In sum,
despite having reported physical IPV at intake, the CTS2 is an effective screening device for
or should they be refused because physical IPV intimate partner violence; however, it should be
is present? Two types of physical IPV have been followed by careful and individual follow-up
identified in the literature as a discriminating fac- with each partner about the antecedents, conse-
tor for treatment modality: situational (reciprocal, quences, and interpretation of the acts reported
low-level violence perpetrated by both partners as on the CTS2.
a way to manage conflict) and characterological
(violence used to induce fear and control partner).
Specifically, couples’ treatment is indicated for Developers
those engaging in situational IPV, whereas only
individual work is deemed appropriate for part- Murray Straus, Sherry Hamby, Sue Boney-
ners engaged in characterological aggression McCoy, and David Bruce Sugarman developed
(Friend et al. 2011; Johnson and Ferraro 2000). the CTS between 1979 and 1996.
Unfortunately, the CTS2 does not provide infor-
mation about motives, and so making this distinc-
tion with the CTS2 alone is not possible. The Description of Measure
CTS2 may be used to screen for IPV; and individ-
ual interviews with each partner can follow to Like its predecessor, the CTS2 measures the fre-
evaluate the context in which IPV occurs and to quency of specific tactics used when differences
assess safety and inform treatment decisions. arise between intimate partners, with a focus on
Definitional debate. An important consider- adult (age 18+) relationships. Despite this initial
ation is how practitioners define and interpret emphasis on adult partners, research has also
demonstrated that the CTS and CTS2 are appro- (no acts occurred), reflecting whether any act
priate for use with adolescent populations on a subscale occurred. This scoring can be used
(Cascardi et al. 1999; Exner-Cortens et al. 2016). to examine the prevalence rate of each CTS2
Respondents endorse the frequency with which subscale. To compute an index of chronicity
they and their partners have engaged in a variety for those who engaged in or experienced at least
of behaviors in the previous 12 months. Fre- one act on a subscale, the midpoints for each
quency is rated on an 8-point scale from never to response option (e.g., 3–5 times = 4, 6–10
more than 20 times, or not in the past year, but it times = 8) are summed. The same scoring
did happen before. Straus et al. (1996) indicate methods for prevalence and chronicity can be
that other reference periods besides the previous applied to create an overall composite that com-
12 months can be used in order to adapt the bines information across the four CTS2 aggres-
measure for different needs (e.g., prior 6 months, sion subscales; however, this strategy is not
time since treatment started, since current rela- recommended because it can obscure important
tionship started). difference in the nature of aggressions reported
There are 39 item pairs (78 items) which can be and their injurious consequences.
completed in 10–15 min. The items are paired so
that respondents indicate which behaviors they
used against a partner (perpetration) and which Psychometrics
behaviors they experienced from a partner
(victimization). There are five CTS2 subscales: The research on psychometric properties of the
CTS2 is difficult to summarize without also con-
1. Negotiation (6 items): explained side of argu- sidering studies using the original CTS, because
ment, showed partner cared, respected part- there are fewer studies on the CTS2 compared to
ner’s feelings the CTS. In addition, investigators have com-
2. Psychological aggression (8 items): insulted or monly modified, added, or deleted certain items
swore at partner, threatened to hit or throw on the CTS and CTS2, for various reasons. Some
something at partner reasons were pragmatic (i.e., to shorten the length
3. Physical assault (12 items): threw something at of the survey), while others were more substantive
partner; pushed, grabbed, or shoved partner; (i.e., removal of specific sensitive items, such as
choked partner threaten with a knife or a gun, or subscales, such
4. Sexual coercion (7 items): made partner have as sexual coercion). The influence of item addi-
sex without a condom, insisted partner have tions, deletions, and modifications on the psycho-
oral or anal sex but did not use physical force, metric properties of the CTS and CTS2 has not
used threats to make partner have sex been systematically studied, so the effects of
5. Injury (6 items): had a sprain, bruise, or small these changes are largely unknown.
cut because of a fight with partner, went to Internal consistency. The items on each of the
doctor because of a fight with partner five CTS2 subscales generally relate strongly to
each other, as evidenced by acceptable to high
Each of the four aggression-related subscales Cronbach a values of internal consistency in the
(psychological, physical, sexual, and injury) were development study (Straus et al. 1996): negotia-
conceptualized to include minor (e.g., insult, tion scale (a = 0.86), psychological aggression
push) and severe (e.g., threaten to hit or throw (a = 0.79), physical assault (a = 0.86), sexual
something at partner, choked partner) behaviors. coercion (a = 0.87), and injury (a = 0.95). Other
Separate scores can be computed for perpetra- research has shown that CTS2 subscales demon-
tion and victimization on each of the five sub- strate acceptable to high levels of internal consis-
scales in a number of different ways. Each CTS2 tency (e.g., Cuenca et al. 2015).
subscale can be scored dichotomously, as pres- Test-retest reliability. One study on test-retest
ence (at least one act occurred) or absence reliability of the CTS2 has been found in the
literature using a sample of men court mandated to settings, separate subscales for moderate and
treatment for wife assault (Vega and O’Leary severe psychological aggression and physical
2007). Over a 9-week interval, men’s reports assault have been identified (Calvete et al. 2007).
about the frequency of their own and their part- Similarly, Viejo et al. (2014) found support for a
ners’ aggressions were generally high, with test- two-factor model of physical aggression that dif-
retest reliability coefficients ranging from 0.67 ferentiated moderate and severe items in a sample
(physical assault) to 0.79 (injury). Reports about of adolescents. In other studies, the distinctions C
partners’ behavior were even more consistent between psychological and physical aggression
over time for physical assault (0.86) and sexual items are not always clear, and a severe physical
coercion (0.80). aggression factor has not been consistently iden-
Couple agreement. The CTS2 questions tified (Barling et al. 1987; Lucente et al. 2001).
respondents about their own and their partners’ For instance, items that have face validity for
behavior; therefore, it is important to understand physical or psychological aggression do not
the degree to which both parties agree about always load accordingly in factor analysis. For
reports of aggression. Studies of couples have example, the “threatened to throw something at a
consistently found that agreement about the partner” item has face validity for psychological
occurrence and frequency of physical aggression aggression, but loads with physical aggression
on the CTS and CTS2 is low to moderate. This items (Caulfield and Riggs 1992). In addition, in
finding has been observed among married a sample of adolescents, there were not clear dis-
couples in the community (Arias and Beach tinctions between physical and psychologically
1987; O’Leary and Williams 2006), newlyweds aggressive behaviors, such that threats and
and clinic-referred samples of couples seeking aggression toward objects aligned more closely
marital therapy (Heyman and Schlee 1997), and with physical assault than psychological aggres-
men referred to treatment for wife assault sion (Cascardi et al. 1999).
(Browning and Dutton 1986). In general, both Convergent validity. Research has consistently
spouses tend to report that their partners engaged supported significant associations between psycho-
in more violence than the other reported. In addi- logical aggression, physical assault, injury, and
tion, males tend to minimize or discount their sexual coercion. Psychological aggression and
aggression compared to females (Browning and physical assault tend to be moderately to strongly
Dutton 1986; Simpson and Christensen 2005). associated for males and females, with correlation
Couple disagreement about the occurrence and coefficients ranging from 0.33 to 0.71 (e.g., Mur-
frequency of aggression underscores the com- phy and O’Leary 1989; Straus et al. 1996). In
plexity of measuring this phenomenon, and it prospective research, psychological aggression
has led some to suggest that reports about victim- also predicts physical assault (Murphy and
ization may be more accurate than perpetration. O’Leary 1989; Salis et al. 2014). Additionally,
However, others have argued that when informa- more severe psychological aggression, such as
tion can be collected by both partners, any report public insults, nasty name calling, and property
of aggression or victimization from either spouse destruction, are more strongly associated with
should be counted (O’Leary and Williams 2006). severe physical assault, particularly for males,
Construct validity. One way to examine con- compared to passive or expressive psychological
struct validity is with factor analysis. This type of aggression, such as yelling or sulking (Hamby
study has focused primarily on the psychological and Sugarman 1999). Sexual coercion is also
aggression and physical assault subscales of strongly associated with psychological aggression,
the CTS and CTS2, yielding mixed results about physical assault, and injury for males (r’s range
the purity of the subscales and distinctions 0.66–0.91) but not for females (Straus et al. 1996).
between moderate and severe aggressions (e.g., Research has also examined risk factors asso-
Barling et al. 1987; Viejo et al. 2014; Yun 2011). ciated with psychological aggression and physical
In samples of women from various community assault to provide evidence of convergent validity.
As would be expected, both psychological and previously disclosed at intake interview. The hus-
physical aggression have been consistently band admitted to some of these acts and also
related to anger, hostility, and a wide range of reported that his wife never engaged in aggression
emotional distress (e.g., posttraumatic stress dis- toward him. Follow-up interviews with each
order, depression; Birkley and Eckhardt 2015; spouse indicated that the wife was fearful of her
Straus and Mickey 2012). husband’s potential for escalating in aggression.
Consequently, couples treatment was not
Applications in Couple and Family recommended for this case, and the wife was pro-
Therapy vided with legal and community resources aimed
to protect her from harm. After careful rapport
A young couple entered into therapy to seek help building, the husband consented to individual treat-
with problems in their marriage. They have been ment to develop more effective ways to manage his
married for 5 years and have a 2-year-old son. The anger and reduce aggressive behavior.
wife threatened to end the relationship if they did An unmarried couple of 8 years began couples
not seek professional help, and she is concerned therapy. During the intake interview, each partner
about her husband’s potential for aggression reported experiencing psychological aggression
toward their son. Consequently, the husband was from the other partner, including swearing and
pressured to enter therapy by his wife to learn how insulting one another on a frequent basis. In the
to manage his anger and stop acting in aggressive past, the girlfriend has threatened to destroy her
ways. The wife reports that her husband often boyfriend’s property by slashing his car tires. This
criticizes and belittles her and on a few occasions couple is worried that their behaviors will escalate
has grabbed her to prevent her from leaving the and thus sought intervention before this occurred.
room during an argument and punched her once. The CTS2 was administered and showed that each
She says he has started to prevent her from spend- partner engaged in a different forms of psycholog-
ing time with her friends and family. The husband ical aggression (e.g., swearing, insulting) more
reports that his wife flirts with other men when they than 20 times in the past year. Based on prior
socialize, which she then denies and refuses inti- research (Salis et al. 2014), this couple is at high
macy with him. At the start of treatment, the clini- risk for physical aggression with each other.
cian administered the CTS2 to each spouse. A large component of therapy focused on how the
Although the CTS2 does not have norms, it pro- couple should communicate with one another and
vides useful descriptive information about the fre- were encouraged to take the necessary time to
quency of discrete acts of psychological, physical, resolve the conflict to its entirety. Impulse control
and sexual aggression, as well as injury. Because and anger management were topics that were also
prior research has shown that individuals tend to addressed. After 20 sessions of therapy, presence of
underreport IPV when asked directly, the CTS2 is a the items on the psychological aggression scale of
helpful means to assess the severity of IPV in a the CTS2 decreased for both partners. In addition,
more comprehensive manner that takes both part- both partners engaged in greater negotiation behav-
ners’ perspectives into account. It may also indicate iors with one another. These results indicate that
areas that would benefit from additional probing improved communication and levels of respect are
with each spouse individually about the context of likely to prevent escalation of aggression.
IPV so that fear and efforts at domination and
control can be evaluated more fully. Discrepancies Cross-References
between partners’ reports may also indicate each
partner’s level of denial, minimization, and/or self- ▶ Assessment in Couple and Family Therapy
awareness. In this case, administration of the CTS2 ▶ Couple Violence in Couple and Family
revealed sexual aggression and more frequent acts Therapy
of physical aggression, which the wife had not ▶ Family Conflict in Couple and Family Therapy
▶ Gottman, John Hamby, S. L., & Sugarman, D. B. (1999). Acts of psycho-

▶ High Conflict Couples logical aggression against a partner and their relation to
physical assault and gender. Journal of Marriage and
▶ Jacobson, Neil the Family, 61(4), 959–970. https://doi.org/10.2307/
▶ O’Leary, Dan 354016.
▶ Violence in Couples and Families Heyman, R. E., & Schlee, K. A. (1997). Toward a better
estimate of the prevalence of partner abuse: Adjusting
rates based on the sensitivity of the conflict
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564 Conjoint Couple and Family Therapy
Viejo, C., Sanchez, V., & Ortega-Ruiz, R. (2014). Physical couple as a system in which individual members
dating violence: The potential understating value of a interact with each other so an individual’s thoughts
bi-factorial model. Anales de Psicología, 30(1),
172–180. and behaviors are understood in relationship with
Yun, S. H. (2011). Factor structure and reliability of the the other family members’ behaviors and thoughts.
revised conflict tactics scales’ (CTS2) 10-factor model In conjoint treatment, the therapist, rather than only
in a community-based female sample. Journal of Inter- hearing about family interactions from individuals,
personal Violence, 26(4), 719–744. https://doi.org/
10.1177/0886260510365857. can also see the family members directly commu-
nicating together allowing conjoint couple and
family therapists the opportunity to observe these
interactions first-hand and to intervene directly
Conjoint Couple and Family with family members in a session. The rationale
Therapy for working conjointly is based on the premise the
therapist can help an individual and the other mem-
Ronald Chenail bers of the family change concurrently. If one
Nova Southeastern University, Fort Lauderdale, member of the couple or family can change behav-
FL, USA iors, feelings, or thoughts, then other members may
also change actions, beliefs, and views in relation-
ship to the individual. The same relational pattern
Introduction can also hold that changes among family members
can help an individual achieve new insights or
Conjoint couple and family therapy refers to ways of acting.
couples and families treatment wherein the cli-
nician sees two or more family members in the
same session simultaneously. Conjoint treat- Populations in Focus
ment differs from collaborative approaches
(i.e., different therapists who collaborate on Conjoint couple and family therapy is used with all
the treatment see individual family members types of couples and families. Therapists may also
separately) or concomitant approaches (i.e., include nonfamily members such as case workers,
one therapist sees members of the families sep- teachers, and friends in conjoint sessions.
arately in individual sessions). All three
approaches may be employed in the same case
Strategies and Techniques Used
depending on the presenting problem or treat-
in Model
ment process.
Conjoint couple and family therapists may use
Prominent Associated Figures in-session enactments by asking family members
to participate in conversational or behavioral
In 1959, Donald Jackson first used the term “con- activities to learn directly how the individuals
joint family therapy” and Virginia Satir produced interact with each other, to intervene in interac-
the first conjoint family therapy book in 1964 tional patterns of behavior, and to assess possible
(Olson 1970). change. Therapists may also ask participants to
attempt tasks together as homework and to report
on progress in subsequent sessions.
Therapists use a conjoint approach when they want Research about the Model
to focus on the relationship between a couple or
among family members. From a relational Researchers have conducted a large volume of
perspective, the therapist theorizes the family or outcome, process, and participant experience
Conjoint Sex Therapy 565
studies on this model with significant evidence References

indicating effectiveness of conjoint couple and
family therapy for a variety of emotional, behav- Olson, D. H. (1970). Marital and family therapy: Integra-
tive review and critique. Journal of Marriage and
ioral, or physical health problems (Sprenkle
Family, 32(4), 501–538.
2012). Sprenkle, D. H. (2012). Intervention research in couple and
family therapy: A methodological and substantive
review and an introduction to the special issue. Journal C
of Marital and Family Therapy, 38(1), 3–29. https://
Case Example doi.org/10.1111/j.1752-0606.2011.00271.x.
Javier and Maria entered couple therapy after

5 years of marriage reporting a deterioration in
their relationship including a lack of communi- Conjoint Sex Therapy
cation. In the first session, the therapist asked
the spouses to discuss their treatment goals and Darbi M. Miller, Jennifer McComb and Ryan M.
to share perspectives on each other’s objectives. Earl
Learning communication was their primary The Family Institute, Northwestern University,
goal; the therapist asked each spouse to describe Evanston, IL, USA
times in their relationship when they communi-
cated better. The therapist encouraged each
spouse to reflect on the other’s depiction of Synonyms
those times and to tell each other how those
positive times made them feel. The therapist Couple’s sex therapy; Couple’s therapy with
noted times when Javier and Maria listened to sexual issues; Systemic sex therapy
and expressed positive comments towards each
other. The therapist asked the couple to observe
times next week when they communicated well.
Introduction
In the next session, Javier and Maria shared how
the previous week had been more positive. The
Until recently, psychological and/or medical inter-
therapist asked them to share how they felt when
ventions were the treatment of choice for sexual
the other one appreciated them. The therapist
dysfunction. Psychological treatment often
asked the clients to evaluate their progress and
focused on the individual with the sexual concern
to discuss things they would see the other one
and included cognitive and/or behavioral tech-
doing that would be a sign of an improved rela-
niques to alleviate sexual problems, whereas med-
tionship. The therapist asked the couple to con-
ical treatment alters an individual’s physiological
tinue the between-session observation
response (Heiman 2002). More recently, conjoint
assignment. Therapy was concluded after three
sex therapy has emerged as a more systemic
sessions when Javier and Maria reported they
approach to treating sexual dysfunctions that
were satisfied with their level of
attends to the role of relationships in the etiology
communication.
and treatment of sexual concerns.
In 1970, Masters and Johnson proposed there
was value in including partners as a way of help-
Cross-References ing the individual with sexual dysfunction. Even
with this new approach, Masters and Johnson
▶ Common Factors in Couple and Family were criticized for only giving lip service to the
Therapy idea of working with couples as they did not
▶ Couple Therapy conceptualize and treat sexual problems systemi-
▶ Family Therapy cally. Even still, this view contrasted the typical
566 Conjoint Sex Therapy
treatment for their era which conceptualized and either behaviorally or medically driven, the
treated most psychological problems and sexual Intersystem Approach (Weeks 1986) attends
dysfunction within an individual psychoanalytic to the simultaneous influence of the individual-
framework (Kleinplatz 2015). biological/medical, individual – psychological,
In 1977, Helen Singer Kaplan critiqued Mas- couple, dyad, family of origin and larger contex-
ters and Johnson’s work for only looking at phys- tual factors (i.e., religion, culture) on sexual prob-
iological factors of sexual responses and ignoring lems (Weeks and Gambescia 2015). Furthermore,
subjective aspects such as desire, psychological it emphasizes the importance of including partners
arousal, and sexual satisfaction (Kaplan 1977). in treatment and conceptualizing the couple as
Kaplan’s work expanded the field of sex therapy the treatment unit.
by moving beyond the focus on behavioral inter-
ventions to addressing the individual psychologi-
cal factors influencing sexuality. Rationale for the Strategy or
In 2002, in response to the advances in the Intervention
medicalization of sex therapy and the refocus
on the individual as the treatment system, the Due to the prevalence rates of sexual dysfunction
Working Group for a New View of Women’s which are estimated to be 40–45% for adult
Sexual Problems postulated that sexual dysfunc- women and 20–30% of adult men (Lewis et al.
tions should “be assessed in terms of sociocul- 2010), it is important to develop treatments that
tural, political, or economic factors; problems address the range of factors that influence sexual
relating to partner and relationships; psychologi- functioning.
cal and medical factors” (Tiefer 2002). This state- The medicalization of sex therapy and the
ment recognizes the complexity of factors reliance on drugs such as Viagra and Cialis
influencing sexual functioning. Furthermore, it provided evidence that there are limits to the
highlights the role of partners and relationships effectiveness of medications that do not address
in the development, maintenance, and treatment the individual and relationship dynamics
of sexual dysfunctions. influencing sexual functioning. Klotz et al.
(2005) reported that the rate of noncompliance
for people using Viagra was 31% and the major-
Theoretical Framework ity of participants reported that the reason they
stopped using the drug was because “they had
There continues to be a lack of theory and theory- had no opportunity or desire for sexual inter-
informed research underlying the treatment of course or that their partners had shown no sex-
sexual disorders (Weeks and Gambescia 2015). ual interest” (Klotz et al. 2005, p. 2). Therefore,
Historically, people within the field have focused by treating the symptom only and not working
on treating the symptoms of sexual dysfunctions systemically, these patients were still experienc-
and disorders without a clear theoretical frame- ing sexual problems.
work to guide their work (Kleinplatz 2015). It is now widely recognized that it is important
This is beginning to change as theory informed to look at the context in which the problem
sex therapy models begin to emerge such as the is embedded. Usually, a sexual problem is “cre-
Intersystem Approach. This is a meta-framework, ated within or maintained by the relationship”
which is grounded in systems theory and (Weeks et al. 2016, p. 42). Certain risk factors
informed by Sternberg’s Triangular Theory of can predispose a couple to sexual problems
Love (Sternberg 1986), The Theory of Interaction including: anger, resentment, fear of intimacy,
(Strong and Claiborn 1982), and Attachment The- conflict management styles, and power struggles
ory and Sexuality (Johnson and Zuccarini 2010). (Weeks and Gambescia 2015), making it crucial
Unlike the historically dominant models of sex to work systemically when treating a sexual
therapy which were individually focused and dysfunction.
Conjoint Sex Therapy 567
The field of sex therapy has changed in notable their family, sexual relationship, and medical his-
ways, and conjoint sex therapy is now considered tory (for a list of detailed assessment questions
the treatment of choice for many sexual concerns refer to Weeks et al. 2016). The rationale for this
and dysfunctions. This shift is reflected in the in the context of conjoint sex therapy is that many
American Association for Sex Educators and clients are able to talk more openly and honestly
Counselors (AASECT) new requirement that all about their sexual and relationship history and
sex therapists have training in couple therapy. their experience of the sexual problem in an indi- C
vidual context. Therapists must be clear with cli-
ents about how information shared during the
Description of Strategy or Intervention individual sessions will be used in the couple’s
context. Many couple therapists have secret poli-
Conjoint sex therapy is focused on treating the cies that can inform this process. All of the infor-
couple system from the onset of therapy. The mation gathered in the individual sessions will
inclusion of partners in therapy challenges the inform case conceptualization and treatment
idea that the individual experiencing the sexual planning.
concern is the focus of treatment by including and The fourth session is typically focused on the
attending to the partner’s role in the development, therapist sharing their clinical impressions and
maintenance, and treatment of the problem. recommendations for treatment which can include
The initial couple session is focused on build- individual therapy, medical intervention, and/or
ing the alliance with the couple, the therapist couple therapy. Collaboratively, the clients and
modeling comfort and safety discussing sexual therapist create a treatment plan that is congruent
issues, eliciting clients’ experience of the pre- with the client’s goals.
senting problem, attempted solutions, and hopes One of the challenges that often emerges in
for the treatment process. It is important that the conjoint sex therapy is the comorbidity of sexual
therapist be mindful that many couples do not concerns with other psychological, relational,
discuss their sexual relationship directly, so this and/or medical conditions. Weeks et al. (2016)
initial session can be very challenging for some developed The Triage Tree to assist clinicians in
clients. Many clients feel embarrassed, uncom- treatment planning by helping clarify which pre-
fortable, ashamed, or pessimistic from previously senting problem to treat first, treating a comorbid
trying to solve the issue (Weeks et al. 2016). problem and treating multiples sexual dysfunc-
Furthermore, therapists should be mindful that tions in a sequence that makes sense.
the partners might have very different experiences Also, it is important to note that not all clients
related to the sexual concern and it is important presenting for treatment have a partner. In these
that therapists acknowledge, validate, and normal- cases, it is still possible and important to attend to
ize both partners experience. For example, “it the systemic and relational influences on the pre-
makes sense that your worry about losing your senting problem. For example, asking questions
erection gets in the way of wanting to have sex such as: in previous relationships when you expe-
and it also makes sense that his lack of interest in rienced vulvar pain, how did you navigate this?
sex leaves you feeling undesirable and inade- How did your partner(s) respond? How did this
quate.” While details about sexual functioning make you feel? How does this influence your
are important for the therapist to assess the prob- current sexual relationship with yourself and
lem, it is sometimes therapeutically wise for ther- others?
apists to discuss the issue more broadly in the If the client is in a relationship but is unwilling
first session and to ease into the more detailed to involve their partner in treatment, it is the
questions in subsequent sessions. therapist’s responsibility to be clear with the client
The initial couple session is often followed by about the potential limitations to treatment and to
the therapist meeting individually with each part- explore their reluctance to include their partner.
ner to develop a more detailed understanding of Sometimes as a client becomes more comfortable
568 Conjoint Sex Therapy
in sex therapy, trust the therapist and experience presenting problem and their family, relational,
the limitations of individual treatment, they recon- and sexual history. The psychosexual assessment
sider involving their partner in treatment. revealed numerous possible contributing factors
to the erectile dysfunction including: performance
anxiety, relational dynamics, and unrealistic
Case Example expectations about erectile functioning.
Based on the information derived from the
A heterosexual couple in their early 60s present assessment, sex therapy was focused on five pri-
for treatment due to concerns about the male part- mary treatment goals: (1) conceptualizing erectile
ners erectile functioning. The couple sought treat- dysfunction as a relational issue rather than the
ment after a consultation with an urologist who male partner’s problem, (2) psychoeducation
report no physiological origins for the problem about erectile functioning and normative changes
and referred the patient to sex therapy. as men age, (3) increasing communication about
During the initial call, the therapist asked if his sexual needs and desires, (4) identifying and
partner would be willing to attend the first session. interrupting relational dynamics that maintain
The client expressed some reluctance which pro- performance anxiety and avoidance of sexual inti-
vided an opportunity for the therapist to explain macy, and (5) developing mindfulness and relax-
that his partner’s involvement in the process will ation skills. All of the interventions used in
be critical to the desired outcomes. Clarifying the treatment were targeted to address one or more
four session assessment process was reassuring to of these treatment goals.
the client as he felt that it would be important to be Four relational interventions were particu-
able to discuss his experience without his partner larly helpful to the couple. First, the therapist
due to the conflict that it has created. helped the couple understand the interactional
The couple presented as uncomfortable during sequences that contributed to performance anx-
the initial session. Both partners acknowledged iety and the avoidance of sexual intimacy. She
that it was difficult to talk to a stranger about highlighted how the partners expressed sadness,
such a personal aspect of their life. The therapist frustration, and perceived undesirability when
validated these concerns and modeled that she her partner loses his erection contributed to the
was willing to work at their pace and invited the partner feeling inadequate and anxious about his
clients to let her know if she asks a question that performance which resulted in him avoiding
they are not comfortable answering. The first ses- sexual intimacy and the emotional distress that
sion focused on exploring the onset of the pre- it creates for both partners. The therapist nor-
senting problem, the impact of erectile malized this dynamic as many couples find
dysfunction on them individually and on their themselves stuck in some version of this
relationship, and their hopes for treatment. At dance. Second, a series of sensate focus exer-
the end of the session, the therapist created some cises helped the couple work through barriers to
time to reflect on the process and elicited their sexual and emotional intimacy and develop
experience of the session. This is a helpful way mindfulness skills. Both partners became more
for the therapist to access some insight into cli- comfortable discussing their physical relation-
ent’s experience of the process. In this case, both ship and were able to develop skills to be present
partners acknowledged that talking directly about with each other sexually. Third, the couples
their sexual relationship was difficult but that they engaged in some wax and wane exercises that
felt more comfortable than they expected and helped both partners gain confidence in the male
hopeful about the process. partner’s erections. This was very important for
The subsequent individual sessions were this couple as their typical dynamic was that as
focused on developing a more detailed under- soon as the partner’s erection decreased in rigid-
standing of each partner’s experience of the ity the male partner’s anxiety would increase
Contemplation as a Stage of Change in Couple and Family Therapy 569
and the female partner would become frustrated

and give up. Fourth, the partner’s involvement Contemplation as a Stage of
in the treatment process played a critical role in Change in Couple and Family
helping the male partner feel supported and Therapy
trusting that they could navigate his erectile
difficulties when they emerged. This helped Carlo C. DiClemente and Alicia E. Wiprovnick
decrease his performance anxiety and increase University of Maryland, Baltimore County, C
his ability to relax which are both necessary for Baltimore, MD, USA
optimal erectile functioning.
This case example highlights the value of con-
joint sex therapy as an individual approach would Synonyms
fail to address the relational dynamics that both
contributed to the maintenance of the problem and Ambivalence; Considering Change; Decision-
were critical to problem resolution. making; Decisional balance; Risk reward analysis
References
Overview and Theoretical Context
Heiman, J. (2002). Sexual dysfunction: Overview of prev-
alence, etiological factors, and treatments. Journal of Stages of change represent a series of steps and
Sex Research, 39(1), 73–78. tasks that assist in understanding the multi-
Johnson, S., & Zuccarini, D. (2010). Integrating sex and
dimensional nature of the process of intentional
attachment in emotionally focused couple therapy.
Journal of Marital and Family Therapy, 36, 431–445. behavior change. According to the trans-
Kaplan, H. S. (1977). Hypoactive sexual desire. Journal of theoretical model (TTM), the process begins
Sex & Marital Therapy, 3(1), 3–9. with an individual in precontemplation and not
Kleinplatz, P. J. (2015). The current profession of sex
considering change through contemplation
therapy. In K. M. Hertlein, G. R. Weeks, &
N. Gambescia (Eds.), Systemic sex therapy (2nd ed., (decision-making), preparation (planning and
pp. 17–31). New York: Routledge. committing), and action (making the change and
Klotz, T., Mathers, M., Klotz, R., & Sommer, F. (2005). revising the plan) to reach maintenance where the
Why do patients with erectile dysfunction abandon
new behavior is sustained and integrated into
therapy with sildenafil (Viagra ®)? International Jour-
nal of Impotence Research, 17, 2–4. one’s life (Prochaska and DiClemente 1984).
Lewis, R. W., Fugl-Meyer, K. S., Corona, G., Hayes, R. D., When individuals in couples and family therapy
Laumann, E. O., Moreira, E. D., Rellini, A. H., & need to make a change in personal or interpersonal
Segraves, T. (2010). Definitions/epidemiology/risk fac-
behaviors, the stages can be helpful for under-
tors for sexual dysfunction. The Journal of Sexual
Medicine, 7, 1598–1607. standing their readiness and motivation. Thus,
Sternberg, R. (1986). A triangular theory of love. assessing stage status enables therapists to match
Psychological Review, 93(2), 119–135. their approaches to meet the needs of clients in
Strong, S., & Claiborn, C. (1982). Change through inter-
different stages of change. However, motivation
action: Social psychological processes of counseling
and psychotherapy. New York: Wiley. often differs for different members of the couple
Tiefer, L. (2002) A new view of women’s sexual problems. or family system. Often partners and family mem-
Women & Therapy, 24(1), 1–8. bers disagree on who and what needs to change, as
Weeks, G. R. (1986). Individual-system dialectic. American
well as why there is a need for change. Applying
Journal of Family Therapy, 14(1), 5–12.
Weeks, G. R., & Gambescia, N. (2015). Toward a new the stages to couples and family behavior change
paradigm in sex therapy. In K. M. Hertlein, is challenging since the therapist must understand
G. R. Weeks, & N. Gambescia (Eds.), Systemic sex who needs to make changes, what changes are
therapy (2nd ed., pp. 32–52). New York: Routledge.
needed, and how ready individuals are to make
Weeks, G. R., Gambescia, N., & Hertlein, K. M. (2016).
A clinician’s guide to systemic sex therapy (2nd ed.). changes. To maintain equality within couples or
New York: Routledge. family therapy, it is recommended that all clients
570 Contemplation as a Stage of Change in Couple and Family Therapy
be requested to make some type of change vaginismus in sex therapy, or taking actions
(Jacobson and Christensen 1998). Moreover, needed to meet a goal, like taking more time to
stage status is goal and behavior specific so indi- do activities with an adolescent child (Prochaska
viduals can differ in the goals (desired amount of and DiClemente 1984). Furthermore, an emphasis
contact with in-laws) and behaviors (cutting down on shared goals can be helpful when considering
or quitting smoking) as well as in their readiness behavior changes with couples or families. Goal
to make the change. setting can involve elucidating the behavior
changes that will lead to the achievement of larger
goals (such as reduced conflict) by considering
Application of Concept in Couple and each family member’s role in the problem and
Family Therapy the solution, as well as an exploration about
what changes are needed and acceptable to family
Tasks of the contemplation stage of change members (Lebow and Rekart 2007).
include serious consideration of the pros and When exploring reasons for change, it is
cons of change, overcoming ambivalence, and important to distinguish between change viewed
making a firm decision to change (DiClemente as chosen and change viewed as imposed. The
2003). Usually individuals move on to prepara- focus of the TTM is on intentional behavior
tion and action only after having completed either change that is chosen by the individual, driven
a formal or informal cost-benefit analysis, which primarily by intrinsic motivation, and supported
results in a decision that this change is in their best by important explicit or implicit values and rea-
interest. Ambivalence, feeling two ways about a sons. A solid decision to change should be based
specific change or vacillating about whether to on an individual’s belief that the change will be
take action or not, is a normal part of the personally rewarding and worth the effort and risk
decision-making process (Janis and Mann 1977). of making the change. Sometimes, however, a
This is particularly true when interpersonal as well behavior change is primarily made for extrinsic
as personal considerations are in play. reasons, e.g., “I will do this because you want me
Contemplation activity in couples and families to” or “because it is important to you” or “because
is complicated because each member of the dyad you will leave or not let me use the car if I do not
or family system has their personal decisional do this.” Imposed behavior change can be suc-
considerations that can complement or conflict cessful so long as the extrinsic motivations are in
with the considerations of others. This potential place, but often fail when these motivations dis-
discrepancy among reasons and motives for a appear unless the individual finds personal, intrin-
behavior change can disrupt decision-making sic motivations to persist and maintain the change
whether it is focused on the behavior change of a (Stotts et al. 2000). However, in couples and fam-
single individual or a shared set of changes to be ily therapy, making a change for someone else
made by multiple members (Bradford 2012). In may not represent imposed change. Some of the
treatment settings, the role of the intervenor is seemingly extrinsic reasons for change represent
often to explore the different motivations of the important intrinsic values (keeping the marriage,
couple or family members to see if there is some love, or a good parental relationship) and support
common motives or decisional considerations. In intrinsic motivation and a personal decision to
other words, the search is for pros and cons for a change. Nevertheless, it is important for the ther-
specific change that could influence the decision- apist to assess when the behavior change seems
making of each member of the dyad or family to more like an imposed change rather than a chosen
make the changes needed for problem solving and change. Several examples may help. A wife may
optimal functioning. The desired or recommended agree to spend holidays with the in-laws to “save
behavior change could be following through on a the marriage” because this is a deal breaker for the
therapeutic strategy, like doing the recommended husband. However, when she learns that he had an
sensate-focusing strategy for overcoming affair, she is no longer motivated to continue
Contemplation as a Stage of Change in Couple and Family Therapy 571
making this effort and refuses to visit even though (Velasquez et al. 2015). If one or more of these
they stay together. A child may go along with considerations are critically important, it does
doing things a certain way under threat of not not matter how many others are on the other
receiving allowance money but rebel once he side. So, look for how meaningful each consid-
gets a job and no longer has this extrinsic reason eration is, and do not focus simply on generating
to compel him. On the other hand, something that or expanding the list.
is done out of a deep respect or gratitude may In couples counseling, for example, there is C
represent an intrinsically motivated change that often a negotiation about reasons for change.
is capable of being sustained. In relationships, Thus, it is important to understand the dimen-
there is always a need to compromise and to “go sions of decision-making for each member of
along to get along” to some degree. This usually the dyad and the importance of solid, intrinsic
works as long as there is perceived reciprocity and reasons for change. Often there is a desire for
mutual benefit. compromise and a negotiation in finding spe-
cific behavior changes that can reduce conflict,
Evaluating the Pros and Cons promote more effective communication, solve
In working with decisional considerations, it is problems, or improve intimacy (Jacobson and
often helpful to construct or discuss the pros and Christensen 1998). Counselors should make
cons for change. In any such conversation, argu- sure that they are not short-circuiting the
ments for change consist of negatives about the decision-making process of every individual
current status quo (I don’t like all this fighting; especially when there is a dominant partner or
I feel like I am missing something if we do not a more passive-aggressive participant. More-
have children) and the pros for the change over, counselors need to be cognizant of their
(I would stop nagging if you stop drinking; a own values and not interject or impose their
baby would enrich our lives). Arguments against values into the decision-making process
change consist of the positives of the current (Heatherington et al. 2005); this is especially
status quo (drinking with my friends is my only important when cultural differences exist
social outlet; I like the freedom I have without between the therapist and clients since many
children) and the negative aspects of the proposed individuals will have values that reflect the cul-
change (I would lose friends; we would have to ture they identify with and not those of the
give up going to football games). These consider- counselor’s culture. These considerations are
ations represent what motivational interviewing particularly critical in the negotiation and dis-
(Cordova et al. 2005; Miller and Rollnick 2013) cussion of individuals in contemplation for
recommends to reflect upon, whether you are making a change.
hearing change talk (statements supporting Consideration of the pros and cons for change
change) or sustain talk (arguments against can result in several different outcomes. At mini-
change). It is important in these conversations to mum, the exploration of decisional considerations
focus more so on reasons for change and not on should lead to every individual in the couple or
the sustain talk or arguments against change. Con- family system understanding the motives and
centrating on the cons of change can reinforce motivation of the other members. Ideally the dis-
ambivalence and undermine decision-making cussion leads to a decision to make a change or
(Miller and Rose 2015). attempt to make a change. Decisions can be based
Another key consideration when examining on personally as well as interpersonally meaning-
pros and cons is to make sure that you do not ful reasons that can be shared among family mem-
mistake numbers for importance. The more bers. The important outcome is that each person
important element that tips the decisional bal- finds a risk/benefit calculation that supports mak-
ance toward change is not the number of con- ing a commitment and implementing a plan for
sideration for or against but the value or change that would represent the action stage of
importance of each of these considerations change.
572 Contemplation as a Stage of Change in Couple and Family Therapy
Example and reconnect, and second, they recommitted to

having children at some point but decided to
Skylar and Tammy have been married for wait and revisit trying to become pregnant in
5 years. She is 33 and he is 35. They have 3 months. Skylar began to agree that he was
come to marital therapy to discuss their con- being a bit selfish as he had some concerns
cerns about the deterioration of their marriage. about losing Tammy’s attention once children
They are having more arguments about whether were in the picture, and Tammy realized that she
to have children right now and have been grow- also was not convinced that they needed three
ing apart with Skylar spending more time with children. Shared and unique decisional consid-
his friends and Tammy at home alone more. eration allowed for a decision-making process
They do not seem to do much together anymore that fostered shared goal setting and negotiation
and Tammy is frustrated seeing herself as of immediate and longer-term behavior
housekeeper and cook and not an equal partner. changes.
Both work and have rather satisfying jobs; they A 2-year follow-up contact with the couple
are financially stable and own their own home. found them with a 1-year-old child. Skylar was
In this session, the counselor focused on their still progressing in his job and working long
thoughts about having children and explored their hours but also spending more time doting over
decision-making about this issue. Although his daughter and spending time with the family.
Tammy was concerned about how pregnancy Tammy has gone to part-time work to spend
and a child would affect her career and whether more time with their daughter and was consid-
she would be a good mother, she felt that it was ering starting her own business with several of
time and many of her college friends already had a her colleagues so she could be her own boss.
family, so she felt behind. Her family was also
encouraging her since she was the youngest and
her two older siblings each had three children Cross-References
already. Skylar wanted children but was not
ready at this point to spend the time and energy
▶ Action as a Stage of Change in Couple and
to be a father. He was just promoted and much of Family Therapy
his going out was to cultivate business connec-
▶ Precontemplation in Couple and Family
tions and to spend time winding down from job
Therapy
pressures. He was an only child and did not see
any rush since he did not want to live like her
siblings running around trying to keep up with the
References
activities of the children.
As the counselor probed the pros and cons, Bradford, K. (2012). Assessing readiness for couple ther-
she discovered that both wanted children but apy: The stages of Relationship Change Questionnaire.
had different visions of what a family would Journal of Marital and Family Therapy, 38(3),
486–501. https://doi.org/10.1111/j.1752-0606.2010.
look like and the demands of children. As they
00211.x.
shared and discussed personal concerns, they Cordova, J. V., Scott, R. L., Dorian, M., Mirgain, S.,
began to realize that they still had a number of Yaeger, D., & Groot, A. (2005). The marriage checkup:
shared values and goals, as well as a number of An indicated preventive intervention for treatment-
avoidant couples at risk for marital deterioration.
different but important concerns about becom- Behavior Therapy, 36(4), 301–309.
ing parents. They discussed their differences, DiClemente, C. C. (2003). Addiction and change: How
and the counselor was able to have each high- addictions develop and addicted people recover. New
light the key risks and benefits. This discussion York: Guilford Press. (Released in paperback in 2006).
Heatherington, L., Friedlander, M. L., & Greenberg,
led them to a better understanding of one
L. (2005). Change process research in couple and fam-
another and to developing shared goals. Their ily therapy: Methodological challenges and opportuni-
first goal was to begin to do more things together ties. Journal of Family Psychology, 19, 18–27.
Context in Family Systems Theory 573
Jacobson, N. S., & Christensen, A. (1998). Acceptance and thoughts, and emotions as independent entities;
change in couple therapy: A therapist’s guide to trans- the context was truncated (Mesquita et al.
forming relationships. New York: Norton.
Janis, I. L., & Mann, L. (1977). Decision making. NYC: 2010). There were attempts to understand the
The Free Press. influence of social surroundings on individuals;
Lebow, J., & Rekart, K. N. (2007). Integrative family for example, Wundt (1894/1998) discussed the
therapy for high-conflict divorce with disputes over impact of social context on an individual’s men-
child custody and visitation. Family Process, 46(1),
79–91. tal life (Mesquita et al. 2010). Neo-Freudian C
Miller, W. R., & Rollnick, S. (2013). Motivational psychologists developed personality theories
Interviewing: Helping People Change (3rd ed.). New based on human interactions within the social
York, NY: Guilford Press. and cultural context (Hair et al. 1996). Family
Miller, W. R., & Rose, G. S. (2015). Motivational
interviewing and decisional balance: Contrasting pro- systems theory emphasized the importance of
cedures for responding to client ambivalence. context (Breunlin et al. 1997).
Behavioural and Cognitive Psychotherapy, 43(2),
129–141.
Prochaska, J. O., & DiClemente, C. C. (1984). The trans-
theoretical approach: Crossing the traditional bound- Theoretical Framework for Concept
aries of therapy. Malabar: Krieger.
Stotts, A. L., DiClemente, C. C., Carbonari, J. P., & Mul- Family systems theory from its earliest incarna-
len, P. D. (2000). Postpartum return to smoking: Stag- tions has had a major focus on context. It is
ing a suspended behavior. Health Psychology, 19(4),
324–332. a central postulate of family systems theory that
Velasquez, M., DiClemente, C., Crouch, C., & Stephens, behavior can only be understood in the context of
N. (2015). Group treatment for substance abuse: the system in which it occurs. Family theorists
Stages of change therapy manual (2nd ed.). have varied in how radically this stance is held.
New York: Guilford.
For some, especially early family therapists, all
meaning occurs in context, and thus even the most
severe mental illness can be understood in relation
to other behaviors occurring in the family. Most
Context in Family Systems subsequent family theorists emphasize context
Theory but also hold the notion that there is an objective
reality that transcends context and that behavior is
Aalaa Alshareef and Emily C. Klear
influenced by other forces such as biology.
The Family Institute, Northwestern University,
Two recent traditions have extended the con-
Evanston, IL, USA
sideration of the importance of context: social
constructionism and feminism. Social construc-
tivism developed in the 1950s aimed to transform
Synonyms
the oppressing effects of the meaning-making
processes by considering the political and social
Background; Perspective; Situated cognition;
context, including but not limited to poverty,
Situated realities
sexism, and racism (Lock and Strong 2010).
Considering sociopolitical context significantly
impacts the process of therapy in conceptualizing
Introduction cases and building therapeutic relationships.
Feminist theory highlighted that family sys-
Family systems theory originated to account for tems theory was predominantly developed by
individuals in the context of their family and heterosexual males and criticized that it could be
how the process of interaction between family rigid in its approach to considering the context of
members impacted the individual members. gender. Frequently, family therapists took for
Historically, psychological theories focused on granted the power dynamic that was transmitted
objects and drives, and identifying behaviors, to couples and families through history and
574 Context in Family Systems Theory
socially constructed gender roles. Feminist cri- must consider the contexts in which clients’ lives
tiques of family systems theory offered explana- occur (Wetchler and Hecker 2015). Clinicians
tions as to how the process of creating meanings should consider contexts in which behavior occurs.
occurs within context (Taggart 1985). This includes the meanings of behavior in family
In respect to the collaborative and systemic and larger systems. Other important contextual vari-
therapeutic work along with the complexity of ables include gender role and social expectations
human experiences in the changing world, family that are transmitted from each client’s family of
therapists integrate context into the process of origin and cultural background.
therapy (Wetchler and Hecker 2015). Most Clinicians often explore relationship patterns in
human experience can be thoroughly conceptual- terms of power dynamics throughout generations
ized only if it is analyzed within the broader and within the sociopolitical context (Wetchler and
context; therefore, it is critical for therapists to Hecker 2015). Clinicians also consider cultural fac-
consider the multiple layers of context that may tors, such as ethnicity, race, and immigration status
impact the therapeutic process. (Wetchler and Hecker 2015). Often such under-
standings can not only inform assessment and inter-
vention but help in increasing empathy as behaviors
Description are reframed in terms of context.
Context is defined as the circumstances and con-

ditions in which a specific situation occurs, Clinical Example
including its history and future (Boszormenyi-
Nagy and Krasner 1986). Context can refer to The following is an example of how context
many factors, such as the intrapsychic system is critical when conceptualizing a case.
that is situated within the mind (patterns of A heterosexual couple is seeking therapy to navigate
thoughts) and the interpersonal system that hap- power dynamic; wife reports that she hates to be the
pens between individuals and their environment, controller, however, she is scared that the world will
or between individuals and each other (verbal/ fall apart if she does not control everything. For her,
nonverbal exchange) (Boszormenyi-Nagy and making mistakes is not acceptable. Wife maintains
Krasner 1986). Context can include but is not control over husband, and he responds to her con-
limited to: gender, sexual orientation, race, ethnic- trolling behaviors by following her rules, which in
ity, religion, nationality, socioeconomic status, turn upsets the wife because she wants him to advo-
political ideology, and community norms cate for himself. After the initial assessment, it was
(Wetchler and Hecker 2015). found that (a) the wife has a history of trauma, that
The functionality of context in family therapy impacts how she perceives the world. Her perfec-
mainly lies on conceptualizing experiences and tionism plays a significant role in making her feeling
case material within its frames in which it occurs safe and protected (historical context); (b) the hus-
(Boszormenyi-Nagy and Krasner 1986). band was the only male child in his family of origin,
As Watzlawick et al. (2011) suggested, behavior leaving him feeling isolated. He does not want to
that looks strange otherwise may make much reexperience rejection with his wife, so he works
more sense when considered in context. very hard to please her, which prevents him from
asserting his needs; (c) both clients were emotion-
ally rejected and they have developed anxious
Application of Concept in Couple and attachment styles with their own parents, and there-
Family Therapy fore, they do not know how to deal with emotions in
effective ways. Understanding these contexts helps
There are two major ways to integrate context the therapist grasp what underlies their exchanges
into therapy work: assessment and intervention. and constitutes a crucial part of case formulation and
To thoroughly assess and intervene, clinicians treatment planning.
Contextual Family Therapy 575
Cross-References Synonyms
▶ Reframing in Couple and Family Therapy Contextual family therapy

▶ System in Family Systems Theory
References Introduction C
Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between Contextual therapy was founded by one of the
give and take: A clinical guide to contextual therapy.
pioneers of family therapy, Ivan Boszormenyi-
New York: Brunner/Mazel.
Breunlin, D. C., Schwartz, R. C., & Kune-Karrer, B. M. Nagy (1987, first print 1979). It evolved out of
(1997). Metaframeworks: Transcending the models of intergenerational family therapy, which he had
family therapy. San Francisco: Jossey-Bass. developed with his early associates, and from
Hair, H., Fine, M., & Ryan, B. (1996). Expanding the
his seminal work on family loyalties
context of family therapy. American Journal of Family
Therapy, 24(4), 291–304. (Boszormenyi-Nagy and Spark 1984, first print
Lock, A., & Strong, T. (2010). Social constructionism: 1973). Contextual therapy is based on the pos-
Sources and stirrings in theory and practice. tulate that fairness and loyalty play a major role
New York: Cambridge University Press.
in intergenerational family dynamics. It pro-
Mesquita, B., Barrett, L. F., & Smith, E. R. (2010).
The mind in context. New York: Guilford Press. poses that relational ethics, an ethics based on
Taggart, M. (1985). The feminist critique in epistemological mutual respect and reciprocity, not on pre-
perspective: Questions of context in family therapy. Jour- existing moral values, is a core determinant of
nal of Marital and Family Therapy, 11(2), 113–126.
close relationships.
Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (2011).
Pragmatics of human communication: A study of inter- Based on clinical observations, contextual
actional patterns, pathologies, and paradoxes therapists postulate that relational injustices and
(Pbk. ed.). New York: W.W. Norton & Co. distributive injustices, which are the result of
Wetchler, J. L., & Hecker, L. L. (Eds.). (2015). An intro-
adverse circumstances, can have an impact on
duction to marriage and family therapy (2nd ed.).
New York: Routledge. individuals and on families that may affect multi-
ple generations. Conversely, they believe that fair
giving and trustworthiness are at the core of
healthy relationships, as well as at the core of
Contextual Family Therapy individual success.
Contextual therapy is based on a core strategy,
Catherine Ducommun-Nagy multidirected partiality. It requires that contextual
Drexel University, Philadelphia, PA, USA therapists take into account all the people who
The Institute for Contextual Growth, Inc., could be affected by their therapeutic interven-
Glenside, PA, USA tions and that they offer their partiality and empa-
thy successively to each and all family members
as a means to bring them to offer more consider-
Name of Model ation to each other and to restore their capacity for
a genuine dialogue.
Contextual therapy Since the approach developed within the
general field of family therapy, it is also known
as contextual family therapy. But its founder
gave a clear preference to the term contextual
therapy to indicate that this approach is not
Note: A full multilingual bibliography on the work of Ivan
constrained to work only with families. It can
Boszormenyi-Nagy and on contextual therapy with over a
thousand entries has been established by Ilse Siebesma- inform individual therapy and couple therapy as
Niewöhner and is available at http://www.icbnederland.nl. well. It has been used to promote an
576 Contextual Family Therapy
interpersonal dialogue between people in vari- members, i.e., their reciprocal loyalty, is a major
ous kinds of settings. It can also be used as a factor of family or group homeostasis because it
guideline to address interethnic conflicts defines a boundary between the group of all the
(Boszormenyi-Nagy 2002). people who are bound by mutual loyalty commit-
ments and all the others, the people, who are not
the recipients of this commitment. It is also a
Prominent Associated Figures source of individual resilience because people
who can count on reliable relationships have
Here is a list of the main authors who have con- more resources to withstand adversity.
tributed to the development of the approach or to Boszormenyi-Nagy proposed that people’s
its visibility: expectation of fairness and reciprocity constitutes
USA: Ivan Boszormenyi-Nagy, Margaret a major determinant of close relationships, which
Cotroneo, Catherine Ducommun-Nagy, Peter he describes as relational ethics. He borrowed the
Goldenthal, Judith Grunebaum, Terry Hargrave, term relational ethics from the vocabulary of the
Janet B. Hibbs, Austin Joyce, Barbara Krasner, philosopher Martin Buber (1985). He presents
and Geraldine Spark relational ethics as a form of ethics, whereby
Europe: Magda Heireman, Jean-François Le people treat each other in accordance with an
Goff, Jean-Marie Lemaire, Hanneke Meulik-Korf, understanding of the direct impact of their behav-
Pierre Michard, May Michielsen, Luc Roegiers, ior on others, not in accordance with preset moral
Gérard Salem, Dick Schlüter, Else-Marie van den or religious guidelines.
Eerenbeemt, and Amy van Heusden For contextual therapists, the issue is not to
determine what is moral or not but to bring the
family members into a dialogue whereby they
Theoretical Framework can learn about their respective needs and
expectations. From this perspective, the defini-
Rationale for the Model and Core Concepts tion of justice is intersubjective. It results from a
Contextual therapy contains elements that are dialogue between the involved parties, not from
common to all models of family therapy. All the an abstract definition of what is just or unjust.
pioneers of family therapy share a common real- Loyalty belongs to the dimension of relational
ization: individual behaviors are not the sole result ethics in as much as it is a special form of relational
of individual factors like biology or psychology, commitment that individuals offer to people or
but also the result of complex interactions groups in reciprocity for their care and support.
between these individuals and the systems in This commitment shows as an inclination to give
which they are embedded. Consequently, health more weight to their needs and expectations than to
and dysfunctions depend on supra-individual the needs and expectations of others. In families,
determinants, not just individual ones, and ther- filial loyalty originates from the parents’ commit-
apy needs to be built on an understanding of the ment to provide care to their children. As a result, in
workings of the family system. time, the children will be inclined to repay their
On the other hand, contextual therapy does not parents for their commitment by placing their inter-
rely just on systems theory to explain family dynam- ests before the interests of other people. Family
ics. Contextual therapists propose that both individ- loyalty is not limited to the parent-child relationship.
ual fulfillment and relational health are directly It can be the result of a mutual commitment between
connected to our capacity for fairness and siblings or any other relatives.
generosity. Loyalty can also be based on factors that lay
The approach is based on the clinical observa- outside the dimension of relational ethics, such as
tion that people’s expectations of justice and loy- an unconscious internalization of parental expec-
alty play a major role in family dynamics. It is tations, a fear of retaliation, or the need to main-
assumed that the mutual commitment of family tain a relationship with an absent parent.
The model describes the many ways in which The contextual model underlines that unmet
family loyalties can lead to individual and rela- expectations of justice in the family lead to
tional pathologies when loyalties get divided, many additional negative relational consequences
resulting in loyalty conflicts and split loyalties, besides invisible loyalties. Injustices can lead to
or when loyalty is expressed in an indirect and negative reciprocity (“you didn’t do anything for
invisible way. me, so I won’t do anything for you”), revenge
Loyalty conflicts result from loyalty expecta- (“you hurt me, so I’ll hurt you”), and destructive C
tions coming from several parties at the same entitlement. This term is used by contextual ther-
time. It is exemplified by the difficulties that can apists to describe the predicament of people who
occur when people try to balance the loyalty they have been the victim of injustices that were not
owe to their family of origin with the loyalty they repaired by the wrongdoers and of injustices that
owe to their spouse. were the simple result of unfortunate circum-
Split loyalties result from an extreme version stances. Their legitimate right to seek justice
of loyalty conflict. They occur when parents give may lead them to turn to the people who are the
signals that the only evidence of loyalty they will closest to them to obtain some compensation,
accept is an evidence of disloyalty to the other which is unfair and destructive. When destructive
parent (“As long as you still talk to your father, do entitlement leads to a lack of parental accountabil-
not even think of sending me a mother’s day ity and to the exploitation of children, especially
card”). This is a common predicament of children in the form of parentification, it results in pathol-
whose parents are involved in a contentious ogies that can affect multiple generations
divorce. (Boszormenyi-Nagy and Krasner 1986).
Invisible loyalties are understood as indirect Another element that characterizes contex-
expressions of loyalty that occur when people tual therapy is the dialectic theory of the person-
get blocked in their capacity to express their loy- ality proposed by Boszormenyi-Nagy (1987,
alty in a direct fashion. This is the case of adopted first print 1965). According to this theory, the
children who often try to maintain a link with their Self cannot exist outside of a relationship with
biological parents who have disappeared from its counterpart a Non-Self (an Other) and vice
their lives. Since they have no idea about what versa. This theory is based on the premises of
these people would consider as a valid expression existential philosophy (Theunissen 1984). In
of loyalty, they often express their loyalty simply contextual therapy, the dependence of the Self
by pushing away their adoptive parents. At the on the Other to exist as a Self is described as an
end, nobody benefits from the situation. The ontic dependence. According to Spielberg
adoptive parents get hurt, the children get blamed, (1960), the adjective ontic describes “a structure
and their loyalty to their biological parents inherent in being itself.” This means that this
remains invisible since these people have no way ontic dependence is inherent to the dialectical
to hear about their children’s efforts to bring them definition of the Self and not the result of any
into their lives. kind of pathology. This fundamental mutual
Also, people who reject their parents out of dependence is one of the determinants of close
resentment for their shortcomings can rarely relationships.
afford to become entirely disloyal to them because In this model, individuation can only result from
of the determinants of loyalty that lay outside the the meeting of the Self with a Non-Self, and auton-
dimension of relational ethics. For instance, a omy becomes a paradoxical notion since it can only
person who was determined to cut off a parent be reached through relating. Therapists have always
from her life out of anger may at the same time known that a core ingredient of the therapeutic
sabotage a friendship that could have evolved into process comes simply from their presence, not
a marriage. The end result is that it is her partner from any specific treatment strategy. Contextual
who is pushed out of her life, not the parent whom therapists offer an explication for this clinical obser-
she wanted to cut off. vation. They go further by proposing that family
therapy may foster more individual autonomy than of fair and responsible relating between family
individual therapy, which is counterintuitive. members and from direct and non-sacrificial expres-
Contextual therapists consider a relational con- sions of family loyalty. They also propose that indi-
text whose span is wider than the family system, a vidual fulfillment and relational health result in good
term that usually references only those people part from our capacity for generous giving.
who are in direct observable transactions. The Boszormenyi-Nagy proposes that people who
relational context is defined as the sum of all the are capable of generosity toward others accrue
people who are brought into a relationship what he calls constructive entitlement. He coined
through giving and receiving and who are this term to describe the fact that people who show
connected by accountability and indebtedness, generosity to others make a gain that does not
even if they will never have direct interactions. depend on the response of the beneficiary. This
One can be indebted to ancestors who have gain manifests itself as an increase in self-worth,
worked toward securing a successful future for self-esteem, and inner freedom. Decades later, his
the family long before being born. One can care clinical impressions have been validated by neuro-
to provide good circumstances for the children scientists and other researchers who have become
one plans to have even if in the end, one never interested in documenting the benefits of compas-
becomes a parent. The relational context also sion and altruism on physical and mental health
includes the sum of all the people who are depen- (Ricard 2015).
dent on one another for their self-delineation. In contextual therapy, the healing moment is
Lastly, what distinguishes contextual therapy defined relationally. It comes about as the result of
from other approaches is that it aims to encom- intent, the willingness to give, not from an insight
pass all the major determinants of our behavior about the situation. At the moment of giving gen-
in one coherent model of relationships and of erously, the giver makes an indirect gain in the
therapy. They are presented as the five dimen- form of constructive entitlement, while the bene-
sions of relational reality: (1) the dimension of ficiary of this gesture gains in a direct manner.
facts, which is the world of historical determi- Contextual therapists see this double gain as the
nants, of biology, and of medical sciences; main source of therapeutic optimism and of pre-
(2) the dimension of psychology, which is the vention: generous giving does not require selfless
world of individual psychology informed by altruism, and people who receive their fair dues
cognitive sciences and psychoanalysis; (3) the are less likely to accumulate destructive entitle-
dimension of transactions, which is the world of ment and to hurt subsequent generations.
systemic family therapy informed by systems
and communication theories; (4) the dimension Therapeutic Goals
of relational ethics, which is the world of jus- In general, contextual therapy focuses on two broad
tice, loyalties, and reciprocity, the world spe- categories of pathologies: the individual and rela-
cific to contextual therapy; and (5) the more tional pathologies resulting from problems in the
recently added ontic dimension (Boszormenyi- expression of family loyalties and pathologies
Nagy 2000), a dimension that could also be resulting from the individual and relational conse-
called the dimension of mutual becoming, quences of destructive entitlement. As an integrative
which is the world of the relational definition approach, it also encourages a multidimensional
of the Self (Ducommun-Nagy 2002). assessment of clinical situations and relational prob-
lems. It permits the use of psychopharmacological
Theory of Change interventions, psychological interventions promot-
Since contextual therapists have been able to dem- ing individual insight, or systemic interventions to
onstrate clinically that there is a correlation between promote changes as long as these interventions
the experience of injustices and individual or rela- don’t contradict the core principles of relational
tional pathologies, they believe that changes and ethics, especially the mandate of parental
clinical improvement will come from the restoration accountability.
In the area of pathologies related to family permanent change occurs when family members
loyalties, the therapeutic goal is to bring people become able to reengage in positive reciprocity
to find the means to express their loyalties in direct without the support of the therapist.
and nondestructive way. In general, contextual
therapists prefer to explore issues related to family
loyalty with all the parties involved and explore Populations in Focus
with them what each could accept as a valid C
expression of loyalty. When this is not possible Contextual therapy applies to a vast array of
because the parents cannot be included for any populations and clinical problems. It can be used
kind of reasons, or when the parents present such a in the treatment of people affected by any major
degree of rigidity due to their own pathologies that mental illness either as patients or as family mem-
any dialogue becomes impossible, the therapists bers. There, one of the key contributions of con-
choose a different strategy. They encourage the textual therapy comes from the view that any
children to work independently on finding ways mental illness can be the source of injustices both
of expression of loyalty that are compatible with for patients and for family members. In these cases,
their individual pursuits. contextual therapy offers a unique framework that
When people are willing to care enough about allows for the integration of psychopharmacologi-
their family legacy to sort out what they have been cal intervention with relational therapy.
handed down and by taking the risk of refusing to Contextual therapy can offer significant help to
transmit elements of their family heritage that populations affected by intergenerational exploi-
could be detrimental to subsequent generations, tation resulting from the experience of injustices,
they are not disloyal to their parents because they ensuing destructive entitlement, and the
give a better chance to their posterity. Also, these parentification of the next generations. This can
people will earn constructive entitlement by trying include people who have experienced relational
to give a fair chance to the future. injustices in their personal lives. It can also
When it comes to injustices and destructive include people or populations victimized by his-
entitlement, the main strategy for change con- torical events, natural disasters, social injustices,
sists in helping people to realize that they can or any kind of discrimination.
gain more by displaying generosity toward Because of its understanding of the workings of
other people than from insisting on their dues. family loyalties, contextual therapy can be a major
Contextual therapists foster a dialogue between resource for populations that have experienced
family members encouraging them to present major disruption in parent-child relationships. Dis-
their claims and to discuss their expectations. ruptions can come from adoption, divorce, or place-
Each moment of the dialogue leads to a bifurca- ment in foster families and institutions.
tion: one can insist on one’s claims, and refuse Contextual therapy also offers a framework to
to listen to others, or one can open one’s mind to think about blended families resulting from divorce
the possibility that others have valid claims too, and remarriage and the new type of blended families
which will earn them constructive entitlement. formed by couples faced with infertility or by same-
When destructive entitlement leads to blocked sex couples, their children, and the third parties
giving, therapists try to devise situations where involved in their procreation (known or anonymous
the gesture that needs to be made toward the donors or surrogate mothers).
other is small enough to be feasible. This small
experience can then bring just enough positive
inner rewards to push the destructively entitled Strategies and Techniques Used in the
person to take the risk of giving a little more at a Model
next occasion. Another source of motivation
will come from the positive response of the To reach their treatment goals, contextual therapists
beneficiaries of these gestures. A more use a specific strategy: multidirected partiality.
The therapist wants to offer each and every member Since contextual therapists want to keep their
of the family a fair chance to be heard and to present focus on relational ethics, they recommend
their claims and, very importantly, an equal chance weekly sessions whenever possible. They believe
to earn constructive entitlement. If one participates that when there is too much space between ses-
in the treatment session, the therapist needs to offer sions, people tend to focus on reporting on what
one time to present one’s position without interfer- has happened in their life and less on what is
ence by others. If, for whatever reason, one family happening between them.
member cannot be included in the treatment, at a In general, contextual therapists don’t give
minimum, the therapist needs to try to understand their clients direct tasks, and they don’t give
that family member’s situation based on whatever them specific directives to follow between the
information is available. sessions, but sometimes they ask them to go
The rationale for this multidirected partiality back to their family to gain more information on
does not come simply from a humanistic attitude the life of their parents or their ancestors. Like the
and from the belief that all people deserve a fair vast majority of couple and family therapists,
hearing no matter how well or badly they have contextual therapists use genograms in their ses-
behaved. It is part of a specific strategy to bring sions as a tool for recording information about
people out of the vicious circle of negative reciproc- families. More specifically, they use the genogram
ity. Once clients receive the caring attention of the to explore the dimension of relational ethics. They
therapist, they will lose some of the justifications want to record the direction of giving and receiv-
that they had for refusing to hear others, and they ing between family members and identify the
will be more likely to reengage in a dialogue sources of injustices that may have affected family
with them. members over the generations. On occasion, they
The second rationale for multidirected partial- may ask their clients to obtain more information
ity comes from an understanding of the workings from family members about illnesses, losses, life-
of family loyalty and from the notion that any changing events, and sociohistorical circum-
improvement in one person will benefit all the stances that may have affected their family.
other family members. It is even true in the case This kind of information is especially useful in
of children who have been the victim of abuse or cases of clients who have been parentified. If they
neglect. These children will be freer to discuss the can see that their family was impacted by adverse
destructive aspect of their parents’ behaviors events, they may be more likely to understand the
without having to worry about disloyalty if the shortcomings of their parents and to make peace
therapist cares about their parents too. with them. If clients can see that their parents too
During the entire course of therapy, the main were seeking redress for past injustice, and not
tool of the therapist remains multidirected partial- simply acting out of callousness, they will be
ity. Here, the timing is crucial. One guideline is more likely to forgive them and to move on with
that people who are in the most difficult predica- their own lives. Contextual therapists have
ments, who have been treated the most unjustly, described this process as exoneration, and they
who are the most vulnerable, or who are the least believe that it is one of the major sources of
likely to present their claims spontaneously clinical improvement.
should receive the partiality of the therapist first. The decision to terminate treatment results
Therapists also want to reward people who from a discussion that involves all family mem-
take the risk of speaking and who volunteer help- bers. Improvements are measured both in terms of
ful comments. Rewarding people for their positive symptom relief and in terms of an increased
contributions is a powerful strategy to decrease capacity to engage in a fair dialogue with each
chaos during the sessions. If people see that the other without the help of an outsider.
therapist gives them more attention when they try Experience has shown that families who have
to be helpful than when they act out, they will stop made excellent progress in these regards can still
creating havoc. experience problems when they meet new life
challenges. For this reason, at the time of termina- The family is composed of a father and a
tion, therapists offer their client the resource of mother in their early 50s, a teen daughter still in
returning for further sessions at a later time if high school, a boy in his early 20s still living at
needed. home, and an older daughter who is attending
college. The parents requested professional help
because of their concerns about their son’s behav-
Research About the Model ior. He started to display angry outbursts toward C
his younger sister that were so severe that the
Most of the relevance and efficacy of contextual parents had concerns about her safety. Over the
therapy has been established empirically, and most course of treatment, the situation improved signif-
research concerning the model is qualitative rather icantly, but the therapist still remained concerned.
than quantitative. Ivan Boszormenyi-Nagy was The father had remained unable to address his past
among the first family therapists who used objec- history of alcoholism and its impact on the family.
tive recording of their sessions, first by recording Also he was insisting that the early loss of his own
on audiotapes and later on videotape. In addition, father did not play any role in his adult life. Since
he was one of the first to use the one-way mirror to there was a risk that these unaddressed issues
allow team members to provide their observations could impact the family in the future, the therapist
about ongoing sessions. Most of the early discov- offered them the opportunity to meet with
eries leading to the development of contextual Boszormenyi-Nagy for a consultation.
therapy were the result of a detailed analysis of The first session included the two parents only.
recorded therapy sessions. This methodology was The consultant started with a review of their his-
used by Boszormenyi-Nagy throughout his life, tory. He offered partiality to the wife who had
and his method was also followed to a lesser extent significant medical problems and asked to hear
by some of his colleagues. more about that. She reported that she did not
Many of the authors who have written about feel supported by her husband. He then offered
contextual therapy have included a clinical case the husband a chance to respond. The husband
in their publications to illustrate the use of the admitted that she was right, but he insisted that his
approach. In most cases they start from the ini- attitude was not the result of lack of caring but due
tial consultation to the end of the treatment. to a sense of helplessness. He felt that whatever he
They discuss their initial hypothesis, their inter- would have tried to do would be irrelevant.
ventions, and the results of their interventions This gave an opening to the consultant to show
measured in terms of documented clinical partiality to the husband. He asked him if his sense
improvements. of hopelessness could be related to the loss of his
Over the years a large quantity of material has father. After all, he was just a little boy when he
been published that documents the efficacy of the was taken out of school to be told that his father,
approach for a vast array of clinical problems. who was healthy in the morning, had just died at
However, large quantitative studies evaluating his job. This must have been extremely
contextual therapy, like those that exist for other distressing. The husband was adamant that this
therapies such as cognitive and behavioral thera- was irrelevant. For him this was just life: one has
pies, are largely absent from the literature. to accept what it brings. The consultant indicated
that he was willing to hear that, but that for him the
death of his father was also an injustice. Most
Case Example children don’t have to face the early loss of a
parent. Could he see that? He did not.
This case example comes from a two-session con- The consultant did not back off from this idea
sultation with Boszormenyi-Nagy that is available and raised his question a couple more times. Sud-
as a commercial teaching tape (Boszormenyi- denly the husband broke down, his voice changed,
Nagy et al. 1990). and he started to talk not only about the day of his
father’s death but about his life as a young man, clients’ capacity to offer fair consideration to
his early adulthood, the early years of his mar- others. This results in an improved trust among
riage, and all the way to his drinking years, which family members and a better chance to protect the
he had never done before. He soon mentioned an new generations from the impact of past injustices
incident for which he still felt ashamed. His son, and destructive entitlement.
who was still a boy, had caught him drinking in
the family kitchen in the morning. He remem-
bered that his son’s eyes were full of sadness and
disapproval. He reported that this was the moment Cross-References
when he realized that he had failed his child.
While he should have been the parent who cared ▶ “I-Thou” in Couple and Family Therapy
about his child, his son had become the worried ▶ Boszormenyi-Nagy, Ivan
parent (parentification). This story was new to his ▶ Buber, Martin
wife. But she had to admit that at the time she was ▶ Family Loyalty
herself too overwhelmed by the situation to be ▶ Intergenerational Couple and Family Therapy
able to offer support to her children. ▶ Invisible Loyalties in Families
The next session included the entire family. ▶ Ledgers in Couple and Family Therapy
Soon, the father opened up to his son about what
he had shared with the consultant in the couple’s References
session and about his regret for his behavior. The
Boszormenyi-Nagy, I. (2002). Foreword. In F. Kaslow
son was very surprised and immediately turned to (Ed.), comprehensive handbook of psychotherapy
his younger sister. He told her that indeed he knew (Vol. III, pp. xi–xii). New York: Wiley.
that not only he had helped their father but that he Boszormenyi-Nagy, I. (1987). Foundations of contextual
therapy: Collected papers of Ivan Boszormenyi-Nagy,
had also shielded her from his alcoholism by taking
M.D. New York: Routledge.
responsibilities beyond his age. He gave a reason Boszormenyi-Nagy, I., & Framo, J. (1985). Intensive fam-
for his violent outburst toward her: he was mad ily therapy. Theoretical and practical aspects.
because she never showed him the respect that he New York: Routledge. [First print 1965].
Boszormenyi-Nagy, I., & Krasner, B. (1986). Between give
believed he deserved for having protected her.
and take. A clinical guide to contextual therapy.
This revelation took the entire family by surprise. New York: Routledge.
The consultant moved to offer partiality to both Boszormenyi Nagy, I., & Spark, G. (1984). Invisible loy-
children. To the son, he offered his understand- alties. New York: Routledge. [First print 1973].
Boszormenyi-Nagy, I, et al. (1990). From symptom to
ing that indeed he was placed in a demanding and
dialogue, a clinical consultation with Ivan
unfair position, but he also pointed out that his Boszormenyi-Nagy [VHS], U.S.A., G.-N. Productions.
parents had started to acknowledge the damages Boszormenyi-Nagy, I. (2000, April 13). General address in
they had caused. The consultant then moved to the plenary of the annual conference of the Hungarian
Family Therapy Association. Szeged.
offer partiality to the sister: she too was a victim
Buber, M. (1985). Between man and man. Trans.
of the circumstances, and she could not be made New York: MacMillan.
responsible for the unfairness of the predica- Ducommun-Nagy, C. (2002). Contextual therapy. In
ment. The boy started to be able to recognize F. Kaslow (Ed.), Comprehensive Handbook of psycho-
therapy (Vol. III, pp. 463–487). New York: Wiley.
that. Later in the session, the two siblings were
Ricard, M. (2015). Altruism: The power of compassion to
able to talk more openly about their experiences, change yourself and the world. Boston: Little, Brown,
and slowly a new trust grew between all family and Company.
members.
These two sessions give a good example of the
kind of changes that contextual therapists expect to
Note: A full multilingual bibliography on the work of Ivan
bring to families. Changes are not measured sim-
Boszormenyi-Nagy and on contextual therapy with over a
ply by a decrease in individual and relational thousand entries has been established by Ilse Siebesma-
pathology. They show as an improvement in Niewöhner and is available at http://www.icbnederland.nl.
Contingency Contracting in Couple and Family Therapy 583
Spielberg, H. (1960). The phenomenological movement: a controlling conditions of behaviors to understand

historical introduction. The Hague: Martinus Nijhoff. how they can be changed (Bandura 1971). Dis-
Theunissen, M. (1984). The other: Studies in the social
ontology of Husserl, Heidegger, Sartre, and Buber. tressed families and couples tend to use coercion
Cambridge, MA: The MIT Press. and punishment rather than rewards and coopera-
tion in their interactions to make another family
member or romantic partner behave in desired
ways (Fatis and Konewko 1983). Contingency C
Contingency Contracting in contracts change the environmental conditions by
Couple and Family Therapy promoting cooperation, rewarding or reinforcing
desirable changes, and introducing negative conse-
Mariana K. Falconier1 and Norman B. Epstein2 quences to weaken the undesirable behaviors.
1
Virginia Polytechnic Institute and State According to social exchange theory, individ-
University, Falls Church, VA, USA uals’ perceptions about the costs and benefits of
2
University of Maryland, College Park, MD, USA engaging or not engaging in a behavior govern
their decisions (Thibault and Kelley 1959). Fam-
ily members and partners are more likely to
Name of Intervention engage in behaviors desired by others if they
perceive equity, reciprocity, and fairness in the
Contingency contracting in couple and family exchange. By requiring commitment from all
therapy parties involved and introducing consequences
for maintaining or failing to maintain the prom-
ises, contingency contracts can be seen as
Introduction reestablishing equity, reciprocity, and fairness in
the exchange system.
Contingency contracting is a tool based on social
learning principles and that has long been used
in marital and family therapy, particularly in Rationale for Contingency Contracts
behavioral, cognitive-behavioral, and systemic
therapies. Contingency contracts are written Since the 1970s contingency contracting has
agreements in which partners or family members been used in couple and family therapy, partic-
agree to engage in a behavior identified as desir- ularly in treatments with behavioral (e.g.,
able by another partner or family member(s) and Jacobson 1977) and cognitive-behavioral (e.g.,
in which positive consequences for compliance Epstein and Baucom 2002). Contingency
and negative consequences for noncompliance contracting is introduced in therapy as a tool
with the contract are specified (Jacobson 1977). that can help couples and families move from
These contracts structure reciprocal exchanges aversive control and coercive, negative interac-
with agreements on “who is to do what, for tions to cooperative, positive reinforcing
whom, under which circumstances, times, and exchanges. Having an agreement in writing con-
places” (Liberman et al. 1976, p.392), on the tributes to making the rules of exchange clearer
specific rewards for desirable behavior, and on and more explicit (Fatis and Konewko 1983).
the consequences for undesirable behaviors. Contingency contracts require families and cou-
ples to be precise and concrete about expected
behaviors, positive reinforcers, and negative
Theoretical Framework consequences in their contracts and to use lan-
guage that is not harsh, blaming, or accusatory,
Contingency contracting is consistent with social all of which reduces the likelihood of conflict.
learning principles and the social exchange per- But most importantly, the contract in itself can
spective. Social learning theory focuses on the be seen as representing “a pledge of a mutual
584 Contingency Contracting in Couple and Family Therapy
commitment to work on a relationship” (Faits introduced parallel or good faith contingency con-
and Knoweko 1983, p. 161). tracts to work with couples. In this type of contract,
Since all contracts require negotiation among each partner’s engagement into a desirable behavior
family members or partners, it has been is independent from the other partner’s behavior. In
recommended not to use it in isolation but in good faith contracts, each partner commits to engag-
conjunction with problem-solving training ing in certain behavioral changes desired by the
(Jacobson 1977) and communication training other partner, and reinforcers or punishers are inde-
(Weathers and Liberman 1975). Both types of pendent from the other partner’s expected behav-
trainings allow family partners to be able to empa- ioral changes.
thize, compromise, and negotiate successfully. Some clinicians have developed specific pro-
cesses to arrive to a contingency contract. For
example, Weathers and Liberman (1975) have
Description of Contingency Contracting designed the family contracting exercise to be
used in a group format. The exercise helps couples
Two types of contingency contracts have been iden- go from identifying personal needs to the negotia-
tified: quid pro quo and good faith. In quid pro quo tion of responsibilities and corresponding privi-
contracts, individuals agree to engage in behaviors leges and includes communication skills training.
that are desired by another family member(s) or Couples are invited to keep records of each part-
partner, and this other family member(s) or partner ner’s adherence to the contract, which is reviewed
commits to behaviors that will serve as reinforcers in the group meetings. Couples can also refine and
or consequences for not complying with the terms of renegotiate various aspects of the contract in group
the contract (Weiss et al. 1974). This type of contract meetings. Similarly, Blechman, Olson, Schornagel,
is used in both couple’s and family therapy. In Halsdorf, and Turner developed the family contract
family therapy contracts may be developed between game (1976) that enables families to resolve prob-
a parent and a child, between siblings, or among any lems by themselves and develop contingency con-
other family members. They have been particularly tracts. This board game includes card decks
used between parents and their children when par- (problems, rewards, risks, bonuses), contract
ents would like their children to take responsibility forms, tracking forms for positive behaviors and
for household chores, academic work, social activ- rewards, and play money. The game is only played
ities, or other aspects in their lives, and children by the family, who can use it to write new contracts
want their parents to provide them with some priv- or revise and renegotiate previous ones.
ileges (e.g., watching a movie, arriving later, etc.).
The children’s desired behavior is reinforced by
parents granting or withdrawing privileges, which Case Example
act as reinforcers or punishers of their children’s
behavior. Quid quo pro contracts have also been A family sought therapy to resolve the increasing
used in the couple’s therapy context in which part- level of conflict with their 12-year-old son. The
ners agree to engage in behaviors that are desired by parents were concerned about the increasing
the other partner, and the other partner commits to amount of time that their son spent on his cell
behaviors that will serve as reinforcers. Conse- phone and his computer while neglecting his
quences for not complying with the terms of the schoolwork and household chores. The son felt
contract are also included. However, Weiss et al. that his parents did not trust him and invaded his
(1974) have argued that in the case of couples’ personal space. When parents considered that the
therapy, this type of contingency contracting creates son had spent too many hours on his electronics,
the “who goes first” problem, particularly for they asked the son to do his schoolwork. An hour
severely distressed couples in which high levels of following the request, the parents would go into the
mistrust may keep partner from making any change. son’s room to check if he was doing what he had
This is the reason why Weiss et al. (1974) have been asked to do, which usually triggered
Contracting of Goals in Couple and Family Therapy 585
arguments that were followed by the parents Epstein, N. B., & Baucom, D. H. (2002). Enhanced
removing the son’s phone. These escalations left cognitive-behavioral therapy for couples:
A contextual approach. Washington, DC: American
both parents and son feeling angry and exhausted Psychological Association.
and had strained the relationship between them. Fatis, M., & Konewko, P. J. (1983). Written contracts as
The therapist helped them negotiate a contingency adjuncts in family therapy. Social Work, 28, 161–163.
contract in which the son agreed to start doing his Jacobson, N. S. (1977). Problem solving and contingency
schoolwork 1 h after returning from school while
contracting in the treatment of marital discord. Journal
of Consulting and Clinical Psychology, 45, 92–100.
C
leaving his cell phone in another room and having Liberman, R. P., Wheeler, E., & Samders, N. (1976).
no access to video games and TV series in his Behavioral therapy for marital disharmony: An educa-
computer. Once he was able to prove that he had tional approach. Journal of Marriage and family
counseling, 2, 383–396.
finished his schoolwork, the son would be given Thibault, J. W., & Kelley, H. H. (1959). The social psy-
the cell phone and would have full access to his chology of groups. New York: John Wiley.
video games and TV shows for as much time as he Weathers, L., & Liberman, R. P. (1975). The family
had spent doing his schoolwork. The parents contracting exercise. Journal of Behavior Therapy
and Experimental Psychiatry, 6, 208–214.
agreed not to get into his room while the son was Weiss, R. L., Birchler, G. R., & Vincent, J. P. (1974). Con-
doing his homework. However, if the son failed to tractual models for negotiation in training marital dyads.
complete his schoolwork or lied about its comple- Journal of Marriage and the Family, 36, 321–330.
tion, the access to his electronics would be reduced
by 30 min on the first day and 30 more min every-
day if the pattern continued. If the parents got into
his room to check whether the son was doing his Contracting of Goals in Couple
homework, the son would be given 30 extra min of and Family Therapy
use of electronics. This contingency agreement
committed both the son and the parents to make Katie M. Heiden-Rootes and Rachel L. Hughes
behavioral changes that reinforced each other’s Saint Louis University, Saint Louis, MO, USA
changes and introduced specific consequences for
moments in which either party was not following
through their commitment. Synonyms
Therapeutic Alliance
Cross-References
▶ Behavioral Couple Therapy Introduction

▶ Cognitive-Behavioral Family Therapy Considered a significant portion of the therapeutic
▶ Communication Training in Couple and Family alliance*, the process of contracting goals sets the
Therapy direction therapy is proceeding in order to reduce
▶ Problem-Solving Family Therapy the presenting problem (Bordin 1979; Escudero
▶ Social Learning Theory et al. 2008).
References Theoretical Context for Concept
Bandura, A. (1971). Social learning theory. New York: The goals the client establishes are connected to a
General Learning Press. therapist’s conceptualization of the problem and
Blechman, E. A., Olson, D. H. L., Schornagel, C. Y.,
interventions – derived from the therapist’s theory
Halsdorf, M., & Turner, A. J. (1976). The family con-
tract game: Technique and case study. Journal of Con- of change (Sprenkle et al. 2009). For instance, if a
sulting and Clinical Psychology, 44, 339–455. couple comes to therapy saying that they want to
586 Contracting of Goals in Couple and Family Therapy
increase their “communication about difficult couple and family therapists (Sprenkle
topics,” a Bowenian therapist may conceptualize et al. 2009). The phrasing will also depend on
the problem as resulting from low differentiation their theory of therapy. For example, for couple
of self (e.g., fusion, pseudodifferentiation, or therapy using Emotionally Focused Therapy a
cut-off) in one or both of the partners. The thera- therapist may work with the couple to set the
pist may then proceed to explore the family his- goal of changing the cycle of conflict between
tory of fusion using a genogram to accomplish the the partners. The cycle is then named based on
Bowenian goal of increasing differentiation of self the behavior of each partner (e.g., “pursue-
of the partners and, thereby, increasing open distance”: “attack-attack,” etc.) and then specific
“communication about difficult topics.” goals about how to change the attachment strate-
Contracting for goals, then, is a joint therapeutic gies for connection will be set (e.g., soften the
endeavor where the client expresses their expec- attacker; Johnson et al. 2013).
tations or goals for therapy and the therapist uti- Creating shared goals between members in
lizes their theory of change for understanding how the couple or family is a common factor to
to accomplish the client’s goals. successful couple and family therapy (Sprenkle
et al. 2009). By establishing common goals,
participants create a shared sense of purpose in
Description the therapeutic process. The shared sense of
purpose can empower the family or couple for
The process of contracting goals sets the course of enacting necessary change in therapy but also
therapy and is an integral part of promoting when facing future problems. The therapist can
change for clients (Bordin 1979). At the start of help facilitate the creation of goals between
therapy, clients share their understanding of the discordant family members by highlighting
problem. As the clients explain, the therapist col- potentially unseen shared goals. Additionally,
lects contextual information related to the prob- different members of the client system may
lem, the impact of the problem on the client and have individual goals they pursue based on
others (e.g., partner, family, work functioning), their understanding of the problem.
and then sets the goals for therapy that would
reduce or eliminate the problem (Sprenkle
et al. 2009) or perhaps make the problem more Clinical Example
manageable. After establishing goals and a mutu-
ally respectful and trusting relationship (i.e., Jennifer entered therapy with her 13-year-old
bond), the therapist and the client work together daughter, Jessica, because of truancy issues.
to create the steps towards accomplishing the As the Structural Family therapist conducted
goals (i.e., tasks of therapy). The interdependence the assessment interview, she used circular
of the therapeutic alliance* and the components questioning to map the hierarchy and organiza-
of goals – tasks and bond – has been well tion of the family relationships. During the con-
documented in therapy (Bordin 1979). Without a versation the therapist noticed that Jennifer and
strong therapeutic alliance*, clients and therapists Jessica were describing a peer-like relationship
may struggle establishing clear and attainable where Jennifer felt like she had little parenting
goals in session. authority to respond to the truancy issues
because of how Jessica’s father (Jennifer’s
ex-husband) allowed Jessica to “have no rules”
Application of Concept in Couple at his home and because Jennifer feared losing
and Family Therapy her daughter to her father. The therapist and
family discussed a goal of allowing Jessica to
Goals for treatment in couple and family therapy “be a kid” again. Both agreed this would be a
are phrased relationally and in a process form for relief for Jessica who frequently carried
Control in Couples and Families 587
messages between her parents, saying she felt

like “their secretary” and would sometimes feel Control in Couples and
like she was getting in trouble for simply deliv- Families
ering a message. This goal also included
increasing Jennifer’s parental communication Erin Ferenchick and David Rosenthal
with her ex-husband and removing Jessica Columbia University, New York, NY, USA
from the middle of her on-going parents’ con- C
flict. The third goal required Jennifer to seek the
advice and support of her friends and family Name of Concept
instead of relying on Jessica for emotional and
social support. These goals, though not directly Control in couple and family therapy.
aimed at the truancy, did address what Jessica
said was her biggest stressor – feeling like her
parents’ “secretary” – and she was motivated to Introduction
change this aspect of the family relationships.
Increasing hierarchal structure in the family A therapist who is in control comfortably guides
allowed Jennifer to become an authority figure the couple or family through the therapeutic pro-
in the home again; Jessica maintained the posi- cess. Interruptions, couples arguing, and other
tion of the “kid” in the family and returned to behaviors that might illustrate the nature of their
school on a regular basis. relationship can at times seem disruptive. An
emphasis on control is an integral part of many
different models of therapy. In strategic family
therapy, in particular, the therapist identifies with
Cross-References the family issues that need to be worked on or
behaviors that they are interested in changing and
▶ Bonds in Couple and Family Therapy designs a strategy for each problem, taking
▶ Goal Setting in Couple and Family Therapy responsibility for what happens during therapy.
▶ Goals in Couple and Family Therapy Other models of couple or family therapy may
▶ Tasks in Couple and Family Therapy employ different approaches to gain control dur-
▶ Therapeutic Alliance in Couple and Family ing the session. Irrespective of the theoretical
Therapy position, however, evidence suggests that repli-
cating what goes on in the home or simply allo-
wing a couple to vent during the session is not
References therapeutic (Bushman 2002).
Bordin, E. S. (1979). The generalizability of the psycho-

analytic concept of the working alliance. Psychother- Theoretical Context for Concept
apy: Theory, Research and Practice, 16(3), 252.
Escudero, V., Friedlander, M. L., Varela, N., & Abascal,
A. (2008). Observing the therapeutic alliance in family Control of the therapeutic process in couple and
therapy: Associations with participants’ perceptions family therapy differs in its application within
and therapeutic outcomes. Journal of Family Therapy, the different theoretical models, including stra-
30(2), 194–214.
Johnson, S. M., Bradley, B., Furrow, J. L., Lee, A., Palmer,
tegic, structural, multigenerational, and integra-
G., Tilley, D., & Woolley, S. (2013). Becoming an tive behavioral. The concept of control,
emotionally focused couple therapist: The workbook. however, is commonly associated with strategic
Taylor & Francis. family therapy. This theory emerged in tandem
with, and out of, other theories, most impor-
Common factors in couple and family therapy: The
overlooked foundation for effective practice. New tantly structural family therapy in the late
York: Guilford Press. 1960s and early 1970s (Haley 1971).
588 Control in Couples and Families
Jay Haley and Cloé Madanes were the main Clinical Example
proponents and creators of the theory of strate-
gic family therapy. Their theory supported As the family or couple demonstrates their home
exploring how families work on a structural behaviors during a session, the therapist will
level, but also expanded this thinking by argu- respond in ways that are consistent with his or
ing that the therapist should take more initiative her approach to therapy. For example, Karen is
and control over the therapeutic process (Haley 15 years old and has been arguing with her parents
1976; Madanes 1981). about what time she needs to be home in the
evening. In addition, her school grades have
been poor, and there are reports that she is using
drugs. During the family therapy session, Karen
Description
deflects attention from her parents by “acting out”
and disrupting the therapy session. The therapist
The therapist is ultimately responsible for control-
can choose to ask the parents to discuss how they
ling the process of therapy. Control is emphasized
want to respond and guide them to gain control of
not to be pushy or manipulative but to render a
their adolescent. The therapist can also reframe
problem solvable.
the situation by discussing with Karen her diffi-
culty in getting what she wants and learning how
to best negotiate with her parents. During this
Application of Concept in Couple and situation, the therapist might even take some
Family Therapy time to “teach” Karen how to negotiate.
Similarly, in couple therapy, a husband and
The theory of strategic family therapy dictates that wife argue during the session illustrating the
the therapist controls the session and takes a more intensity of their relationship. As they are seem-
active role in changing the behavior of the family. ingly out of “control,” some therapists might
The therapist examines family processes and become immobilized by the intensity and sit
functions, such as communication or problem- quietly while others might try and “take over”
solving patterns, and identifies solvable problems, reducing the intensity for the moment but not
sets goals, designs interventions to achieve these really using the argument as a teachable
goals, and examines the responses and outcomes moment. By observing the husband and wife
of the therapy (Haley 1976; Madanes 1984). Ther- interact, the therapist is often in a better position
apeutic change is enacted when the therapist to determine how best to intervene. However, it
actively intervenes through tasks and directives also important that the situation not escalate
and attempts to substitute new behaviors for dys- such that the couple becomes abusive during
functional ones. The therapist focuses on chang- the session or the session ends without reaching
ing problem behavior rather than generating some type of closure or agreement that there will
insight. By comparison, using a structural be no violence at home. In situations where
approach, the therapist may decide to raise inten- couples have a history of violence, it might be
sity by unbalancing the couple or family system but appropriate for the therapist to see each person
still remain in control of the session by guiding the alone so he or she can determine safety before
couple or family through that intensity to a new having sessions together.
way of relating. A multigenerational couples ther-
apist, on the other hand, might use a genogram to
reduce intensity and illustrate previous patterns that Cross-References
might be impacting the relationships, while an
integrative behavioral approach might use assign- ▶ Strategic Family Therapy
ments and other behavioral strategies to structure ▶ Structural Family Therapy
the sessions. ▶ Unbalancing
Controlling Sessions in Couple and Family Therapy 589
References are: (1) viewing conflict in relational terms,

(2) broadening the system of treatment,
Bushman, B. J. (2002). Does venting anger feed or extin- (3) interrupting problematic relational patterns,
guish the flame? Catharsis, rumination, distraction,
and (4) widening the scope of the therapeutic
anger and aggressive responding. Personality and
Social Psychology Bulletin, 28, 724–731. alliance (Sprenkle et al. 2009). Emphasis remains
Haley, J. (1971). Changing families. New York: Grune & on the fundamental concept of building the thera-
Stratton, Inc.. peutic alliance and fostering trust among the ther- C
Haley, J. (1976). Problem-solving therapy: [new strategies
apist and clients. Consideration must be placed on
for effective family therapy]. San Francisco: Jossey-Bass.
Madanes, C. (1981). Strategic family therapy. San the multiple alliances for therapists working with
Francisco: Jossey-Bass. couples and families in order to effectively guide
Madanes, C. (1984). Behind the one-way mirror: Advances the therapeutic process.
in the practice of strategic therapy. San Francisco:
Jossey-Bass.
Description
Safety is a key component. Guidelines are

Controlling Sessions in Couple
established to ensure constructive interaction
and Family Therapy
among a couple or family. The therapist is charged
with intervening when guidelines are violated and
Agnes Jos1 and Jessica L. Chou2
1 reminds those present of the agreed parameters.
Community Treatment, Inc. (COMTREA),
Guidelines can be written and therefore referenced
Comprehensive Health Center, St. Louis, MO,
easily in instances where counterproductive behav-
USA
2 iors need redirection (Gurman 2008). A competent
therapist has an understanding of how much struc-
ture is needed for clients whose behaviors threaten
this safety as well as when less structure is needed
Introduction
for those with more effective communication pat-
terns (Sprenkle et al. 2009). Cultural context helps
Control refers to guiding the therapeutic process
therapists understand what maintains problems and
as opposed to the control of individuals, couples,
what types of interventions to employ; this occurs
or families (Leader 1983). The therapeutic pro-
through conversation as well as the therapist’s own
cess can include the structure of therapy, continu-
observations (Gurman 2008). During this process,
ous assessment, and collaborative goals. Control
the therapist must maintain a balance of not siding
begins at initial contact and continues through
with any one person in the couple or family.
termination.
Application of Concept in Couple

Theoretical Context for Concept and Family Therapy
Methods for guiding the therapeutic process Controlling sessions hinges on the therapist’s abil-
extend across multiple theoretical formulations ity to collaborate and be transparent with clients.
and can be contextualized using the common fac- Reappraisal of goals and on-going negotiation of
tors approach. The common factors approach the therapeutic process ensures the therapist and
posits that change in couple and family therapy clients are moving in the direction to reach desired
can occur via certain variables despite theoretical goals. When met with high resistance during var-
orientation (Sprenkle et al. 2009). Four elements ious stages of couple and family therapy, a thera-
that are distinctive in couple and family therapy pist should decrease directives (Sprenkle
that must be considered when controlling sessions et al. 2009) and utilize transparency to reassess
590 Conversation and Discourse Analysis in Couple and Family Therapy
when a change of course is needed that is agreed The therapist invested in learning about cultural
upon by the therapist and clients. In addition, the influences for Mark and Sienna to understand how
therapist can review the agreed upon guidelines those influences might impact their interactions
when one or more person begins to fall back on with each other and with the therapist. Over
behaviors or interactional patterns that have been time, the core mechanisms of safety, trust, trans-
counterproductive. While the therapist acknowl- parency, and competency all contributed to a
edges the hierarchies that exist in families, they strong therapeutic alliance that allowed for the
are not looking to level the playing field by elim- therapist to collaboratively control the sessions
inating the role of a dominant family member but in order for Mark and Sienna to improve their
rather ensure that the established hierarchies are interaction cycle and strengthen their relationship.
not perpetuating the “problem” or negative inter-
action patterns.
Cross-References
Clinical Example ▶ Control in Couples and Families

▶ Power in Family Systems Theory
Sienna and Mark entered couple’s therapy for ▶ Resistance in Couple and Family Therapy
frequent arguments over finances and parenting
styles. The couple had been together for 5 years
with one daughter, 2, and had a negative pattern of References
communication in which Sienna would become
upset and argumentative with Mark, who would Gurman, A. S. (2008). A framework for the comparative
study of couple therapy: History, models, and applica-
then proceed to walk away or dismiss her con-
tions. In A. S. Gurman (Ed.), Clinical handbook of
cerns. While the couple was working through couple therapy (4th ed., pp. 1–26). New York: Guilford
their dysfunctional pattern of communication, Press.
Mark would “shut down” and provide minimal Leader, A. (1983). Therapeutic control in family therapy.
Human Sciences Press, 11(4), 315–361.
responses to his partner and the therapist; at times
of high frustration he would not communicate Common factors in couple and family therapy: The
verbally. The therapist’s attempts to reduce com- overlooked foundation for effective practice. New
bative communication from Sienna while engag- York: Guilford Press.
ing Mark often ended in Mark becoming
disengaged in the session. Ultimately, this would
dominate the session.
The therapist worked collaboratively with Conversation and Discourse
Sienna and Mark to build a therapeutic relation- Analysis in Couple and Family
ship with the couple in order to bring balance and Therapy
control back to the therapeutic process. During
this process, the therapist was able to build trust Eleftheria Tseliou
and revisit the negative interaction that Mark and Laboratory of Psychology, Department of Early
Sienna had outside of therapy and the manifesta- Childhood Education, University of Thessaly,
tion of that cycle in therapy. Transparency was Volos, Greece
utilized as the therapist perceived resistance when
either partner would resort to old communication
patterns between each other or the therapist. This Introduction
allowed for the therapist and clients to have an
open and honest conversation about the dynamics Conversation Analysis (CA) and Discourse Anal-
present in the therapeutic process and to ensure ysis (DA) are two qualitative research methodol-
everyone was moving towards the same goals. ogies argued as a promising choice for systemic
Conversation and Discourse Analysis in Couple and Family Therapy 591
couple and family therapy research. CA and DA central role of language for the constitution of
share the emphasis on language, context, and every phenomenon, thus approaching knowledge
interpersonal communication for the understand- as a historically and sociopolitically situated con-
ing of human interaction and psychological struction. This turn to discursive, intersubjective
phenomena that systemic pragmatic and construc- practices and the acknowledgement of the impor-
tionist approaches endorse. They are also part of tance of understanding them from an insider’s/in
the hermeneutic/qualitative research methodol- situ perspective, links with the development of C
ogy tradition, which has incorporated the call for language-based research methodologies, like CA
methods attentive to participants’ own under- and DA (Wooffitt 2005).
standing of the phenomena under study. This
tradition has also attended to the constructionist
emphasis on discursive interaction as the locus for
the construction of any phenomenon (Wooffitt Conversation Analysis
2005). Such epistemological proposals have led
to the development of naturalistic, observational, CA was developed in sociology by Harvey Sacks
and language-based approaches in psychotherapy and his associates in the 1960s and 1970s (see
research. Schegloff 2007 for an overview). It incorporated
In couple and family therapy research, there basic premises of the ethnomethodological tradition,
have been calls for research methodologies which like the emphasis on adopting an endogenic, i.e.,
can attend to the epistemological and theoretical participants’ own, perspective for the understanding
particularities of the field, like the emphasis on of the social world. CA constitutes a rigorous meth-
recursiveness and interactional patterns. Accord- odological approach, suitable for the study of natu-
ingly, for the last few decades, a growing number rally occurring, every day or institutional, talk-in-
of couple and family therapy studies have interaction. It offers systematic and sophisticated
deployed CA and DA mostly for therapy process ways for the detailed, microanalysis of conversa-
research (Tseliou 2013). However, their use still tions, utterance by utterance, which exemplify the
remains marginal, whereas the fragmented and interdependence between them, in the sense that
methodologically flawed picture of their deploy- each utterance is shown as dependent upon the
ment necessitates a more thorough and indepth previous one and as constitutive of the next one.
exploration of their potential for couple and fam- A basic CA premise is that talk is indexical,
ily therapy research. i.e., depends upon context and has a reflexive
quality, in the sense that it entails markers which
indicate how each speaker has interpreted the
Definition and Historical Evolution other’s utterances. CA also adheres to the idea
that talk exhibits ordinariness and structure in
CA and DA are part of the hermeneutic/qualitative that there are normative rules for the organization
research tradition which started flourishing in the of conversation, which can be identified via anal-
humanities and social sciences in the 1960s. The ysis. When such rules are breached, then speakers
variety of qualitative research methods reflects var- become socially accountable, like when one
iant choices of epistemological perspectives, i.e., rejects an invitation by his/her coconversant
perspectives about the “how” in the quest of knowl- (Wooffitt 2005).
edge and the relationship between the subject CA allows for the capturing of how the social
(observer/researcher) with the object (of knowl- world is coconstructed by people in conversation.
edge). These extend from realist ones adhering to Some of its basic notions are “turn-taking” which
the reality of an objective world existing “out there,” denotes the taking of turns by speakers as they
to relativist, constructivist/constructionist proposals. alternate between the role of the speaker and
The latter acknowledge the interdependency the role of the listener, “adjacency-pair”
between the observer and the observed and the which denotes how utterances are organized in
interdependent pairs, where when the first part is Poststructural DA, like Foucauldian Discourse
uttered the second is expected (e.g., question- Analysis (FDA), usually entails a macroanalytic
answer) and the notion of “preference structure” approach, in that it aims at identifying wider sets
which denotes that there are socially or norma- of historically and discursively constituted mean-
tively preferred responses (e.g., acceptance of an ings/constructs, i.e., Discourses, which are consid-
invitation instead of rejection) (Schegloff 2007). ered as constitutive of subjectivities. It further
CA is an ideal choice for the pursuing of identifies how dominant institutional and political
research questions which aim at investigating contexts shape language use and thus our lives.
conversational structures and/or the ways in Thus, texts are analyzed with the aim to bring to
which social actions are conversationally the fore these subjugating aspects of language.
coconstructed. Further to the extensive body of Michael White’s narrative approach is similarly
CA empirical research which has contributed to endorsing a poststructuralist perspective by
our knowledge of conversational structures in highlighting the oppressing aspects of discourse in
many settings, CA has also been deployed in respect of psychological distress.
psychotherapy research. There is a growing DPsy has gone through different phases of
body of CA studies which have investigated development, including Critical DPsy which
various aspects of the therapeutic conversation has incorporated Billig’s theorizing on ideolog-
across models, like the use of formulations by ical dilemmas and a recent, more CA affiliated,
the therapist, i.e., of statements where the ther- perspective (see Potter 2012 for an overview). It
apist offers a version of his/her understanding of has contributed a discursive, interactional
client’s previous utterance (Peräkylä approach to psychological phenomena like
et al. 2008). memory, cognition, attributions etc., evidently
departing from mainstream psychological theo-
ries. For DPsy, language use reveals how
Discourse Analysis speakers construct social actions and attend to
interpersonal aims. In that sense, it shares basic
DA is a term denoting a variety of approaches premises of pragmatic approaches, like Austin’s
for the study of written or spoken discourse or Wittgenstein’s which have equally inspired
which have an interdisciplinary flavor as they systemic, communication approaches (Tseliou
include proposals from linguistics, psychology, 2013). DPsy also entails a strong, rhetorical
education, sociology, etc. (Wooffitt 2005). Most aspect in that it adheres to the idea that we
approaches share social constructionist pre- engage into argumentative “language games”
mises in that they acknowledge that language trying to construct our version of the world as
constructs phenomena whereas shapes and is the “real” one and not a subjective, biased one.
shaped by sociopolitical and historical condi- DPsy also adheres to the ethnomethodological
tions (Tseliou 2013). In psychology, DA notion of social accountability, according to
approaches were developed in the 1980s by which we are held accountable for our talk,
social psychologists like Jonathan Potter, Mar- concerning both our choices to make certain
garet Wetherell, Derek Edwards, Michael Billig, reports but also their content. DPsy analysis
and Ian Parker. DA approaches which have been includes a micro, detailed emphasis on both
inspired by poststructural thinking (see Parker the content but also the structure of discourse
2015), like Foucault’s theorizing, emphasize the which heavily leans on CA methodological
constitutive and restraining aspects of language. contributions.
DA approaches, like Discursive Psychology Like CA, DA and DPsy have been deployed
(DPSy) (Potter 2012), which have incorporated for psychotherapy research, illuminating of our
the ethnomethodological flair of CA, mostly understanding of the therapeutic dialogue
focus on how people use language to achieve details but also of the institutional aspects of
interpersonal aims. the psychotherapeutic establishment. Due to
Conversation and Discourse Analysis in Couple and Family Therapy 593
their potential for both a micro- and a macro- Conversation Analysis, Discourse
analytic perspective, CA and DA are suitable for Analysis, and Couple and Family
the pursuing of research questions aimed to Therapy Research
investigate how therapeutic interventions or
the therapy process overall get constructed in Couple and family therapy process research has
the minute-by-minute interaction between ther- deployed a variety of quantitative but also quali-
apist(s) and family members. They are also a tative research methodologies including C
good choice for the pursuing of research ques- languaged-based approaches. In this context, a
tions, which aim at addressing the political and growing body of CA and DA research of couple
institutional aspects of psychotherapeutic and family therapy (see Tseliou 2013 for an over-
discourse. view) has evolved in the context of recent devel-
As concerns quality criteria, CA/DA research opments in discursive research methodologies
adheres to the criteria defined for constructionist, (e.g., Borcsa and Rober 2016; Tseliou and Borcsa
qualitative research which include analytic coher- in press). These studies have explored significant
ence, the analysis of deviant cases, the grounding of issues like problem talk in initial family therapy
analysis on participants’ orientation, the evaluation sessions in respect of blame allocation/attribution
of readers on the basis of the provision of transcripts of responsibility for the reported problem(s), col-
alongside with analysis, etc. (see Potter 2012 for a laboration and or alliance, certain therapeutic
discussion). techniques or notions like circular questioning or
neutrality, shifts in agency or subjectivity
concerning the identified patient, etc.
Couple and Family Therapy Research However, existing CA and DA research of
couple and family therapy is fragmented as there
There is a variety of models and approaches clus- seems to be no systematic pursuing of the study of
tered under the term “couple and family therapy,” notions which could lead to consistent theory
most of which are affiliated with the systemic building. Furthermore, it seems to suffer from
paradigm in psychotherapy. Systemic couple and methodological shortcomings like inconsistencies
family therapy is a constantly evolving field with between the pursued research question(s) and the
various proposals for the relief of psychological research design (Tseliou 2013). Also, most of the
distress. Like in research methodology, the field studies usually lean on the analysis of a very
has incorporated the constructionist turn to lan- limited sample of data due to the methods’ labo-
guage which gave rise to discursive approaches rious “nature.” In that sense, CA and DA research
like the collaborative, the dialogic, etc. of couple and family therapy is still “work in
The field’s evolution has witnessed a number progress.” Nevertheless, the existing examples
of tensions, including fervent debates evolving are revealing of CA and DA potential. These
around the most “appropriate” choice of research methodologies can facilitate analysis of the thera-
methodologies for couple and family therapy peutic dialogue in ways attentive to the recursive-
research. These have culminated in often unfruit- ness of therapist/couple and family members’
ful quantitative versus qualitative debates as well interaction. Furthermore, they can illuminate
as strict divides between process and outcome us – in a very systemic way – on how therapeutic
research. Recently pluralism has been forwarded interventions are implemented in the context of
and more inclusive proposals have argued for a therapist and client joint dialogue. In that sense,
both/and perspective like in the case of sugges- they can become valuable tools for the develop-
tions for the study of process as small outcomes or ment of therapist reflexivity as they can highlight
change-process research. In parallel, the need for minute by minute the ways in which therapist
observational methods attentive to the complexity interventions are delivered and responded by fam-
of the multiactor dialogue in the family therapy ily members (Tseliou 2013). Additionally, they
setting has been stated emphatically. can alert us to the ways in which the institutional
aspects of couple/family therapy get downplayed ▶ Qualitative Research in Couple and Family
in the “here and now” of therapist / family mem- Therapy
bers’ interaction. ▶ Research About Couple and Family Therapy
▶ Research in Relational Science
▶ Social construction and Therapeutic
Examples of CA, DPsy, and FDA of Practices
Couple and Family Therapy ▶ Social Constructionism in Couple and Family
Therapy
The following studies constitute three indicative ▶ White, Michael
examples of the deployment of CA, DPsy, and
FDA for the study of couple and family therapy.
Muntigl and Horvath (2016) aiming to study
References
therapist-family members’ alliance, used CA to ana-
lyze the first 5 min of a transcribed, videotaped Borcsa, M., & Rober, P. (Eds.). (2016). Research perspec-
session of family therapy, conducted by Salvador tives in couple therapy: Discursive qualitative methods.
Minuchin for training purposes. Their analysis high- Cham: Springer International.
lights in detail the conversational practices by means Muntigl, P., & Horvath, A. O. (2016).
A conversation analytic study of building and repairing
of which the therapist repairs a rupture in alliance the alliance in family therapy. Journal of Family Ther-
with family members. It also indicates how struc- apy, 38, 102–119. https://doi.org/10.1111/1467-
tural family therapy techniques like joining or 6427.12109.
accommodating are conversationally constructed Parker, I. (Ed.). (2015). Critical discursive psychology
(2nd ed.). London: Palgrave Macmillan.
and serve to the establishment of positive alliance. Patrika, P., & Tseliou, E. (2016). Blame, responsibility and
Patrika and Tseliou (2016) explored problem talk systemic neutrality: A discourse analysis methodology
in nine, initial, Milan – systemic family therapy to the study of family therapy problem talk. Journal of
sessions. Their DPsy analysis exemplified how ther- Family Therapy, 38(4), 467–490. https://doi.org/
10.1111/1467-6427.12076.
apist attempts for relational problem definitions by Peräkylä, A., Antaki, C., Vehviläinen, S., & Leudar,
means of circular questioning or the final team- I. (Eds.). (2008). Conversation analysis and psycho-
message intervention seem entangled within blame therapy. Cambridge: Cambridge University Press.
sequences, as family members seem to decode such Potter, J. (2012). Discourse analysis and discursive psy-
chology. In H. Cooper (Ed-in-Chief), APA handbook of
therapist discursive moves as instilling blame on research methods in psychology, (Research Designs,
them for the reported problem(s). Vol. 2, pp. 119–138). Washington, DC: American Psy-
Sutherland et al. (2016) used FDA to analyze chological Association. https://doi.org/10.1037/13620-
transcripts of three videotaped, systemic/construc- 008.
Schegloff, E. (2007). Sequence organization in interaction.
tionist couple therapy sessions conducted at a family A primer in conversation analysis I. Cambridge: Cam-
therapy training center by therapy trainees. Their bridge University Press.
aim was to investigate heterosexual couple partners’ Sutherland, O., Lamarre, A., Rice, C., Hardt, L., & Jeffrey,
discursive interactions for traces of the ideology of N. (2016). Gendered patterns of interaction:
A Foucauldian discourse analysis of couple therapy.
sexism. Their analysis provides exemplars of the Contemporary Family Therapy, 38, 385–399. https://
operation of gender inequality discourses in partic- doi.org/10.1007/s10591-016-9304-6.
ipants’ talk, seemingly reproducing gender inequal- Tseliou, E. (2013). A critical methodological review of
ity in partners’ positioning. discourse and conversation analysis studies of family
therapy. Family Process, 52(4), 653–672. https://doi.
org/10.1111/famp.12043.
Tseliou, E., & Borcsa, M. (in press). Discursive methodol-
Cross-References ogies for couple and family therapy research: Editorial
to special section. Journal of Marital and Family
Therapy.
▶ Foucault, Michel Wooffitt, R. (2005). Conversation analysis and discourse
▶ Postmodernism in Couple and Family Therapy analysis: A comparative and critical introduction.
▶ Process Research in Couple and Family Therapy London: Sage.
Co-parenting in Couple and Family Therapy 595
and the other parent feels frustrated, burned

Co-parenting in Couple and out, and all alone managing the majority of
Family Therapy the parenting responsibilities;
4. Intense unresolved marital conflicts or irrecon-
Matthew D. Selekman cilable differences and the parents being sepa-
Partners for Collaborative Solutions, Evanston, rated or divorced
IL, USA 5. Are having grave difficulty working together C
as a co-parenting team.
Introduction Over time, the aforementioned problem-

maintaining couple role behaviors described
Family therapy pioneers, researchers, and parenting above can fuel vicious cycles of destructive
experts alike have found that when there is consis- blame-counter-blame interactions between the
tent parental teamwork and unity with providing partners, and one or both partners possibly
nurturance to and consistent limits for their children recruiting their most loyal child, adult sibling,
when they misbehave, their kids are more likely to their own parent, or extended family member to
thrive and function well in all areas of their lives join them in a coalition against the other partner.
(McHale and Lindahl 2011; Minuchin and Fishman When this couple dynamic occurs, it is not
1981; Haley 1976; Minuchin 1974; Satir 1983; Sax uncommon for one or more of the parents’ chil-
2016; Taffel 2009; DeFrain 2007; Omer 2004). This dren to become the symptomatic family member
parenting style described above is well researched (s) that brings them to a therapist’s office.
and known as authoritative parenting (Baumrind
1966; Larzelere et al. 2013). Additionally, the stron-
ger the parents’ bonds are with their kids, the better Description
they will be able to cope with life’s challenges; self-
regulate their moods; are more self-motivated and Co-parenting in couple and family therapy
self-confident; have more self-control; tend to be involves the therapist assessing with the parents
more resilient; less likely to develop anxiety and the level and quality of their parental teamwork
depressive symptoms or engage in self-destructive, and unity and assisting them with further honing
aggressive, and delinquent behaviors; or join nega- their parenting skills and becoming even more
tive peer groups (Selekman 2010, 2017; Selekman unified as a team in helping them to resolve their
and Beyebach 2013; Diamond et al. 2014; Kang symptomatic child’s or children’s behavioral prob-
2014; Alexander et al. 2013; Szapocznik et al. 2012; lems. If they contract to work on parenting diffi-
Liddle 2010; Henggeler and Sheidow 2011; Taffel culties, it is most beneficial to first invite the couple
2009; Seligman et al. 1995). to identify any pre-counseling changes they have
When parents seek couple and family therapy already made that can be amplified and consoli-
around parenting issues, there often is a lack of dated; find out what their key individual, couple
parental teamwork and unity due to the following parenting, family strengths are that can be utilized
couple dynamics: in problem areas; and explore with them what their
past successes as a parental team have been. Any
1. One parent is too permissive and the other past successful couple-generated problem-solving
parent tries to be ultra-strict; strategies at resolving past difficulties with their
2. One parent is overly responsible and protec- children can be used as blueprints for future suc-
tive, while the other parent is peripheral and cess in resolving current difficulties that may be
too emotionally disconnected from their part- occurring with them. As they become more unified
ner and the kids; as a parental team and increase their successes with
3. One parent may have serious mental health, their kids, we want to encourage them to do more
substance abuse, or physical health problems, of what works.
596 Co-parenting in Couple and Family Therapy
Major Couple and Family Change Strategies is instructed to play detective using his or her
With some parents rigidly entrenched in imaginary magnifying glass to carefully
longstanding negative interactions with one observe for the times when the other parent is
another, have little or no teamwork, and have engaging in specific parenting responsibilities
grave difficulty identifying any past or present that he or she thinks were well managed, crea-
successes or entertaining the possibility of future tive, and produced positive outcomes with the
success as a team, there are three highly effective children, write them down and bring his or her
therapeutic options that can be pursued. They are: list to the next session. This information can be
exchanged and discussed in the next couple or
1. Separate the couple partners and establish family session to determine together what
separate goals and work projects geared works and needs to be increased. In many
toward changing their negative interactions cases well before the next scheduled appoint-
with one another and how they interact with ment, the observing parent will have already
the symptomatic child. The use of the spontaneously either complimented the other
do-something-different experiment or other parent at least once or on multiple occasions or
pattern intervention strategies (De Shazer even joined in and supported him or her in
et al. 2007; Selekman and Beyebach 2013; disciplining one of the children who was test-
Selekman 2009, 2010, 2017; Cade and ing their limits or acting out.
Hudson-O’Hanlon, 1993) is a very effective 3. Another therapeutic option that can be pursued
therapeutic option. The do-something- with couples that have a long history of being
different experiment involves having one or oppressed by specific intergenerational parent-
both partners respond in surprising and novel ing practices and rigid patterns of interactions
ways when triggered by their other partner with each other and their children is to exter-
that he or she has never experienced from nalize the parenting practice or pattern
him or her before. The experimenting part- (Selekman 2017; White 2007). When parents
ner(s) are to keep track of what works in report in our sessions finding themselves fall-
disarming or altering the other partner’s neg- ing prey to these practices or patterns and the
ative behaviors. These strategies are particu- ways they have been wreaking havoc in their
larly helpful with high-conflict couples relationships with one another and inadver-
where conjoint work early in treatment pro- tently fueling more acting out behaviors from
ves to be counterproductive. Once the emo- their children, we can ask them the following
tional climate becomes more relaxed and the questions:
intensity of the couple conflicts have greatly • “Tell me, when you were growing up, did
decreased, we can bring the partners back ‘yelling’ get the best of you and your rela-
together and establish a mutual tionship with your parents?”
treatment goal. • “What effect did ‘yelling’ have on
2. If on a random basis the partners work together you – your thoughts and feelings towards
or one parent is stuck in the dominant discipli- your parents?”
narian role while the other parent is too under- • “After ‘yelling’ did its dirty work, did you
involved or laissez-faire, the couple can be find yourself being more or less cooperative
given an intervention that has a random com- with your parents’ wishes?”
ponent to it, such as: flipping a coin daily and • “In what ways has ‘yelling’ infiltrated and
the heads partner is completely in charge of all tried to tear apart your relationship with
of the disciplining for that day or on odd days Cindy (daughter)?”
of the week, one partner handles all of the • “Has there been any times lately where you
disciplining, and on the even days the other could sense ‘yelling’ was tempted to push
partner takes over this responsibility. With you and Cindy around but you thwarted it
both of these interventions, the day off parent instead?”
• “What specifically did you do to frustrate it (1966). In her research, she identified three par-
and not cave into its wishes to make you enting prototypes or styles of adult control, they
lock horns with Cindy?” are: permissive, authoritarian, and authoritative.
• “What did you tell yourself to pull that off?” Permissive parents tend to adopt a hands-off par-
• “Are there other helpful things you tell enting style where there is a lack of consistent
yourself or do to outsmart ‘yelling’ at limit setting, or if it is minimal, there is a lack of
times?” concern about their children’s impulse control, C
affective expression, little concern about their
Once parents are onboard with viewing the children’s poor decision-making and the conse-
parenting practice or pattern as the real culprit quences of their actions, and a strong belief that
behind their difficulties, it helps foster more pos- children should be independent and free of
itive interactions and teamwork in both their rela- restraint. On the opposite end of the parenting
tionship and their relationships with their kids. To continuum are authoritarian parents. They tend
help ensure that the oppressive parenting practice to be very controlling, may squelch their chil-
or pattern is conquered for good, we can have dren’s desires for more autonomy, uphold rigid
them implement a habit control ritual to help rules and standards, and may dish out harsh,
foster more teamwork and changes in their family lengthy, and extreme consequences for mis-
relationships (Selekman 2010, 2017; Selekman behavior. According to Baumrind (1966), the
and Beyebach 2013; Durrant and Coles 1991). most ideal style of parenting is authoritative,
I have the couple or family come up with both a which combines the best elements of permissive
team name for them and a name for the oppressive and authoritarian parenting. Authoritative parents
parenting practice or pattern. As a team, they are work well together as a team in consistently pro-
to keep track daily of the various things they do to viding a nurturing and positive family environ-
stand up to and achieve victories over the oppres- ment but, when necessary, set immediate limits
sive parenting practice or pattern. They are also to and enforce their consequences when their chil-
keep track of the parenting practice or pattern’s dren misbehave.
victories over them. This information can be In studying a wide range of families from dif-
recorded daily on a chart. Nightly after dinner, ferent cultural and socioeconomic backgrounds,
they are to get together to discuss how well they DeFrain (2007) has identified six characteristics
are working together as a team and how to further of strong families: appreciation and affection for
minimize the likelihood of surprise attacks by the each other, commitment to each other, positive
sneaky parenting practice or the pattern. We can communication, successful management of stress
have them train together through some form of and crisis, enjoyable time together, and spiritual
cardio exercise and/or weightlifting in order to well-being. He and his colleagues developed
have the endurance and physical strength to con- questionnaires to administer to each family mem-
quer the longstanding parenting practice or pat- ber to gain access to their unique perspectives on
tern for good. the level and quality of how much or little each of
these six characteristics exist in their families.
This information can prove invaluable to family
Relevant Research therapists in that we can learn what their key
family strengths are, examples of the use of
The research literature on co-parenting is quite these strengths in action, and past family or paren-
extensive. For the sake of brevity, this discussion tal successes at problem-solving that can be
is limited to ways to enhance co-parenting team- tapped for resolving their current presenting diffi-
work and create a positive and nurturing climate culties. Finally, there may be one or more of these
ripe for healthy child development in multiple family strengths families may wish to further cul-
family environments. One of the first pioneering tivate or hone that can be incorporated into their
co-parenting researchers was Diana Baumrind treatment plan.
598 Co-parenting in Couple and Family Therapy
When it comes to parents in the divorcing most challenging behaviors, which can be
process or in the postdivorce transitional phase revisited in a future conjoint parenting session
with their children, family research has indicated once their anger and conflict levels have greatly
that parental conflict can have a deleterious effect decreased. Additionally, the therapist can see each
on their children’s development and adjustment to parent separately with the kids to address the
the divorce (Pruett and Donsky 2011; Pruett and latter’s adjustment to the divorce situation and
Pruett 2009; Marquadt 2006; Wallerstein 2004; any other day-to-day difficulties they may be
Isaacs et al. 2000). According to Pruett and experiencing in their relationships with one
Donsky (2011), the co-parenting mantra we need another or at school (Isaacs et al. 2000). It is
to encourage divorcing and divorced parents to important to remind the parents that in order to
adopt is: “It is all about the kids.” As therapists we help their kids in the best way possible to adjust to
have to help parents put aside their past conflicts the divorce process, they need to refrain from
and issues with one another and strive to support bad-mouthing the other parent or recruiting one
one another’s parenting actions and decisions, or more of the kids to take their side against the
make and stick to agreements about how to raise other parent and treat each other as civilly as
their children, and to the best of their abilities possible when they are together in the kids’ com-
refrain from undermining each other by deviating pany. Wallerstein (2004) observed from her lon-
from these agreements on their own without any gitudinal research that children adjust well to
warning or discussion. parental divorce when the parents are civil and
respectful toward one another in their company
and when they work together as a parenting team,
Special Considerations for Couple and which fosters in the children a strong sense of
Family Therapy security, resilience, and higher self-esteem. Once
the parents are in a much better emotional place to
There are two major and common clinical situa- work together, we can resume conjoint parenting
tions that can lead to a breakdown in couple unity and/or family therapy sessions and address com-
and teamwork, they are: parents entering the mon concerns and other difficulties they may be
divorce process with high conflict and/or post- experiencing with their kids.
divorce lack of cooperation and parental In some cases, in spite of conducting separate
remarriage and stepfamily adjustment difficulties. parent and parent-children subsystem sessions,
Below, I discuss each of these clinical challenges one or more of the children are still experiencing
and propose therapeutic strategies for addressing emotional or behavioral difficulties. When this
these treatment dilemmas. is the case, it can be most advantageous to coach
one or both of the parents to abandon their
Parents Entering the Divorce Process with unproductive ways of interacting with the
High Conflict and/or Postdivorce Lack of other parent or the children and experiment
Cooperation with the do-something-different change strat-
When parents either enter the divorce process egy described earlier in this chapter (De Shazer
with high conflict or have already divorced, due et al. 2007; Selekman 2017). Another challenge
to their intense rage and bitterness toward one that the custodial parent may experience with
another, it may prove to be futile to see them their kids following a visit with the noncustodial
together initially. With these clinical situations, it parent is that they come back home agitated or
is much more practical to meet with each partner act up. We need to help the custodial parent
alone, establish separate parenting goals and work come up with a few different rituals or activities
projects, and listen carefully for any common to engage the children in for easing the transi-
ground where there is parental agreement involv- tion of their return back home. Finally, in spite
ing their kids’ needs and the management of their of our Herculean efforts to help the divorcing or
divorced parents work together around the kids lead to a child or children developing symptoms
and we are unsuccessful, we need to make our- or behavioral difficulties. This will need to be
selves available to each parent, provide support, addressed in family therapy.
and continue to try separate parent-children sub-
system sessions to help each parent and the
children better cope and adjust to this challeng-
ing family life cycle transition. References C
Alexander, J. F., Waldron, H. B., Robbins, M. S., & Neeb,
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887–907.
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De Shazer, S., Dolan, Y., Korman, H., Trepper, T.,
most critical is the need for the parents to continue McCollum, E., & Berg, I. K. (2007). More than mira-
to strengthen their relational bond and be very cles: The state of the art of solution-focused brief ther-
clear with one another about who will have what apy. Binghamton: The Haworth Press.
parenting responsibilities, what the household
Attachment-based family therapy for depressed adoles-
rules and consequences are going to be for the cents. Washington, DC: American Psychological
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approach. In T. C. Todd & M. D. Selekman (Eds.),
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Family therapy approaches with adolescent substance
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take the lead in disciplining their own biological Bacon.
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mon challenge for stepparents is to try and balance
Isaacs, M. B., Montalvo, B., & Abelsohn, D. (2000). Ther-
out their time and love for their own children apy of the difficult divorce: Managing crises,
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their stepchildren. The parents also have to work dren, and expediting court processes. Northvale:
Jason Aronson.
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Kang, S. (2014). The self-motivated kid: How to raise
one another. A final challenge remarried partners happy, healthy children who know what they want
face is working together with their ex-partners and and go for it without being told. New York: Jeremy
their new partners around parenting needs, rules, P. Tarcher.
Larzelere, R. E., Morris, A. S., & Harrist, A. W. (2013).
and expectations for the children. The more con-
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and with their communications, the more DC: American Psychological Association.
smoothly and better the children will adjust to Liddle, H. A. (2010). Treating adolescent substance abuse
using multidimensional family therapy. In J. R. Weisz
their new reconstituted families. When both sets
& A. E. Kazdin (Eds.), Evidence-based psychother-
of parents are unable to work together and the two apies for children and adolescents (pp. 416–435).
households operate in opposing ways, this may New York: Guilford Press.
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Marquadt, E. (2006). Between two worlds: The inner lives

of children of divorce. New York: Crown Books. Coping-Oriented Couple
McHale, J. P., & Lindahl, K. M. (2011). Introduction:
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Lindahl (Eds.), Co-parenting: A conceptual and clin-
ical examination of family systems (pp. 3–12). Kevin K. H. Lau1, Chun Tao1, Ashley K. Randall1
Washington, DC: American Psychological and Guy Bodenmann2
Association. 1
Minuchin, S. (1974). Families and family therapy. Cam- Counseling and Counseling Psychology,
bridge, MA: Harvard University. Arizona State University, Tempe, AZ, USA
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Minuchin, S., & Fishman, H. C. (1981). Family therapy Department of Psychology, University of Zurich,
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to violent and self-destructive children. Cambridge,
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divorce: Paving pathways for parental cooperation,
conflict resolution, and redefined family roles. In J. P.
McHale & K. M. Lindahl (Eds.), Co-parenting: Coping-oriented couple therapy (COCT;
A conceptual and clinical examination of family sys- Bodenmann 2004) is a treatment model that
tems (pp. 231–267). Washington, DC: American Psy- emphasizes the role of stress communication and
chological Association. mutual support in couples. COCT posits that
Pruett, K., & Pruett, M. K. (2009). Partnership parenting:
How men and women parent differently – Why it helps experiences of chronic minor stressors (i.e.,
kids and can strengthen your marriage. Boston: inconveniences occurring on a day-to-day basis
DaCapo Books. that may irritate partners over time) often trigger
Satir, V. (1983). Conjoint family therapy. Palo Alto: Sci- unpleasant behaviors in partners, which can then
ence & Behavior Books.
Sax, L. (2016). The collapse of parenting: How we hurt our give rise to relationship tension. Thus, the goal of
kids when we treat them like grown-ups. New York: COCT is to help partners better understand their
Basic Books. individual and joint stress reactions and learn to
Selekman, M. D. (2017). Working with high-risk adoles- cope with daily stressors more effectively, which
cents: An individualized family therapy approach.
New York: Guilford Press. can significantly improve their relationship func-
Selekman, M. D. (2010). Collaborative brief therapy with tioning and overall well-being.
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Selekman, M. D. (2009). The adolescent and young adult
self-harming treatment manual: A collaborative
strengths-based brief therapy approach. New York: Prominent Associated Figures
Norton.
Selekman, M. D., & Beyebach, M. (2013). Changing COCT was derived from Dr. Guy Bodenmann’s
self-destructive habits: Pathways to solutions with
seminal work on couples’ stress and coping. Spe-
couples and families. New York: Routledge.
Seligman, M.E.P., Reivich, K., Jaycox, L., & Gilliam, J. cifically, the systemic-transactional model of
(1995). The optimistic child: A revolutionary pro- dyadic coping, which posits that romantic partners
gram that safeguards children against depression can engage in joint coping efforts to mitigate the
and builds lifelong resilience. Boston, MA:
deleterious effects of stress on their relationship
Houghton Mifflin.
Szapocznik, J., Schwartz, S. J., Muir, J. A., & Brown, C. H. (Bodenmann 1995, 2005), stimulated the creation
(2012). Brief strategic family Therapy: An intervention of this treatment model.
to reduce adolescent risk behavior. Couple and Family
Psychology, 1(2), 134–145.
Taffel, R. (2009). Childhood unbound: Saving our kids’
best selves—confident parenting in the world of Theoretical Framework
change. New York: The Free Press.
Wallerstein, J. S. (2004). What about the kids? Raising The COCT approach has its foundation in behav-
your children before, during, and after divorce.
ioral and cognitive-behavioral couples therapies
New York: Hachette Books.
White, M. (2007). Maps of narrative practice. New York: and thus aims to alter partners’ maladaptive
Norton. behaviors and cognitive processes in their
Coping-Oriented Couple Therapy 601
relationships. Moreover, it builds upon the classi- argument with his/her significant other (Partner
cal cognitive-behavioral couples therapy B). As stress often triggers presentations of indi-
(Baucom et al. 2008) to address the negative viduals’ negative personality traits (e.g., domi-
impact of stress on relationship functioning by nance, rigidity, intolerance, neuroticism; Randall
facilitating romantic partners’ communication of and Bodenmann 2009), understanding how stress
stress (i.e., stress-related self-disclosure) and and personality traits affect relationship dynamics
engagement in coping behaviors (i.e., dyadic cop- may allow couples to develop strategies in over- C
ing). Specifically, this treatment model aims to coming conflicts and emotional distance. Indeed,
train partners to recognize their unique reactions therapists adopting the COCT approach strive to
to stress and to enhance their stress communica- enhance mutual understanding for seemingly dys-
tion and dyadic coping abilities. functional stress reactions that often are experi-
Practitioners adopting this model have three enced as bothering and frustrating by the partner.
main roles: (1) to supervise and facilitate stress Dyadic coping. The process of dyadic coping
communication and support giving (e.g., originates when the partner experiencing the
establishing speaker and listener rules), (2) to stress (Partner A) communicates the stress ver-
guide both partners in exploration of their emo- bally or nonverbally to his/her significant other
tions and insecurities by asking open-ended ques- (Partner B). Partner B will then evaluate Partner
tions (e.g., “How was this for you?”; Why did you A’s stress and respond with a range of actions,
feel sad?”; “What meaning does it have for varying from offering positive support to negative
you?”), and (3) to provide clear structure in regard responses. Positive dyadic coping entails provid-
to the time frame, setting, and speaker and listener ing support that could alleviate some of the part-
roles (Bodenmann and Randall 2012). It is impor- ner’s stress, and there are three types: emotion-
tant for therapists to coach both partners simulta- focused supportive dyadic coping (i.e., providing
neously and to give each one equal attention. emotional support and empathic understanding),
problem-focused supportive dyadic coping (i.e.,
Core Concepts of Model giving practical advice and helping the partner to
Stress in intimate relationships. Stress is an see situations in a new light), and delegated
excessively common experience that can result dyadic coping (i.e., taking on extra responsibili-
in relationship discord. Early work in the couples’ ties to lessen the partner’s workload). On the other
stress literature has focused on the impact of inter- hand, negative dyadic coping refers to partners’
nal stress (i.e., stress that originates within the reactions to each other’s stress in hostile, ambiv-
relationship, such as conflicts arising from a dif- alent, or superficial ways. In addition, another
ference of opinion between partners) on relation- form of dyadic coping – common dyadic
ship well-being. While internal stress plays an coping – depicts partner’s joint coping efforts
important role in close relationships, recent stud- (e.g., searching for shared solutions together) in
ies have found that external stress (i.e., stress that the face of stress that affects both partners directly,
comes from outside of the relationship, such as such as stress from children or financial burden.
work and everyday inconveniences; Randall and By engaging in positive dyadic coping, partners
Bodenmann 2009, 2017) has a stronger negative can improve the relationship in two ways:
association with relationship outcomes like com- (1) by relieving the stress and (2) fostering inti-
munication quality between partners and relation- macy and solidarity between the partners
ship satisfaction (e.g., Bodenmann 2005; (i.e., we-ness). Notably, COCT places more
Falconier et al. 2015). For instance, when Partner emphasis on how partners can help each other
A experiences a strenuous day at work, he/she cope with external stress. Such stress often affects
may come home in an agitated mood. As Partner one partner (Partner A) directly and the other
A carries his/her stress over into this relationship partner (Partner B) indirectly due to shared
with his/her agitated mood, he/she may be more interdependence (Kelley 1979). The partner who
likely to initiate or become involved in an is not experiencing the stress directly (Partner B)
is therefore trained to minimize their negative from a clear perspective and to practice ways of
dyadic coping behaviors (e.g., invalidating Part- acting against it by using the clear structure pro-
ner A’s feelings) that they may use to respond to vided by psychoeducation and the three-phase
their partner and, rather, respond with more method, which are discussed below.
emotion-focused (e.g., empathy, encouragement),
problem-focused (e.g., reframing the situation), or
delegated support (e.g., taking on Partner A’s
responsibilities) to help Partner A alleviate stress.
Couples experiencing relationship or marital dis-
Theory of Change
tress can benefit from COCT. This form of treat-
COCT assumes that couples experience relation-
ment can also be applied to couples in which one
ship distress because they do not fully understand
of the partners is depressed (Bodenmann
the role of stress in their relationship. In therapy
et al. 2008) or suffers from another clinical diag-
sessions, therapists educate partners on the detri-
nosis (e.g., anxiety disorder, sexual functioning
mental effects of stress, help partners identify their
disorder, eating disorder).
unique responses to stress, as well as practice
communication, problem solving, and support
giving. This will allow them to becoming more
aware of signs of stress originating from inside or Strategies and Techniques Used
outside their relationship and learn effective com- in Model
munication and coping strategies during times of
stress in their daily lives. The more they under- Techniques used in COCT are psychoeducation
stand and practice, the more their relationship will regarding stress and stress reactions and the three-
improve. phase method. As this form of treatment is derived
from behavioral and cognitive-behavioral couple
Rationale for the Model therapy, techniques such as enhancement of recip-
External stress can have a major negative impact rocal positivity, communication and problem-
on relationship functioning (Randall and solving training, cognitive interventions, and
Bodenmann 2009, 2017); therefore, it is important acceptance work are also utilized. These strategies
for partners to adopt effective coping strategies to are typically used during the beginning sessions to
counter against it. However, many existing thera- help partners rebuild their trust and commitment
peutic approaches do not explicitly mention stress in each other. These conditions must be met
(e.g., traditional behavioral couple therapy), and before partners begin the three-phase method
the ones that do focus on internal stress (e.g., because there needs to be a high level of trust for
insight-oriented couple therapy). COCT is one of partners to be able to disclose emotionally and
the first forms of therapy to address issues arising provide effective support.
from external stress (as well as internal stress) and Psychoeducation. The psychoeducation por-
emphasize the role of dyadic coping in coping tion of COCT aims to help partners learn more
with this type of stress. It builds upon the strengths about themselves and each other, as well as the
of previous, well-established models by integrat- impact of stress on their relationship. It is critical
ing the focus on personal assumptions and beliefs for couples to understand that chronic minor
from cognitive-behavioral couples therapy, the external stressors can cause the relationship to
idea of partners accepting and appreciating each slowly deteriorate (often by increasing feelings
other’s differences from integrated behavioral of alienation) and that engaging in positive dyadic
couple therapy, and the attention to teaching part- coping can mitigate this deleterious effect
ners to learn new aspects about themselves from (Bodenmann 2004). When stress occurs, individ-
emotionally focused couple therapy (Bodenmann uals may have adverse reactions and exhibit some
2004). COCT allows couples to understand stress unpleasant behaviors such as stubbornness or
Coping-Oriented Couple Therapy 603
anxiety. These undesirable behaviors can trigger listens and summarizes. A Therapist’s role at this
relationship conflicts and lead to increased dissat- stage is to encourage deeper emotional disclosure
isfaction in partners over time. by asking open-ended questions and to coach the
In COCT, couples learn that daily stressors speaker in his/her self-disclosure as well as the
often trigger individual personality traits or per- listener in his/her active listening and accurate
sonal insecurities thus resulting in negative stress summaries. Phase 2 consists of Partner
reactions (Bodenmann and Randall 2012). For B providing support specific to the stress that C
instance, Partner A may think, “I am only loved Partner A is experiencing. Typically this involves
when I perform well,” so whenever something emotion-focused support (e.g., providing under-
happens to threaten his/her performance, he/she standing, empathy, encouragement), followed by
will falsely believe to be unloved and will there- problem-focused support (e.g., reframing the sit-
fore act destructively toward Partner B. These uation). This phase should last approximately
schemata or patterns of thought are unique in 10 min. Finally, in Phase 3, Partner A offers feed-
everyone. Thus, an integral component of the back for 5 min on the support that Partner B just
COCT involves helping partners gain a deeper provided regarding his/her satisfaction with the
understanding of their individual differences and support and its efficacy. After this, the partners
personal vulnerabilities in order to build tolerance will switch roles so both of them get equal
and acceptance toward each other. Doing so will amounts of time and attention in each therapy
allow partners to reinterpret each other’s stress session, which lasts a total of 90 min for both
reactions as signs of needing support, which partners in both roles.
would bring them together rather than drive
them apart during stressful times. In the case of
couples in which one partner is suffering from Research about the Model
depression or similar conditions, psychoeducation
may also include teaching partners of depressed Bodenmann and colleagues (2008) compared
patients the difference between beneficial support the effectiveness of COCT with that of
and support that could reinforce depressed symp- cognitive-behavioral therapy (CBT) and inter-
tomatology (Bodenmann et al. 2008). personal therapy (IPT) in a randomized clinical
The three-phase method. The purpose of the trial with 60 depressed outpatients. The CBT
three-phase method is to provide structure to part- approach was individual oriented and focused
ners’ stress communication and support giving. on correcting faulty cognitive assumptions
Speaker and listener rules are especially important about the self, the world, and the future. The
when using this technique to ensure partners are IPT consisted of both individual and couples
not interrupted as they are disclosing emotional therapy sessions and incorporated the explora-
and possibly difficult information. Therapists tion of affect as well as cognitive-behavioral
work with the couple to establish mutual respect, techniques such as interpersonal analysis and
positivity, and commitment in their relationship, communication training. COCT was solely
critical foundations to assist partners in develop- couple-oriented and highlighted the role of
ing and practicing stress-related communication, dyadic stress communication. By the end of
and dyadic coping skills via the three-phase the study, all patients had attended therapy for
method. It is critical to note that the three-phase a total of 20 hours and were found to experience
method takes place in later sessions in the therapy less depressive symptomatology across all three
process because an adequate amount of trust and conditions. Further, there were no significant
respect between the partners must exist for them differences between the decreases in depressive
to confide in one another about their stressful symptomatology between the three treatment
experiences. In Phase 1, Partner A (the speaker) groups, indicating that COCT was as effective
describes his/her stress for 30 min, while Partner in treating depression as the well-established,
B (the listener), prompted by the therapist, quietly evidence-based CBT and IPT.
Contrary to the authors’ hypotheses, there were her. This resulted in many nights of them not
also no differences found in self-reported relation- speaking to each other. At the recommendation
ship quality and dyadic coping between the three of their friends and family, they decided to see
groups (Bodenmann et al. 2008). This was an Dr. M, a therapist trained in COCT.
unexpected finding because previous literature In the beginning, Dr. M taught the couple about
had indicated that the treatment effect on depres- how stress that is external to the relationship can
sion was mediated by relationship well-being often trigger partners’ personal vulnerabilities,
(Bodenmann et al. 2008). Bodenmann and col- which may drive partners apart. Dr. M also pro-
leagues (2008) suggested this could be due to the vided communication and problem-solving train-
use of the time-limited version of COCT in this ing. He observed that the partners actually trust
study or because couples recruited for this study and care about each other but have issues with
were not highly maritally distressed so treatment communicating their stress and thus coached them
effects on relationship well-being were less pro- using the three-phase method. In Phase
nounced. However, they found that partners of 1, Samantha recounted her stress from work due
depressed patients in the COCT condition showed to employees being laid off and her having to take
improvements in another aspect of relationship on more responsibilities. Dr. M and Mark listened
functioning, expressed emotions (i.e., reductions and encouraged her to disclose emotionally. She
in open criticism of patients), and this effect was stated that she felt overwhelmed but did not want
not found among those attending CBT or IPT. to burden Mark about it when in reality, she
Another finding was that while the three condi- wanted more support from him. Then, in Phase
tions had similar recovery rates ranging from 37% 2, Mark told Samantha that he heard that
to 47% at posttest 2 weeks after treatment, relapse Samantha had been experiencing a lot of stress
rates at the 1.5-year follow-up were the lowest in from the recent layoff at her work and the
the COCT group (i.e., 28.6% in COCT as opposed increased workload, which must have been over-
to 42.9% in CBT and 62.5% in IPT), although this whelming to her (i.e., empathetic understanding,
difference was not statistically significant. Addi- an approach of emotion-focused supportive
tional results showed that expressed emotions dyadic coping). Mark shared that he had mis-
mediated the association between COCT and interpreted her behaviors as signs that she no
relapse rates. In other words, couples that received longer cared and promised to check in with her
COCT reported enhanced abilities in expressed every night after work. While he may not be able
emotion, which, in turn, were associated with to fix her problems at work, he would try his best
lower likelihood of experiencing relationship dis- to support her emotionally and take on her respon-
tress 1.5 years after therapy. Taken together, these sibilities at home (i.e., delegated dyadic coping).
results suggest that COCT may promote the main- Additionally, Mark asked if this could be an
tenance of gains even after treatment ends because opportunity for Samantha and him together to
of improvements in couples’ expressed emotions. make positive changes in their relationship (i.e.,
problem-focused dyadic coping). Finally, in
Phase 3, Samantha remarked that hearing Mark’s
Case Example responses made her feel much better and having
Mark’s support would indeed be helpful to her and
Mark and Samantha have been married for 3 years their relationship in the long run. Next, Mark took
and have no children. Mark is a writer and stays at the speaker role and shared his stress experiences,
home most of the time, while Samantha works at while Samantha became the listener following the
an accounting firm. For the past several months, three-phase method.
both of them have become increasingly dissatis- After treatment, although Samantha was still
fied with their marriage. Mark has noticed that experiencing stress from work she was more will-
Samantha would often come home in an irritable ing to confide in Mark and seek his support. In
mood and as a result he has been timid to approach return, Mark listened to her concerns attentively
Cost-Benefit Ratio in Couple and Family Therapy 605
and completed more chores at home to alleviate Kelley, H. H. (1979). Personal relationships: Their struc-
her stress. The couple continued to hone their ture and processes. Hillsdale: Erlbaum.
Randall, A. K., & Bodenmann, G. (2009). The role of
communication and support-giving skills using stress on close relationships and marital satisfaction.
the 3 phases Dr. M taught them, and they saw Clinical Psychology Review, 29(2), 105–115. https://
improvements in their relationship as well as per- doi.org/10.1016/j.cpr.2008.10.004.
sonal well-being. Randall, A. K., & Bodenmann, G. (2017). Stress and its
associations with relationship satisfaction. Current
Opinion in Psychology, 13, 96–106. http://doi.org/10.
C
1016/j.copsyc.2016.05.010.
Cross-References

▶ Communication Training in Couple and Family
Therapy Cost-Benefit Ratio in Couple
▶ Couples Coping Enhancement Training and Family Therapy
Enrichment Program
▶ Psychoeducation in Couple and Family Donna Baptiste, David Kitchings and
Therapy Kelsey Kristensen
▶ Systemic-Transactional Model of Dyadic The Family Institute at Northwestern University,
Coping Evanston, IL, USA
▶ We-ness in Couple and Family Therapy
Name of Concept
References
Cost-Benefit Ratio
Baucom, D. H., Epstein, N., LaTaillade, J. J., & Kirby, J. S.
(2008). Cognitive behavioral couple therapy. In
A. S. Gurman & N. S. Jacobson (Eds.), Clinical hand- Synonyms
book of couple therapy (4th ed., pp. 31–72). New York:
Guilford.
Bodenmann, G. (1995). A systemic-transactional concep- Benefit-Cost Ratio
tualization of stress and coping in couples. Swiss Jour-
nal of Psychology, 54, 34–49.
Bodenmann, G. (2004). Verhaltenstherapie mit Paaren
[Cognitive behavioral therapy with couples: Coping- Introduction
oriented approach]. Bern: Huber.
Bodenmann, G. (2005). Dyadic Coping and its significance
The cost-benefit ratio (also referred to as the
for marital functioning. In T. A. Revenson, K. Kayser,
& G. Bodenmann (Eds.), Couples coping with stress: benefit-cost ratio) is a concept borrowed from
Emerging perspectives on Dyadic Coping (pp. 33–49). fields of economics and finance and applied to
Washington, DC: American Psychological Associa- interpersonal relationships. Economists and
tion. https://doi.org/10.1037/11031-002.
finance professionals use the cost-benefit ratio
Bodenmann, G., & Randall, A. K. (2012). Common factors
in the enhancement of dyadic coping. Behavior Therapy, as a numerical indicator of the profitability of an
43, 88–98. https://doi.org/10.1016/j.beth.2011.04.003. endeavor. The higher the ratio, the better the
Bodenmann, G., Plancherel, B., Beach, S. R. H., Widmer, investment and goals are to maximize benefits
K., Gabriel, B., Meuwly, N., . . ., Schramm, E. (2008).
(also termed returns or rewards) relative to costs
Effects of coping-oriented couples therapy on depres-
sion: A randomized clinical trial. Journal of Consulting (or inputs). Social Exchange theorists were the
and Clinical Psychology, 76(6), 944–954. https://doi. first to apply cost-benefit principles to human
org/10.1037/a0013467. relationships. In brief, Social Exchange theory
Falconier, M. K., Jackson, J., Hilpert, J., & Bodenmann,
suggests that, consciously or subconsciously,
G. (2015). Dyadic coping and relationship satisfaction:
A meta-analysis. Clinical Psychology Review, 42, people appraise relationships to determine
28–46. https://doi.org/10.1016/j.cpr.2015.07.002. their relative benefits or rewards as well as
606 Cost-Benefit Ratio in Couple and Family Therapy
costs (Emerson 1976; Nezu and Nezu 2016). Description

When people view benefits as high, they are
apt to be satisfied and to value relationships. Cost-benefit principles offer a plausible frame-
Correspondingly, subjective views of relation- work to assess and treat couple dissatisfaction,
ships as costly or nonrewarding lead to distress although there are nuances in applying these
and disconnection. ideas across the relationship spectrum. For exam-
ple, a couple enters a romantic union expecting a
reciprocal contract in which each partner holds
Theoretical Framework him/herself and the other accountable for creating
an enjoyable and mutually beneficial union
Starting in the 1960s, family science sociolo- (Emerson 1976). Benefits of the relationship
gists promoted Social Exchange schema to may include love, companionship, affection, sup-
explain patterns in human relationships and port, sex, or financial security. Costs of the rela-
made several assumptions about how costs and tionship might include loss of independence,
benefits operate (Chibucos et al. 2005). First, conflict, and asset-sharing. Research suggests
each person in a relationship seeks to meet that the most costly dynamics may be constant
his/her own needs, in other words, look out for fighting, chores, jealousies, secrets, and tensions
his/her own best interest. Second, each person with extended family. In monogamous unions,
wants to maximize benefits or rewards and forgone opportunities to romantically pursue
decrease costs. Rewards might be actual or sym- others might also be considered as a cost
bolic attitudes or actions that people desire uni- (Emerson 1976; Crosby 1989).
versally (e.g., love or care) or idiosyncratic Cost-benefit principles suggest that partners
actions that people prefer (e.g., a certain type will keep investing in the relationship expecting
of praise). Costs might be punishments (e.g., favorable, or at least acceptable, rewards for what
hostility or nonresponsiveness) or forfeited they are giving up. Each can maintain a relatively
rewards (e.g., another relationship). Inherently, optimistic outlook so long as the cost-benefit bal-
power and competition shape social exchanges ance remains satisfactory to high. This dynamic
as each person seeks to meet his/her own needs occurs when partners get their needs met or feel
(Chibucos et al. 2005). Third, cost-benefit reinforced positively for their contributions.
assessments lead people to value equality and Alternatively, if the relationship becomes too
reciprocity, and both are related to relationship costly or one or both partners feel that their inputs
satisfaction. People tend to be more satisfied in are unappreciated, one or both might disengage
relationships in which they perceive they are which can then lead to a decrease in highly valued
getting as much as they put in. They are also benefits such as affection and intimacy. Cost-
more satisfied in relationships they deem recip- benefit assessments may play out in everyday
rocal, that is, based on give-and-take. In this interactions as couples evaluate and reinforce
regard, constant comparing is a natural dynamic each other. Cost-benefit appraisals also play out
in close and intimate relationships, and in such over time in understanding the union’s worth and
relationships driven by social exchanges, cost- viability. Such appraisals might explain why some
benefit appraisals are inevitable. couples stay together, and others disengage or
Social Exchange paradigms, as described dissolve (Crosby 1989; Schacter et al. 2012).
above, offer a formula to assess and treat issues Some have suggested that cost-benefit princi-
in couples and families, and a skillful couple or ples are inadequate to explain a range of couple
family therapist can utilize cost-benefit princi- dynamics, for example, why couples remain in
ples to improve bonds and in doing so, improve long-term unions although they are deeply hurt.
relationship satisfaction and longevity In such high-cost relationships, couples choose to
(Chapman and Compton 2003; Chibucos stay together perhaps because the alternative (e.g.,
et al. 2005). dissolution or singleness) seems worst. Likewise,
Cost-Benefit Ratio in Couple and Family Therapy 607
cost-benefit principles may not account for exter- Cost-benefit principles are also useful to cou-
nal stressors that impact relational stability. Inter- ples seeking to invigorate relationships and in
nal couple dynamics may be satisfactory, but an premarital counseling. The emphasis is on behav-
external stressor can alter partners’ understanding ioral exchanges that increase each partner’s posi-
of themselves and destabilize the union. tive experience and perceptions of relational
Researchers also suggest that predictors of rela- value. Techniques might focus on helping each
tionship satisfaction and dissatisfaction may oper- to reinforce desirable behaviors through warm C
ate independently and not as interdependently as attentiveness and responding and to increase the
cost-benefit principles suggest. Finally, some balance of positive to negative interactions over-
characterize cost-benefit explanations as mecha- all. The therapist might especially target negative
nistic, ignoring the complex range of factors that interactions (high-cost actions) because of their
inform relational choice (Chapman and Compton links to relationship deterioration. The therapist
2003; Crosby 1989; Schacter et al. 2012). might coach a couple in behavior-exchange such
In parent-child relationships, cost-benefit prin- as caring days, that is, particular days in which
ciples can also explain interaction patterns, still each partner enacts positive behaviors requested
centered on relational benefits or costs. While by the other. The therapist might facilitate behav-
assessments of costs may rarely lead parents or ioral contracts, for example, “quid pro quo”
children to end relationships, per se, such assess- arrangements where both exchanges desired
ments can seed patterns of reactivity, sourness, actions, also “good-faith” contracts where each
and disconnection. takes responsibility to treat the other well regard-
less of reciprocation. The idea is to make small
adjustments in which each partner experiences the
Applying the Cost-Benefit Ratio in other pleasantly, altering the affectional climate
Couple and Family Therapy (Nezu and Nezu 2016; Vernon 2012).
The therapist might educate premarital cou-
In behaviorally focused and other couple thera- ples on negative or aversive behaviors that lead
pies, an obvious application of cost-benefit prin- to poor relationship outcomes. Also, couples
ciples is helping dating couples to validate their should be trained in effective communication,
selection of the current partner (versus another). problem-solving and conflict resolution tech-
A therapist might help couples to examine their niques to increase their capacity to avoid grid-
social exchanges for principles of equity, reci- lock and to repair ruptures. Such techniques
procity, and personal satisfaction. Couples might help to maintain a high ratio of positive to neg-
also be coached on trading high-value actions that ative interactions such that partners might
influence long-term commitment. Another obvi- assess the relationship as a good investment
ous application is helping couples on the brink of (Nezu and Nezu 2016).
dissolution to decide if to stay together. This issue In applying cost-benefit principles to parents
often comes up in couple therapy where one part- and children, family therapists might help parents
ner feels uncertain about the relationship and con- and youth to increase behaviors that the other
templates separation or divorce, while the other considers “high-value” because parents and
wants to save the union. With such uncertainty, youth can often see things differently. Parents, in
the therapist might suspend treatment-as-usual to particular, are prone to ignoring how their young-
lead the couple in a discernment process, typically sters view things and while parents may see their
a cost-benefit assessment, of the historical, own actions as positive and helpful (e.g., guiding
cognitive, emotional, behavioral, and spiritual and instructing) young people may interpret the
components of the relationship. This process is same actions negatively (e.g., as intrusive and
usually brief, and some therapists use a structured nagging). The mismatch in perceptions can fuel
approach such as a cost-benefit inventory (Crosby conflicts and a therapist may need to reframe and
1989; Vernon 2012). reconcile these points of view. Therapists can also
608 Cost-Benefit Ratio in Couple and Family Therapy
help parents and youth to commit to high-value unhappy, sentiments he felt beginning 6 years
attitudes and actions in everyday communication, ago. He thought that he would outgrow these
conflict resolution, and decision-making that feelings, but they persisted. David insisted that
increase the overall ratio of positive to negative he was not interested in any other person and
encounters. Josie believed him but feared that he would have
Additionally, therapists may help families to an affair. Josie wanted the marriage and felt that
uncover relational imbalances, that is, patterns of she was with her life partner, though there were
dependency, unhelpful reinforcements, and pun- things that bugged her about David. The therapist
ishments that feed a climate of conflict and nega- validated the suffering of each and suggested
tivity. For example, most parents accept their three to four sessions of discernment therapy
unbalanced roles in family life, taking on burdens with partners in sessions together and also
of providing, care-giving, and decision-making. alone. The goal was to undertake a thorough
But as children grow towards adulthood, parents cost-benefit assessment of the relationship. The
expect to share responsibilities with their children. therapist used a semi-structured tool to help the
Persistent dependency in young adults or parental couple address several questions in sessions and
overreach in young adults’ decisions are signs of between -session through writing assignments. At
imbalance that can make one or both devalue the end of this period, it seemed clear that David
relationships. Sibling conflicts can also be driven assessed the “cost” of remaining in the marriage
by imbalance and inequality, for example, paren- as high and he was more committed to dissolving
tal favoritism of one child. This may be a costly the relationship. Deeper explorations also
dynamic linked to sibling conflict and therapists revealed that the couple had married young and
may need to promote norms of fairness, reciproc- as their identities evolved, they grew apart. They
ity, and power sharing to restore balance. buried this disconnection in work and routines
with extended families. David had deep feelings
of guilt and shame but also felt self-compassion
Clinical Application and growing resolve. After wrestling with the dis-
tress of these insights, the couple made the painful
In couple therapy a rigorous cost-benefit evalua- decision to separate and shortly after that to
tion of relationship trouble can help partners to divorce. They committed to having integrity in
decide on an outcome as the following vignette the process. The therapist also encouraged
illustrates. boundaries that allowed each to find what
Josie and David, married for 12- years, sought he/she needed to deal with the loss.
therapy to decide if to stay together or divorce. In this vignette above, cost-benefit principles
They seemed miserable, exhausted, and stuck. In offer a plausible framework to understand rela-
the past 6 months, they alternated between high tionship dissatisfaction that explains why one
tension conversations, disconnection, and pas- partner became discontented. In this instance, the
sionate make-ups with neither feeling a sense of couple chose divorce as a resolution. But had they
resolution. Each declared deep love for the other, chosen to repair their relationship, cost-benefit
but David often added a disclaimer that he loved principles still apply. The therapist might have
Josie but was not “in love” with her. The couple’s used the cost-benefit evaluation as a springboard
plans to purchase a home and get pregnant also for behavioral interventions in which both part-
stalled. Two years ago, they were congratulating ners take responsibility to increase the value of the
themselves on their 10-year anniversary, a mile- relationship to each. One approach may have been
stone that many of their friends did not achieve. to use a variety of techniques and strategies to
Six months later, after attending a Men’s weekend help the couple to increase the positive to negative
retreat, David confessed to being bored and ratio of their interactions, and this requires
Countertransference in Couples Therapy 609
attention to everyday social exchanges (Chapman

and Compton 2003; Crosby 1989; Schacter Countertransference in
et al. 2012). Couples Therapy
In sum, most are familiar with the principle of
“gaining a high return on investment,” and this Florence W. Kaslow
metaphor aligns well with cost-benefit principles Kaslow Associates, Palm Beach Gardens,
in couple and family relationships. The cost- FL, USA C
benefit framework does not account for the com- Florida Institute of Technology, Melbourne,
plexity of relationship actions, reaction, or deci- FL, USA
sions which other constructs may better explain.
However, an enduring perspective is that people
invest in relationships that they find valuable and Introduction
disinvest when relationships are costly. Helping
family members to maintain a low cost-high ben- This article explicates various theoretical perspec-
efit ratio might then be key to increasing their tives in the vast array of couples’ treatment modal-
relational satisfaction long term. (Nezu and Nezu ities. It presents an historical overview of major
2016). schools of thought and highlights the phenomena
of transference and countertransference. Several
difficult kinds of patient populations where these
Cross-References twin phenomena are apt to occur are discussed
illustratively. The intertwined, reciprocal complex
▶ Behavioral Couple Therapy dynamics of transference and countertransference
▶ Behavior Exchange Theory are core elements.
▶ Contingency Contracting in Couple and Family “Countertransference” is used to denote the
Therapy clinician’s reactions to patient transferences
▶ Social Exchange Theory which arise unexpectedly from the therapist’s
own unresolved feelings towards his or her par-
ents and/or siblings. These emotional responses
References usually encompass unconscious projections of
thoughts and feelings connected to one’s own
Chapman, A. L., & Compton, J. S. (2003). From traditional family members onto clients. Such reactions, trig-
behavioral couple therapy to integrative behavioral
gered in the therapist, are attributable to the fact
couple therapy: New research directions. The Behavior
Analyst Today, 4(1), 17–25. that how a client acts, looks, expresses his
Chibucos, T. R., & Leite, R. W., with Weis, D. L. (Eds.). thoughts and emotions, or the information the
(2005). Readings in family theory. Thousand Oaks: patient provides ignite submerged emotions and
Sage Publications.
Crosby, J. F. (1989). When one wants out and the other
memories in the therapist which interfere with
doesn’t; Doing therapy with polarized couples. Bristol: remaining neutrally engaged with the couple’s
Brunner/Mazel. problems and transactions. Such reactions are
Emerson, R. M. (1976). Social exchange theory. Annual spontaneous and initially outside of the realm of
Review of Sociology, 2, 335–362.
conscious awareness (Tansey and Burke 1989).
Nezu, C. M., & Nezu, A. M. (2016). The oxford handbook
of cognitive and behavioral therapies. New York: Transference and countertransference dynam-
Oxford University Press. ics are conceptualized as reciprocal and
Schacter, D., Gilbert, D., Wegner, D., & Hood, B. (2012). unresolved phenomena that can only be
Psychology: European edition. New York: Palgrave
comprehended by considering both mainstreams
Macmillan.
Vernon, A. (2012). Cognitive and rational-emotive behav- of this interplay (Kaslow 2001). When one’s coun-
ior therapy with couples. New York: Springer. tertransference becomes conscious, it can be
610 Countertransference in Couples Therapy
positive or negative. Therapists sometimes decide comparison to corresponding interpersonal ones,

to share their countertransference reactions by and that the definition of unconscious should be
providing candid feedback when they believe dis- paralleled by one of the conscious roots of experi-
closing their emotional responses to the material ence, the unreal contrasted with the real, and the
and the behavior of the couple individually and as sequences of past, present, and future
a system will prove illuminating to them. acknowledged.
Ackerman disagreed with Freud’s practice of
isolating the patient from his family and not
Theoretical Context for Concept including the patient’s significant others in treat-
ment when it seemed warranted so the clinician
The terms transference and countertransference could engage in direct observation of the interac-
do not appear in the conceptual base of some tions and not just hear one person’s version of
theoretical schools. Practitioners of approaches these. He postulated that given that the roots of
such as Rational Emotive Therapy (RET) (Ellis transference stem from early and repetitive inter-
et al. 1989), Narrative Therapies (Goolishian and actions, that the real people involved in the rela-
Anderson 1990), and Cognitive-Behavioral Ther- tional conflicts should become part of the
apies (Lazarus 1981) do not discuss these intan- therapeutic dialogue. Freud thought such an
gible phenomena as they assume these do not involvement in psychoanalysis would be a dan-
exist or eschew their significance. The following gerous interference. Conversely, Ackerman came
discussion is predicated upon some of the major to believe Freud’s position had contributed to
theories that incorporate these interlocking con- creating a schism between the individual and the
cepts and one that explains why it is not social, and the conscious and unconscious.
incorporated. Instead he reasoned that the therapist should
enable patients to free themselves of symptoms
and suffering while also fashioning a process
Psychodynamic and Object Relations through which each could create a new sense of
Couples Therapy self conducive to a more fruitful, dynamic bond
with one’s family and society. These principles of
Ackerman (1958), one of the founding fathers of inclusion of key family members in the live treat-
psychodynamic family therapy, posited in Trans- ment process became the substance of the theo-
ference and Countertransference (Bloch and retical foundation which still underlies
Simon 1982, p. 65) how difficult these concepts psychodynamic couple and family therapy.
are to define and that they convey an element of In light of the new knowledge gleaned in the
mystery. He formulated a theoretical shift from post Freudian years, Ackerman (1974) came to
the one person conceptual model foundational to believe that the real issue was not whether the
psychoanalysis to encompass a philosophy of a analyst has or exhibits feelings, but which emo-
two person social reality in therapy in which tions to convey to the patients to facilitate their
transference and countertransference are per- healing; and that for true healing to eventuate, the
ceived as reciprocal and intertwined processes. comprehension of emotions has to flow in both
Herein the therapist observes the interaction of directions. He also realized that the therapist
two individuals and two minds when treating the should sift through his reactions and inject only
couple conjointly. In such a dyadic system, there those emotions that he believes the patient(s) need
is a circular interchange of feelings that provides to hear and experience in order to improve.
the potential to recast the therapeutic context into When Ackerman (1961) was pioneering seeing
an expanded model that encompasses the dynamics couples conjointly, his ideas were considered rev-
of the several personalities in the relationship. olutionary. “Clinical analysts believed doing cou-
Within this biopsychosocial model, he believed ples therapy would be problematic because of the
that intrapsychic events had to be viewed in serious complications caused by multiple
transference and countertransference issues that be manifestations of countertransference. In

would arise” (Kaslow 2001, p. 1031). In the ensu- response, patients, sensing the therapists’ counter-
ing 50 years practitioners of the psycho- transference may act out, regress, unconsciously
dynamically oriented branch of couples’ therapy, try to help their therapist – or abruptly terminate.
including approaches predicated on object rela- Slipp (1988) believed that a dynamic interplay
tions theory, consider transference and counter- between the intersubjective worlds of the family
transference integral dynamics in the therapeutic and clinician occur in object relations family ther- C
relationship. apy and that the clinician’s recognition of the
Alexander and Van der Heide (1997) posited family’s processes of splitting and projective iden-
that few therapeutic situations stir up such tification, which the numerous transferences and
disturbing countertransference reactions as countertransferences herald, are necessary.
patients’ expressions of rage and aggression. Object relations psychodynamic therapy has
When these emotions are exhibited, their great been found to be conducive to a greater degree
intensity can provoke overwhelmingly strong of closeness if the therapist discloses his counter-
reactions in and from the therapist. Becoming transference reactions. However, if this is done
aware of and processing these responses can pro- too soon, it can be detrimental, so timing is of
vide the clinician with a richer understanding of the essence. One must be careful to guard against
the pair’s relational dynamics. How the therapist promoting symbiotic closeness, or it’s opposite,
interprets the origin and role of these affects can narcissistic distancing, which may occur if indi-
have a powerful impact on how he responds to viduation and autonomy are overemphasized
them. By sharing the premise with patients that while sensitivity and empathy are minimized.
anger and aggression usually stem from early Mendelsohn (2011) attempted to expand the
relational patterns and may be reactivated in later concept of projective identification from its
intense emotional relationships and observing being viewed as a phenomenon seen primarily in
their reactions, much needed insight may be gar- those with severe character pathology to one also
nered by all. These can be interpreted to help used to illuminate a frequent process of commu-
hostile, embattled couples cope with their destruc- nication between intimates. He elaborated the
tive, fury-based interactions. It is imperative that term projective identification to refer to a psycho-
clinicians be cognizant of their own wellsprings of logical process through which a person attempts
anger and how to convert their reactions into to achieve greater emotional balance by engaging
feedback in the service of the patient’s growth in a complex projection that involves an interac-
and healing of relational schisms. tive process between two people. One makes
Similarly, in his discussion on countertransfer- assumptions about the beliefs, feelings, and inten-
ence in object relations family therapy, tions of “the other,” and these often lead to their
Slipp (1988) stated that the therapist should behaving “as if” these assumptions are true. In
attempt to be aware of his reactions to the patient’s couples therapy each projects unwanted thoughts,
family and that when disconcerting feelings are actions, and emotions onto their partner and
experienced, realize this usually signals underly- ignores the significance and role of this projective
ing countertransference reactions. These may blaming; this type of interaction often typifies
include hostility, anxiety, boredom, rescue fanta- sessions held with borderline couples.
sies, an urge to withdraw, or a wish to control. He highlights the importance of the therapist
Behaviors on the therapist’s part such as siding using his countertransference reactions to these
with one couple or family member against antagonistic, provocative behaviors and the inher-
another, engaging in sadistic or masochistic inter- ent demands that the other comply with a partic-
actions with a certain family member, dreaming ular role expectation, which is often assigned so
about the family, tampering with the structure of that the partner represents a replica of a parental or
treatment (e.g., shifting from conjoint to concurrent sibling figure from childhood. In dysfunctional
therapy), coming late or missing appointments may marriages these role assignments are rigid and
may be “contagious” (Mendelsohn 2011, p. 397) Bowenian Systems Therapy

in that the therapist may inadvertently engage in
projective identification and respond like one of A brief mention of Bowen, who like the behav-
the patients, acting as a stand-in for one of their iorists did not believe in transference and counter-
original condemning parents. When the clinician transference, is in order here because of his
realizes what is transpiring, he may defend against prominent position in the first generation of fam-
these intense feelings with a sense of superiority ily therapists and the longevity of his body of
and/or disdain; defensive distancing may be work promulgated by respected followers. In
attempted but is unlikely to be effective. But it Bowen’s classic Family Therapy in Clinical Prac-
raises the therapist’s awareness about what “bad- tice (1988), transference and countertransference
disdainful-unloving feelings” each member of the are not mentioned, nor are these concepts alluded
dyad probably experienced as a child and are now to in other early references on systemic family
reenacting in their marriage. Mendelsohn (2011, practice. Bowen dismissed these elusive interac-
p. 238) concludes that using the therapist’s aware- tions as if they did not occur. His theory
ness of the countertransference as a source of infor- highlighted the family of origin and he focused
mation is the most effective way to work with these on coaching patients to deal with the actual family
couples; it helps the therapist to avoid the pitfall of members. He did not perceive transference of
blaming and/or taking sides (this is often what each unresolved and unconscious remnants of feelings
patient’s projective communication is trying to from childhood onto the clinician as significant;
achieve) and enables him to tolerate the intense therefore, these were not a therapeutic concern.
feelings activated by the interactions. Followers of Bowenian theory and therapy still
The major focus of this kind of couple’s ther- adhere to the belief that emotions are more apt to
apy needs to be the couple’s projective identifica- be expressed or acted out to the real significant
tions so that they can see how they communicate others present in the therapy room, or during a
through inciting. One result of such a focus is that voyage home to visit family of origin members,
it will prevent each member of the triad (each than to the clinician as a surrogate figure or trans-
member of the dyad plus the therapist) from ferential object.
enacting old pathological patterns of relating that
can artificially heighten or dampen feelings in
therapy. This formulation adds to the earlier liter- Experiential Family Therapy
ature about the dynamics of borderline couples
and the efficacy of utilizing one’s countertransfer- A third pioneer in the first generation of family
ence reactions to illuminate and facilitate the therapists, Whitaker, along with several col-
healing process. leagues, wrote a core treatise on countertrans-
Object relations and psychodynamic couples ference in family therapy (Whitaker et al. 1965).
therapists use their own reactions to the family’s They stressed that the therapist should be
interaction processes (objective countertrans- involved emotionally “in” the family, but not
ference) to comprehend the shared but “of” the family, and should be able to identify
unspoken experiences of each family member separately with each individual member. To
about these patterns (unconscious family sys- facilitate this process of identification, they
tem of object relations) (Kaslow et al. 1999, recommended that the clinician reflect on expe-
p. 771). These responses are transformed in riences they personally had that were similar to
such a way that the therapist can interpret to those of the family members and ponder “what
the family how the interpersonal patterns it has would I like and need if I were that person?”
created over time to induce one (or several) (Nichols and Schwartz 1995, p. 308). They
member to act in a specific, maladaptive man- hypothesized that becoming aware of the
ner, (for example, a scapegoated child) continue answer could help guide the therapeutic
to have repercussions. interventions.
Whitaker emphasized that sharing feelings self-disclosure should be engaged in consciously

with patient families would help minimize the and deliberately when the therapist thinks it will
destructive potential for acting out of counter- be beneficial for clients. Lankton et al. (1991,
transference emotions more than if they were p. 259) indicate she thought these disclosures
kept hidden. He posited that to be able to achieve should take the form of therapeutic stories,
and maintain the emotional distance necessary to which are partially designed by borrowing from
remain objective with the family (or couple), one personal experience or may be ascribed to C
should work with a co-therapist or use a consul- another, who is spoken about in the third person.
tant in vivo to protect himself from becoming too This technique helps the therapist maintain appro-
emotionally embroiled. He personally often used priate distance and decreases the likelihood that
a co-therapist, male or female, very effectively – the story will introduce countertransference ele-
as evidenced in his writings and videotapes ments that would be too revealing. Ericksonian
(Napier and Whitaker 1978). therapists magnify the importance of clinicians
Experiential family therapists believe that being aware of what they convey to clients
among the best antidotes to countertransference and what conscious and unconscious reactions
reactions are excellent professional training, expe- are evoked (Erickson and Lustig 1976). In
rience, and supervision to be immunized against Ericksonian therapy, such self-disclosure, incor-
side taking. Another proscribed factor is for the porated within a therapeutic metaphor or other
therapist(s) to have a satisfying personal life so as broader therapeutic interventions, is perceived
to reduce the probability of trying to gratify his as a way to focus emotions, attitudes, and
own personal needs through and from clients. actions designed to stimulate clients. Erickson
highlighted the criticality of managing one’s
own countertransference in order not to direct
Contextual Therapy therapy in a manner geared to serving the needs
of the therapist rather than those of clients. There
The concept of countertransference historically seem to be many similarities about the utilization
has been interpreted quite differently in contextual of one’s awareness of and interpretation of coun-
therapy than in classical Freudian treatment. tertransference in the work of Erickson and
Boszormenyi-Nagy, another family therapy pio- Whitaker. However, each was considered a
neer, and colleagues were convinced that counter- unique and often mesmerizing therapist.
transference has its source in prior relational
contexts (Boszormenyi-Nagy and Framo 1965/
1985). They taught that it can be “a resource for Integrative Problem Solving Therapy
deepening one’s capacity for engagement in the
multilateral process” of contextual therapy as the Pinsof (1995), a second-generation couple and
therapist temporarily sides with the stance of each family psychologist, stressed that within the
family member (Boszormenyi-Nagy et al. 1991, framework of Integrative Problem Solving Ther-
p. 231). They purported that since the therapists’ apy, an approach of which he has been a major
definitions of “justice and fairness” and his values proponent, the clinician should contain negative
are communicated implicitly and explicitly, “they alliances with recalcitrant family members, even
become part of the overall therapy context.” if he feels “demeaned or abused” by them. He
purports that a negative reaction to any member
of the patient unit “can critically damage the total
Ericksonian Family Therapy alliance” (p. 111), and should be avoided, espe-
cially in the first session.
A more recently conceptualized theoretical per- One of the few theoretician-therapists who has
spective in the orbit of couples (and family) ther- addressed the possible dilemmas associated with
apy was articulated by Milton Erickson. Herein switching from individual to conjoint therapy
(i.e., changing the structure of the treatment), may not perceive the clinician to be strong nor
Pinsof holds that once ten or more individual active enough and may experience the fears asso-
sessions have been held with a person, that the ciated with childhood sexual abuse (Kirschner
intensity of the transference portions of the bonds et al. 1993, p. 90). These clients, often women,
dimension of the therapeutic alliance will be sense there is no understanding, supportive
disrupted by adding other family members to the “object” available in the treatment situation. If
patient system. The original patient is likely to feel the therapist experiences a negative countertrans-
“abandoned.” The therapist’s attempts to forge ference to this kind of patient, who usually har-
additional alliances often prove deleterious to a bors transferential anticipation that she will be
patient who is “narcissistically vulnerable.” disappointed, she is apt to abandon treatment
The possible risk of jeopardizing the initial quickly. Usually such female patients do not dis-
alliance should be explained to the original patient close that they find the therapist to be similar to
before the patient unit is expanded. Pinsoff rec- their mother, who was neither protective nor avail-
ommends (1995) that whenever possible, if cou- able enough.
ples’ therapy seems warranted, they should be Thus, Kirschner et al. (1993) urge that thera-
referred to a different therapist. If conjoint therapy pists be ultrasensitive to indications that the
is entered into, with the same or another therapist, patient is experiencing a negative transference
it is imperative that these changes be negotiated reaction. They prefer to treat a female adult
with the patient before they commence and that incest survivor conjointly with her partner so
boundaries and commitments be clarified. that her partner’s involvement can reduce her
If making a referral for couples’ therapy seems abandonment fears and augment her sense of
contraindicated when the person conducting the security during and between sessions, as well as
individual therapy deems it important, then the ther- support the therapist’s interventions. The part-
apist should be cognizant of and vigilant about the ner’s participation and witnessing what his part-
positive and negative transferences from each client ner says and feels usually increases his
separately and the couple conjointly to him as well comprehension of the forerunner of the problems
as his own positive and negative transferences to she and they are having, and can make her
each of them. It is incumbent upon the therapist to healing journey feel safer. In dealing with incest
process feelings of favoritism, a tendency to side survivors, countertransference reactions may
with one party in all arguments or conflicts, and/or include avoidance of the topic, blaming the client
of emotions of dislike for them as a couple surface. for not stopping the molestation, becoming over-
Pinsof’s work reinforces the belief that having two stimulated by the content in a voyeuristic fash-
patients in the therapy unit complicates the transfer- ion, and expressing rage at the perpetrator and/or
ence and countertransference and renders these phe- other family members prior to the patient being
nomena harder to fathom and interpret. Whitaker ready to do so (Kaslow et al. 1999, p. 110). It is
claimed that he found adding a valued, respected imperative in these situations that therapists have
colleague as a co-therapist could decrease some of resolved their own issues regarding incest, sex-
the countertransference feelings, rebalance the ther- ual abuse, and secondary traumatization or they
apy system, and facilitate the progress of the may subtly block the issues from emerging into
treatment. the client’s consciousness.
When one partner has suffered childhood sex-
ual abuse (CSA), the couple often experience
Some Especially Difficult Types of severe difficulties in the areas of physical contact,
Patient Couples to Treat sexuality, intimacy, trust, and communications.
Their relationship dynamics may be fraught with
Adult Incest and Abuse Survivors reenactments of traumatic relational patterns
When treating a couple and one member is an which will need to be confronted if healing is to
adult survivor of childhood incest, the patient occur.
As it is incumbent upon a therapist to confront may be difficult for the therapist to accept and may
such behaviors as the patient missing sessions, not arouse familiar but suppressed feelings of animos-
doing agreed upon homework, and forgetting ity displaced from one’s own narcissistic parent.
about concerns on which therapy is focusing, the Dyads comprised of one or two borderline
clinician must be able to process her own coun- members are both likely to tug at the therapist
tertransference reactions to such an unresponsive for more attention and reassurance. They may
and needy client so as to be able to offer positive swing from idolizing the therapist to denigrating C
reinforcement. She needs to understand that many him and each may be functioning near the oppo-
patients perceive discussing such family affairs as site poles of negative and positive responses to the
betrayals of loyalty to the family. The therapist therapist (Lachkar 1992). Once I have begun ther-
eventually must emphasize that love and hate can apy with a couple in which either or both are
coexist and perhaps also to elicit positive feelings borderline, I will not see them separately as
to the perpetrator, but not until some of the anger I have found that after the sessions each relates
and negativity is worked through and the formerly details from their session to their partner to show
unspeakable horrors expiated. Learning such feel- that the therapist favors them; their rendition of
ings can coexist also helps the client understand what transpired is often inaccurate. If each needs a
their ambivalence to the perpetrator, i.e., how they period of individual therapy first, then they will be
can also love him/her. referred to separate therapists, carefully selected
for their competence in treating borderlines and
Borderline, Narcissistic, and Histrionic not permitting splitting. A recommendation will
Couples be made that they return to the original clinician
Therapists may find couples in which one or both for couple treatment, if needed, after they have
have moderate to severe personality disorders, to resolved some of their most intense issues.
be very challenging patients (APA 2004). For
example, the histrionic is excitable and hard to Clinical Example
keep focused; their mood swings make it difficult Recently I had a couple referred by a young ther-
to follow what they are conveying. There is a apist who had been treating the woman for several
strong likelihood that an unemotional person months. This never-married couple had had a
may have chosen her because he found the vola- child out of wedlock 13 months prior to the refer-
tility attractive as it is the opposite of his serious- ral. They did not live together. She had a 15 year
ness and lack of emotionalism; conversely, the old child from a prior relationship (whom she did
histrionic member of the couple was attracted to not list on the in-take form) and he had several
a predictable, steady partner to keep him/her children from a previous marriage. She was attrac-
grounded. However, over time each becomes tive and dressed in a sexy, provocative matter.
annoyed with the other as what were perceived After they filled in the intake forms I asked her
as virtues become vices and this is partly the first to clarify some of her sketchy answers. Her
conundrum that brings them to therapy. responses were terse and given in a hostile man-
In couples in which one or both are narcissistic ner. When I turned to him to engage in a similar
(Solomon 1989), each wants the clinician to sup- process, she listened about 2 minutes and clearly
port their stance and agree with their side of the disliked what he said. She stood up angrily and
argument. To be right is more important than to be said “I won’t sit here and let you malign me”
happy and their extreme narcissism precludes (which he had not done). “I’m leaving and since
achieving real intimacy. They need the therapist you are in my car, you’ll have to find a way back
to express ideas which they find ego-syntonic. to work”. I tried to interject that we would alter-
The more narcissistic someone is, the more they nate hearing each one’s story but she stormed out
demand this. Such behavior can elicit negative and quickly drove away. We were both stunned,
countertransference reactions as the person’s ego- but he stated that this kind of erratic, punitive,
centricity and dismissal of the needs of the other childish behavior when things did not go her
way was typical. My rapid clinical diagnosis of further complicated by the reality that if the most
her of borderline personality with histrionic and respected and often best known senior therapists
narcissistic features was later reiterated based on refuse to see other therapists who have carefully
psychological testing and she was referred to a chosen them because “they want the best,” those
Dialectic Behavior Therapy Group (Linehan who are turned down may experience a tremen-
1993). dous sense of rejection and resentment. Treating
Couples therapy with these types of couples is one’s own colleagues and their partners is simul-
often counterindicated. The amount of negative taneously a privilege, an honor, and a relationship
transferences and countertranseferences can be fraught with potential countertransference chal-
myriad and two individual therapies and/or lenges (Kaslow 2001).
group therapy are more likely to prove beneficial.
Therapists and Their Partners Countertransference in Couples Group

Another domain of practice in which the phenom- Therapy
ena of countertransference is apt to surface is the
treatment of other therapists. Contributing to the Other transference and countertransference issues
complexity of the therapeutic constellation is the arise in couples group therapy. If the group is
reality that all parties may be functioning within co-led by a heterosexual co-therapy team, mem-
intertwined professional systems in which it is not bers, as well as the leaders, may struggle with
possible to totally avoid multiple relationships, which therapist is the more competent or more
such as small rural communities. Also, therapists powerful. Members may “develop parental trans-
are likely to encounter other clinicians whom they ferences reminiscent of family of origin relation-
are treating at professional meetings or social ships” to the therapists (Kaslow and Suarez 1988).
gatherings. This unique category of patients is Participants’ conflicts about closeness may be
more likely to hear gossip or valid personal infor- reactivated through testing the boundaries and
mation about their therapist than other patients strengths of the therapeutic alliance by making
are. They sometimes read books and articles after-hours phone calls or raising questions with
their therapist has written and attend lectures them about the nature of their co-therapy bond. If
they are delivering. The therapist can attempt to the group is co-led by a competent male-female
minimize this and explain why these additional co-therapy team who has a strong working alli-
interactions might interfere with the therapy, but a ance, the team can model effective parenting,
total demarcation between one’s personal and pro- mutual respect, and a positive partnership. Then
fessional identities is not always possible (Kaslow the probability that splitting maneuvers attempted
1984). The patient therapist may have sought out by group members will be effective is decreased
their treating therapist because of their stellar rep- markedly.
utation, having read their work, or attended one of If the co-therapy pair consists of two same sex
their lectures and been favorably impressed, thus therapists, different issues may arise. When it is a
entering therapy with the beginnings of a positive double male team, the female patients may resent
transference. being controlled, perhaps as in the past, by men.
Throughout treatment complex transference Conversely, men may experience a similar resent-
and countertransference issues are likely to be ment if the co-therapy pair consists of two strong
evoked by the numerous images that the patients women. Another potential countertransference
and their therapist glean of each other. The patient stream is that if the leaders are a same sex therapist
may try to emulate the therapist, compare him or team, they each may feel competitive with or
herself to the therapist on many dimensions, expe- overidentify with participants of their own gender
rience competitive strivings, and/or fear his part- and/or experience grave concerns about how to
ner will find their treating therapist better than equalize power for those members whose gender
they think their partner is. This conundrum is is not represented in the team. Some patients may
act seductively toward the therapists if that is their and affects are not a conceptual part of their
customary way of relating to members of the same therapeutic scenarios. Nonetheless it appears in
or opposite gender, and this can elicit counter- the above exposition that when one is engaged in
transference reactions from other group members treating a multipatient unit and the interactions
as well as from the therapists. are more complex because they occur in vivo in
In the event both therapists are gay, lesbian, the moment more than when one treats one
bisexual, or transgender (LGBT), transferences patient only, the transference and countertrans- C
and countertransferenses to and from heterosexual ference aspects may be more submerged in the
group members will need to be addressed as will rapidity and intensity of crossfire between
the other gender issues already mentioned. At patients (Kaslow 2001). Such behavior may
times cross-gender transferences become very emerge in sessions in which, for instance, one
combative and nasty. In addition, the dependency partner is suddenly told that the other has been
within the transferences may escalate when par- involved in a long-term affair or that an incestu-
ticipants sense the possibility of being able to ous relationship is still going on.
finally get their childhood needs met by one of These intertwined transference phenomena
the two parental figures, especially if both are of cannot be wished away just because a therapist
the same gender from which they desperately believes they are not inherent in therapeutic rela-
desire approval and nurturance (Kaslow 2001, tionships. When they do surface, they should be
p. 1036). recognized and handled to the benefit of the
Given that many group members will expe- patient(s) and their healing journey. Some patients
rience the culmination of therapy as a reenact- respond to their therapist(s) by projecting emo-
ment of early childhood losses or desertions, tions and thoughts that are mired in their past
group members should be assisted in processing relationships onto them rather than being aware
the anticipated losses that accompany the termi- of the feelings being dealt with in the current
nation process and other real life current situa- therapeutic encounter.
tions so they do not feel abandoned. If the group The foregoing discussion describes how com-
was commenced utilizing a contract which spec- plex patterns permeate psychoanalytic couple ther-
ified it is structured as a time limited group, (i.e., apy, thus complicating the therapy and the
10 or 15 sessions) then this can be interpreted as therapeutic relationship. “The interpretive focal
an agreed upon ending point and not abandon- point is the couple, not either member but both of
ment. Members can also be offered the option of them together, their relationship, and their collusion”
returning by joining a different group in the (Aznar-Martinez et al. 2016, p. 1). A central princi-
future. ple is that at the inception of treatment the presenting
problem(s) should be reframed in such a way that
the individual goals are transformed into goals for
Clinical Recommendations and the pair and both partners can experience the therapy
Conclusions as “our therapy.”
Some therapists may also mask the basis of
Transference and countertransference are intan- their own feelings and attribute them to their cur-
gible and elusive phenomena that are often pre- rent interactions and not childhood relationships.
sent in couples treatment, even if subliminally, Given the added complexity of treating a two
and are only perceived by those who are acutely (or more) patient unit, and the frequent competi-
sensitive to them. For those who choose to tion of each member for the clinician’s attention
negate the reality of these unconscious processes and approval, it has been posited herein that mul-
and decide to work exclusively with patients’ tiple transferences and countertransferences may
displayed behaviors and articulated cognitions, happen simultaneously.
or who intervene based on the spoken narrative Sometimes therapists are the target of a com-
of the patient’s reality, these intangible thoughts bined attack from the dyad, which may abet a
negative countertransference (Aznar-Martinez Ellis, A., Sichel, J. L., Yaeger, R. J., & DiGuiseppe, R. A.
et al. 2016, p. 17). These emotions can be per- (1989). Rational-emotive couples therapy. Needham:
Allyn and Bacon.
ceived as clues to deciphering important clinical Erickson, M. H., & Lustig, H. (1976). The primer of
data about the self of the therapist as well as the Ericksonian psychotherapy. New York: Irvington.
patient’s interpersonal patterns and internal Goolishian, H. A., & Anderson, H. (1990). Understand-
machinations. When the healing process is sty- ing the therapeutic process: From individuals and
families to systems in language. In F. Kaslow (Ed.),
mied, it is often advisable to be tuned into one’s Voices in family psychology (pp. 91–113). Newbury
own unconscious projections and countertrans- Park: Sage.
ferences and to work with a trusted, respected Kaslow, F. W. (Ed.). (1984). Psychotherapy with psycho-
co-therapist or outstanding consultant to pro- therapists. New York: Haworth Press.
Kaslow, F. W. (2001). Whither countertransference in couples
cess these most productively. Using a and family treatment: A systemic persective. Journal of
co-therapist or consultant when treatment is Clinical Psychology: In Session, 57(8), 1029–1040.
not progressing, or working with a good super- Kaslow, N. J., & Suarez, A. F. (1988). Treating couples in
visor, can enlighten and reinvigorate the thera- group therapy. In Couples therapy in a family context:
Perspective and retrospective (pp. 3–14). Rockvill:
pist and mitigate against the disturbing and Aspen Publishers.
depleting effects of countertransference. Kaslow, N. J., Kaslow, F. W., & Farber, E. W. (1999).
Theories and techniques of marital and family therapy.
In M. B. Sussman, S. K. Steinmetz, & G. W. Peterson
(Eds.), Handbook of marriage and the family (2nd ed.,
pp. 767–793). New York: Plenum.
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for family therapy (pp. 52–67). New York: Family Lankton, S. R., Lankton, C. H., & Matthews, W. J. (1991).
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Ackerman, N. W. (1958). Psych. dynamics of family life: Kniskern (Eds.), Handbook of family therapy
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Ackerman, N. W. (1974). Treating the troubled family. New York: McGraw Hill.
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Alexander, R., & Van der Heide, N. P. (1997). In M. F. borderline personality disorders. New York: Guilford
Solomon & J. P. Siegel (Eds.), Rage and agression in Press.
couples therapy: An intersubjective approach. Mendelsohn, R. (2011). Projective indentification and
New York: Norton. countertransference in borderline couples. Psychoana-
American Psychiatric Association (APA). (2004). Diagno- lytic Review, 98, 375–399.
sis and statistical manual of mental disorder (4th ed.). Napier, A. Y., & Whitaker, C. A. (1978). The family cruci-
Washington, DC: American Psychiatric Association. ble. New York: Harper and Row.
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Aramburee, I. (2016). Couple psychoanalytic psycho- Concepts and methods (3rd ed.). Boston: Allyn and
therapy as the treatment of choice: Indications, chal- Bacon.
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1–20. apy. New York: Basic Books.
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Boszormenyi-Nagy, I., & Framo, J. L. (Eds.). (1965, New York: Norton.
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Boszormenyi-Nagy, I., Grunebaun, J., & Ulrich, D. (1991). empathy. Hillsdale: The Analytic Press.
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Couple 619
cohabitating, while Black, non-Hispanic women

Couple were the most likely to never marry (Copen et al.
2012). Greater education predicted greater likeli-
Katie M. Heiden-Rootes, Dixie Meyer, Kristin hood of being married for women and men, and
McDaniel and Lauren Wilson cohabitation decreased with greater education for
Saint Louis University, Saint Louis, MO, USA women. Men, by contrast, are more likely to never
marry if they are US-born Hispanic or black. Asian C
and foreign-born Hispanic men are most likely to
Name of Family Form be married (Copen et al. 2012). The mean age of
first marriage across all racial groups was 27.4 for
Couples women and 29.5 for men, as compared to 20.5 for
women and 23.7 for men in 1947 (U.S. Census
2016). Finally, most minor children are being
raised in the USA by a couple (U.S. Census 2016).
Synonyms
The federal government does not track same-
sex legal marriage; however, estimates based on
Marriage; Partnered; Romantic relationship
the 2014 number of same-sex marriages performed
suggest about 1% of legal marriages are same-sex
couples and about 25% of same-sex couples legally
Introduction marry (Fisher et al. 2016). Same-sex married cou-
ples tend to be middle to upper class based on tax
Couples are defined as two or more individuals return income estimates (Fisher et al. 2016). Male
engaged in a romantic and/or sexual relationship. same-sex married couples tend to live in densely
Couples may live together, live apart, marry, populated cities (e.g., New York, NY) and be more
divorce, and raise children together. Generally, affluent than female same-sex couples. Female
couples share life’s many transitions and develop- same-sex married couples tend to live in smaller
mental stages together. Some couples stay and mid-size cities (e.g., Madison, Wisconsin;
together for many years and others stay together Fisher et al. 2016). Differences in geographic loca-
for only a brief period of their lives. Couple relation may be connected to childrearing. Same-sex
tionships shift with cultural norms as the accep- female couples (27.4%) are more likely to be rais-
tance of divorce, gay and lesbian adoption of ing children than male couples (10.6%). Approxi-
children, premarital cohabitation and sexual rela- mately 19% of all same-sex couples are also raising
tions, nonmarital childbearing, and same-sex sex- children, and same-sex couples are four times more
ual relationships increases over the past 15 years likely to be parenting adopted or foster care child
(Daugherty and Copen 2016). The following than different-sex couples (Gates 2013).
description and related research will detail cou- Finally, the last reported divorce rates in the USA
pling and couple relationship as seen in the USA were in 2015, putting the rate at 3.1% of the married
including US-born and immigrant couples, inter- population, which is down from 4.0% in 2000
racial couples, same-sex couples, and significant (CDC 2015). Estimates suggest that between 25%
issues facing couples. and 40% of all marriages end in divorce. This rate
increases for subsequent second and third marriages.
Little is known about the divorce rates and experi-
Description ences of same-sex couples given the newness of
legal marriage at the federal level.
Coupling in the USA. Coupling in the USA has Attraction. Romantic coupling continues to
changed over the past 50 years. The most recent evolve. While variety in sexual orientation is not
federal data showed foreign-born, Hispanic women new, recent changes in marriage rights trans-
and men are the most likely to be married or formed societal recognition marriages that do not
620 Couple
adhere to traditional different-sex partnering. Sex- engagement, investment, vulnerability, sacri-

ual orientation or sexual attraction comes in a fice, and play that offers sweet rewards of
myriad of types. Sexual orientation may include greater sexual expressiveness and deepens the
different-sex (heterosexual), same-sex (gay and friendship between partners. Sex may be an
lesbian), bisexual (attraction to both males and expression of (re)commitment, and this recom-
females), pansexual (sexual attraction not limited mitment process may be recursive as it moves
by gender or sex), and asexual (lack of attraction the relationship into deeper intimacy.
and desire) attractions. Yet, a degree of gradation Gender. Gender roles and identities are also
exists for sexual attraction. Fewer individuals are loosening in our society, changing the social ste-
adhering to complete attraction to one sex or one reotypes of the male-female, masculine-feminine,
label of sexual orientation as we continue to see and traditional couple picture. Gender includes a
sexual development throughout the lifespan. It spectrum of identities as they relate to understand-
may be more appropriate to address sexual attrac- ing attraction, roles, and desires across genders.
tion on the continuum of attraction from exclusive Cisgender individuals identify with their sex
attraction to one sex through equal amount of assigned at birth. Transgender individuals do not
attraction across sexes or genders. A similar con- identify with their gender assigned at birth. Non-
tinuum should also exist generically for sexual binary individuals do not identify exclusively
attraction to others in recognition of asexuality. with a gender; rather they may identify as both
These continuums should be considered across male and female, neither male nor female, or
time with couples. another gender. Gender individuals do not iden-
Commitment. Several definitions exist in lit- tify with a gender. Our heteronormative, cis-
erature for the term “commitment” in marital or gender society often stigmatizes individuals that
romantic relationships. The Triangular Theory do not adhere to traditional norms and challenges
of Love (Sternberg 1986) defined commitment the rights of couples who do not follow main-
as the “deliberate choice, first in the decision to stream societal understanding of attraction and
love someone and then in the decision to main- gender identity. Nonheterosexual, non-cisgender
tain that love” (Acker and Davis 1992, p. 22). individuals and couples are more likely to be
Some suggest commitment is the “cold” ele- victimized and rejected by family and struggle
ment of intimacy and lacks perceived sex appeal with mental health issues.
or passion; however, commitment (based on Monogamy and infidelity. Couple relation-
Sternberg’s definition) was shown to be the ships can adhere to monogamous and consen-
best predictor of relationship satisfaction sual nonmonogamous boundaries related to
(Acker and Davis 1992). In evolutionary studies sexual and emotional engagements with others.
on relationships, researchers concluded that Monogamy is the most common structure for
close, committed relationships “may serve as a couples in the USA; however, defining the
fundamental anxiety buffer,” managing existen- boundaries of monogamy in the present, social
tial threats to existence or mortality (Florian media, Internet-driven culture is difficult. Emo-
et al. 2002, p. 538). In other words, long-term, tional and sexual affairs are usually best defined
committed relationships are stabilizing and may by a given couple though there is often influence
be a key element in promoting satisfaction in from culture and religion about what constitutes
relationships. Schnarch (1997) argues for the an affair. Consensual nonmonogamous relation-
centrality of commitment in intimate relationships include a multiplicity of relationship
ships, or rather the ongoing recommitment to structures and boundaries. This could include
the process of personal and relational growth relationships where a couple consents to both
toward intimacy. Recommitment is the choice partners seeking outside sexual relationships,
to remain in the process of intimacy with swinging where both partners of one couple
your partner (Schnarch 1997). It requires may have sexual relations or swap partners
Couple 621
with another couple or group of couples, and dissonance and the couple might feel unprepared
polyamory which may include three (triads) or to deal with barriers. Barriers might include dif-
more partners instead of traditional dyadic cou- ferent philosophies around money, childrearing,
pling. Estimates of consensual nonmonogamous family, gender roles, sex, affection, celebrations,
relationships range from less than half of a percent rituals, and spirituality (Hsu 2001). Sometimes
to 4% of the US population (Conley et al. 2013). cultural norms and beliefs held by each partner
Consensual nonmonogamous relationships are may be incompatible and conflictual given famil- C
growing in popularity partly due to divorce rates, ial and societal pressures. For example, two stud-
increasing rates of (known) infidelity, individual ies suggest that bisexual women in relationships
desire for outside sexual relationships, and cul- with heterosexual men experience additional
tural changes, recognizing that not all couples stigma and more negative health outcomes com-
may choose to bond exclusively with one partner. pared to bisexual women in same-gender relation-
Couples may also recognize that what individuals ships (Dyar et al. 2014; Molina et al. 2015). One
want from a long-term partner (e.g., personality, study reported interfaith couples experience
stability) may be different from what individuals higher rates of divorce, involvement in different
want from a short-term partner (e.g., attractive- groups, and lesser support from social networks
ness, sex drive), thus creating challenges to (Hughes and Dickson 2005). Couples of different
remaining monogamous. Importantly, research immigration status may experience societal pres-
supports that regardless of the type of coupling, sure about possible deportation or where to live if
similar levels of relationship satisfaction are experiencing discrimination (Tien et al. 2017).
found. Jealousy may, in fact, be less likely to Language and communication problems are com-
occur in consensual nonmonogamous relation- mon when partners do not share a common lan-
ships. However, challenges may arise in these guage or native culture. Coping skills and ways to
types of relationships regarding legal recognition deal with conflict also vary by culture and
of relationships, parenting challenges, and dis- upbringing. Additional culturally loaded issues
crimination from others. may arise including where to live, children’s
Intercultural couples. People in relationships names, food choices, assimilation or acculturation
may present in various dynamics including of children’s cultural identify, and extended fam-
intercultural couples, interracial couples, interfaith ilies (Hsu 2001). Family structure and dynamics
couples, mixed orientation couples, and couples of should be closely acknowledged as various cul-
varying immigrant status. People commonly part- tures identify family as the core nuclear family,
ner despite differences in culture, race, ethnic iden- and the family unit in other cultures might include
tity, socioeconomic status, religious beliefs, sexual the entire extended family. Imbalances in cultural/
orientation, or immigration experiences. The num- racial hierarchies may shift as some individuals
bers of interracial and intercultural marriages are may view different groups either superior or infe-
increasing in the USA (Hsu 2001). Interracial and rior to their own. Conflict in this area could result
intercultural relationships offer opportunities to in one partner’s aspiration for a more egalitarian
learn and grow with someone from a different relationship (Hsu 2001).
background and with differing perspectives. In sum, intercultural or interracial couples
Intercultural couples have both strengths and may encounter unique challenges, but also have
challenges. Clarification about definitions and tremendous strengths. These couples should be
meanings of the family and boundaries are impor- reminded of their decision to commit to one
tant to explore based upon each other’s cultural another and use that strength and determination
expectations (Hughes and Dickson 2005). It is to confront or solve conflicts that arise. Despite
important for each partner to proactively examine facing an additional array of barriers, these cou-
and negotiate central issues that could potentially ples need to realize and appreciate positive
arise because if left silent, the conflict may create aspects of their relationship.
622 Couple
Relevant Research disorganized-disoriented, to describe what they

were seeing with highly traumatized children.
Gottman’s couple research. One of the leading Attachment theory suggests that the four styles
researchers on couples and couple dynamics is are acquired during infancy and childhood, are
John Gottman and colleagues. They studied cou- dynamic and change over time, and, ultimately,
ples in their “love lab” for over 30 years and found predict our adult attachment style with our roman-
a consistent result – the problem is not that cou- tic partners. Johnson (2013) crystallizes the theory
ples have conflict but it’s how they engage in the of adult attachment this way: “the good news is
conflict that predicts marital satisfaction and that even if we were emotionally starved in our
divorce (Gottman 2011). Gottman and colleagues childhood relationships, our adult lovers offer us a
outlined the Four Horsemen of the Apocalypse second chance to learn new and more effective
and their associated antidotes that show up in ways to deal with our emotions and signal our
couple conflict: (1) criticism (complaining by longings to others” (p. 78). In many ways, adult-
suggesting there is something defective with the hood is a chance to have a do-over, according to
partner’s personality; the antidote is to complain the theory, and couples have a chance to heal from
with a statement that doesn’t criticize), (2) con- childhood attachment wounds through more
tempt (disgust and fault finding of another; the secure attachment experiences with their partner.
antidote – creating a culture of appreciation), Domestic violence. Intimate partner violence
(3) stonewall withdrawal (shutting down or not (IPV) is defined as any physical, sexual violence,
responding; the antidote – self-soothing, taking threats of physical or sexual violence, stalking, or
productive breaks, and working to stay psychological aggression, perpetrated by a current
connected), and (4) defensiveness (reactive or past intimate partner (Black et al. 2011). Cou-
responses that do not accept responsibility for ples who experience IPV can be in same-sex or
any part of the conflict; antidote – accepting opposite-sex relationships, cohabiting or non-
responsibility for even part of the problem). Con- cohabiting. In the USA, 35.6% of women have
tempt and husband withdrawal in different-sex experienced some form of IPV throughout their
couples, in particular, were the largest predictors lifetime. For men in the USA, 28.5% have expe-
of divorce (Gottman 2011). Gottman and col- rienced IPV in their lifetime. When looking at
leagues also found that about 30% of all topics women who have experienced only one form of
of conflict would go unresolved for a couple, even IPV, 56.8% of women have experienced physical
those who were satisfied in their marriage. violence. 92.1% of men in this same category
Unresolvable conflict was largely due to couples’ reported experiencing only physical violence
ability to handle them without the Four Horse- (Black et al. 2011).
man. Stable and satisfying couple relationships There are two forms of intimate partner vio-
had a 5:1 ratio of positive to negative (e.g., Four lence that are often seen in couple’s therapy. Com-
Horseman) interactions, were able to repair after mon couple violence is situational violence,
negative conflict, and had husbands who accepted where conflict can escalate to violence. This type
the influence of their wives. of couple’s violence lacks the control aspects of
Adult attachment. The primary tenant of intimate terrorism violence. Why intimate terror-
attachment theory is that humans were made to ism is defned as the perpetrator with both physical
be in relationship. We are social beings. This is and non-physical violence. Perpetrators of inti-
evident in the coupling practices of humans across mate terrorism often utilize control tactics, such
time. Different styles of attaching from one as isolation, financial control, threatening other
human to another are postulated for children and family members even children, and physical vio-
then are carried over to adult relationships. Ains- lence. Research has found that victims of intimate
worth et al. (1978) conceptualized three attach- terrorism are more likely to be injured during
ment styles: anxious avoidant, secure, and these violent interactions when compared to their
anxious resistant with a fourth added later called counterparts who experience situational violence.
Couple 623
They are also more likely to frequently experience relational satisfaction and should be addressed in
violence and post-traumatic stress disorder and to premarital counseling (Britt and Huston 2012).
use pain killers (Johnson and Leone 2005). Sexual dysfunction and satisfaction. There
When looking at gender, there is a relationship are many types of sexual dysfunction for both
between marital satisfaction/discord and intimate males and females. The Diagnostic and Statistical
partner violence (IPV) for male partners (Stith Manual Version 5 defines sexual dysfunction as a
et al. 2010). This may imply that when marital significant disruption in a person’s ability to per- C
satisfaction decreases, men may be more likely to form or experience sexual pleasure (American
use violence. Stith et al. (2010) speculate that Psychiatric Association 2013). Thirty-one to
these gender differences may be due to socializa- 43% of men and women experience some form
tion of men and women. Men may be socialized of sexual dysfunction (Laumann et al. 1999).
with a power imbalance, thus more likely to use Often these men and women experience comorbid
violence when unhappy. Similarly, women may physical and mental health diagnoses (Laumann
look for other problem-solving strategies. For et al. 1999). Erectile dysfunction is a common
female partners, there is a relationship between sexual dysfunction for men. Other frequently
being a victim of IPV and marital satisfaction/ treated diagnoses include male hypoactive sexual
discord. Female partners also identify higher dis- desire disorder, delayed ejaculation, and prema-
cord and lower marital satisfaction as compared to ture ejaculation disorder. When looking at
male partners (Stith et al. 2010). Overall, there is a women, common sexual dysfunctions are often
relationship between marital satisfaction/discord related to pain such as genito-pelvic pain/penetra-
and IPV. This relationship may be recursive in tion disorder, vaginismus, and dyspareunia. Other
nature, where IPV reduces marital satisfaction, diagnoses for females may include female orgas-
and lower marital satisfaction increases the mic disorder and female sexual interest/arousal
chances of IPV. It could be that IPV produces disorder. Significant associations exist between
shame for the partners perpetrating violence and common mental and physical health conditions
this feeds the cycle of violence. and sexual dysfunction suggesting sexual health
Finances. Sex and money are some of the most is an indicator of overall well-being for adults and
common topics brought into therapy by couples. couples (Laumann et al. 1999).
However, many therapists and couples feel
uncomfortable bringing up these topics. Nonethe-
less, sex and finances play a major role in a cou- Special Considerations for Couple and
ple’s life. Research has shown that finances are Family Therapy
often a major component for marital distress (Britt
and Huston 2012). Couples who argue about In couple and family therapy (CFT), a therapist
finances often experience lower relational satis- will want to consider several key aspects of couple
faction and increased likelihood of divorce. One dynamics that may impact care for individual
of the leading predictors of divorce is frequent partners, the couple, and children who enter psy-
arguments related to financial disagreements chotherapy. Early family therapists recognized the
early in the marriage (Britt and Huston 2012). use of an “identified patient,” usually a child, for
There appears to be a connection between couples masking marital and couple issues (Napier and
who view their partners spending behaviors neg- Whitaker 1978). Napier and Whitaker (1978)
atively and lower relational satisfaction. The more advocated for assessment and treatment that
a partner spends without including their partner in encompasses the whole family for creating a sys-
the discussion, the more likely they are to experi- temic definition and approach to therapy. The
ence lowered relational satisfaction. Due to the research on couple conflict and domestic violence
unclear line between financial planning and cou- showing a negative impact on children’s mental
ples’ issues, therapist should be aware of the health (Cummings and Davies 2002) suggests
impact that financial difficulties have on couples’ Napier and Whitaker were right in this assertion.
624 Couple
As such, therapists will want to consider issues of attracted to and partner with many different people,
couple dynamics even when the identified patient regardless of gender. More recent research has
is the child of the couple. explored this phenomenon and the psychological
Feminist theorists and family therapists identi- and minority stress impact on the bisexual partners
fied the significant impact of gender, power, and given the erasure or minimization of their sexual
oppression on the couple. Equality in relationship identity (Goldberg et al. 2017).
dynamics is a predictor of couple satisfaction and
is often thought of as an issue of gender
(Knudson-Martin and Rankin Mahoney 2009).
Cross-References
Historically, male partners tend to be sanctioned
with more social power than women leading to
▶ Divorce in Couple and Family Therapy
inequalities in different-gendered partner relation-
▶ Infidelity in Couples
ships. This is perhaps most notable in the research
▶ Marriage
and theory development related to domestic vio-
lence (Stith et al. 2010). Though power differen-
tials can also be a produce of socioeconomic
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family of origin. commitment in adult romantic relationships: A test of
A power issue that is not often discussed in the triangular theory of love. Journal of Social and
CFT is money even though economic hardship Personal Relationships, 9, 21–50.
Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978).
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and Huston 2012) and can have a spillover effect American Psychiatric Association. (2013). Diagnostic and
onto the well-being of children. In CFT the issue statistical manual of mental disorders (5th ed.). Arling-
may be economic hardship causing stress on the ton: American Psychiatric Publishing.
Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G.,
couple relationship and family dynamic overall, Walters, M. L., Merrick, M. T., Chen, J., & Stevens,
and it could also be the issue of who is paying for M. R. (2011). The National Intimate Partner and sex-
therapy. Who pays for therapy between a couple ual violence survey (NISVS): 2010 summary report.
may be an indication of investment in the relation- Atlanta: National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention.
ship and/or suggest something about power in the Britt, S. L., & Huston, S. J. (2012). The role of money
relationship. This can also become an ethical con- arguments in marriage. Journal of Family and Eco-
cern for therapists who are working to maintain a nomic Issues, 33(4), 464–476.
continuity of care for clients and couples in the Center for Disease Control. (2015). National marriage and
divorce rates. Retrieved from https://www.cdc.gov/
face of conflicts about money. nchs/data/dvs/national_marriage_divorce_rates_00-
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Couple and Family Psychology: Research and
Brown. Practice (CFP) is a quarterly peer-reviewed schol-
Johnson, M. P., & Leone, J. M. (2005). The differential arly journal focused on the intersection of theory,
effects of intimate terrorism and situational couple vio- research, and professional practice in the specialty
lence: Findings from the National Violence against
Women Survey. Journal of Family Issues, 26(3),
of couple and family psychology. It was founded
322–349. in 2011 and Volume I commenced with the publi-
Knudson-Martin, C., & Mahoney, A. R. (2009). Couples, cation of Issue 1 in March 2012.
gender, and power: Creating change in intimate relation- CFP was launched by the Society for Couple
ships. New York: Springer Publishing Company, LLC.
Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual
and Family Psychology because of a perceived
dysfunction in the United States: Prevalence and pre- need for a journal that focused on both research
dictors. JAMA, 281(6), 537–544. and practice in the specialty. The idea for the
Molina, Y., Marquez, J. H., Logan, D. E., Leeson, C. J., journal gestated over several years as the division
Balsam, K. F., & Kaysen, D. L. (2015). Current intimate
relationship status, depression, and alcohol use among
bulletin The Family Psychologist increasingly
bisexual women: The mediating roles of bisexual-specific featured journal-level articles. After originally
minority stressors. Sex Roles, 73(1–2), 43–57. proposing to transition the bulletin to a journal, it
Napier, A. Y., & Whitaker, C. A. (1978). The family cruci- was decided to keep the bulletin and entitle the
ble. New York, NY: Harper Collins.
Schnarch, D. (1997). Passionate marriage: Keeping love
new journal CFP to differentiate the two publica-
& intimacy alive in committed relationships. tions and highlight the emphasis of the new
New York: Henry Holt and Company. journal.
626 Couple and Family Psychology (Journal)
Location Contributions (What It Is Known for and

Relevant to CFT, Mission, and Values)
CFP is a joint publication of the Journals Program of
the American Psychological Association in CFP is known especially for its focus on the nexus
Washington, D.C., and the Society for Couple and of research and practice in couple and family
Family Psychology (APA Division 43). It is included psychology. Research is broadly defined, includ-
in the PsycINFO and PsycARTICLES databases of ing quantitative, qualitative, mixed methods, and
the APA with the most frequent index terms being evidence-based case studies. Authors of research
couples, family therapy, couples therapy, family rela- articles are encouraged to provide practice impli-
tions, attachment behavior, relationship satisfaction, cations of their findings, and theoretical or prac-
marital relations, commitment, interpersonal rela- tice articles are expected to demonstrate scientific
tionships, and intervention. A print copy of the jour- foundations (Stanton 2014) because “it is at that
nal is provided to all members of the society. intersection that many new and important ways of
thinking and working in couple and family psy-
chology can be found” (Sexton 2014, p. 138).
Prominent Associated Figures Originally, each issue featured two to four arti-
cles on an identified theme in couple and family
Several leaders in the Society for Couple and psychology, such as the systemic epistemology of
Family Psychology created the proposal for the the specialty, coping with HIV risk and infection,
journal during the presidency of George Hong in treating depression in couple or family therapy,
2010. Susan McDaniel, Marianne Celano, John technological innovations for specialty practice,
Thoburn, and Thomas Sexton collaborated with neuroscience of interpersonal relations, integrated
Hong to submit a plan to APA (Stanton 2011). systems of healthcare, and evolving couple or
APA publisher Gary R. VandenBos approved the family forms (Stanton 2014). As the journal
proposal in November 2010. evolved, it shifted to occasional theme issues,
Mark Stanton was the inaugural editor such as relationship uncertainty in couples ther-
(2011–2014), joined by Cindy Carlson and Thomas apy and obesity in the family, adding a scholarly
L. Sexton as associate editors. Each was a prior commentary to provide context and direction
president of the Society for Couple and Family across the theme articles, and more general topics
Psychology, as well as the author or editor of in the specialty (Sexton 2014). CFP now high-
books and journal articles related to the specialty. lights change mechanisms and innovative models
They gathered a panel of over 30 consulting editors for “real world” interventions.
and principal reviewers who represented a wide
spectrum of specialty research and expertise, includ-
ing Steven R.H. Beach, Myrna Friedlander, Alan Cross-References
Gurman, Michele Harway, Susan Johnson, Florence
Kaslow, Susan McDaniel, Timothy O’Farrell, ▶ Anderson, Harlene
Galena Rhoades, Douglas Snyder, Harlene Ander- ▶ Beach, Steve
son, James Bray, Kristina Coop Gordon, Joseph ▶ Carlson, Cindy
Cervantes, Frank Dattilio, Ivan Eisler, and Froma ▶ Eisler, Ivan
Walsh. ▶ Emery, Robert
Thomas L. Sexton is the second editor (2014–pre- ▶ Falicov, Celia
sent), with Anthony Chambers and Cindy Carlson ▶ Friedlander, Myrna
serving as associate editors. Additional consulting ▶ Gurman, Alan
editors joined the journal, such as Robert Emery, ▶ Johnson, Susan
Celia Falicov, Doug Breunlin, Mona Fishbane, ▶ Kaslow, Florence
Anne Fishel, Shalonda Kelly, Mudita Rastogi, Shel- ▶ Liddle, Howard
ley Riggs, Tamara Sher, and Howard Liddle. ▶ McDaniel, Susan
Couple and Family Therapy in the Digital Era 627
▶ O’Farrell, Timothy ICTs and relationships, e-mental health and cou-

▶ Rhoades, Galena ple/family therapy (CFT), online supervision,
▶ Sexton, Thomas online training and training on ICT use, as well
▶ Snyder, Doug as ethical and legal issues.
▶ Society for Couple and Family Psychology,
American Psychological Association
▶ Stanton, Mark ICTs and Relationships C
▶ Walsh, Froma
One key research question in the field is whether
ICTs are used to sustain preexisting connections
References or to establish relationships that start online and
then move offline (Chambers 2013). Despite the
Sexton, T. L. (2014). Moving forward: Next steps in the option of being potentially linked with a large
evolution of the Couple and family psychology:
number of persons, all kinds of digital media
Research and practice. Couple and Family Psychology:
Research and Practice, 3(3), 137–140. https://doi.org/ and a “media multiplexity” (communication
10.1037/cfp0000027. conducted through more than one medium) are
Stanton, M. (2011). Welcome to Couple and family psy- mostly used to connect with a smaller group of
chology: Research and practice. Couple and Family
intimates (ibid.; Jennings and Wartella 2013;
Psychology: Research and Practice, 1(S), 1–2. https://
doi.org/10.1037/2160-4096.1.S.1. Webb 2015). Even social network sites are mainly
Stanton, M. (2014). Editorial. Couple and Family Psychol- activated to maintain or deepen already existing
ogy: Research and Practice, 3(2), 65–66. https://doi. relations or for tracing people already known
org/10.1037/cfp0000021.
offline, rather than to initiate new relationships.
Most communication is with and about the loved
ones like partners, family members and friends;
Couple and Family Therapy in synchronous (compared to asynchronous) and
the Digital Era voice communication (compared to written) are
looked at as having a higher degree of intimacy.
Maria Borcsa1 and Valeria Pomini2 Nevertheless, an increasing number of singles
1
University of Applied Sciences Nordhausen, in the industrialized world regard online platforms
Nordhausen, Germany as the best place to find a partner for their real life.
2
First Department of Psychiatry, National and The particularity of intimate relationships
Kapodistrian University of Athens, Athens, established via social media lies in an accelerated
Greece self-opening compared to face-to-face situations
(“disinhibition effect”), leading to intensified
closeness in emerging online relationships but
Introduction revealing contradictory results concerning the sta-
bility of these partnerships (Eichenberg
Information and communication technologies et al. 2017).
(ICTs) have deeply changed the way people com- ICT use in couple relationships can strengthen
municate and relate in their personal and profes- the relationship by allowing to convey signs of
sional lives. The use of ICTs influences not only affection, desire, and lust; it can ease all forms of
family life and all kind of relationships; it also everyday communication, especially in short- or
introduces new interactional modalities in a wide long-term geographical separation. Couple iden-
range of social practices, including health services tity work may start with wedsites (web pages
and education. Moreover, ICTs have created new created in conjunction with an upcoming wed-
relational models based on a networked society. ding), followed by joint Facebook accounts, and
This article presents some significant topics for continued by viewing sexually explicit online
couple and family therapists in the digital era: material together. Vulnerability in couple
628 Couple and Family Therapy in the Digital Era
relationship is linked to certain forms of online on one activity, to think logically as well as being
interaction with nonfamily members. If performed able to read), the function of using ICTs changes
in joint couple/family time, the use of ICTs, espe- in the respective family stages (Jennings and
cially mobile phones, to communicate with non- Wartella 2013). The child’s growing indepen-
family members (for work-related or private dence in adolescence goes hand in hand with
purposes) may be annoying; hours spent alone in parents’ need to support and protect the child.
front of the computer might create a “computer Because most children and adolescents use their
widow.” Cyber-affairs, cyber-cheating, Internet ICTs for direct and private access to peers, they
pornography, and cybersex may have negative often perceive attempted parental regulation as
effects on relational trust (Webb 2015). privacy invasion, although, interestingly enough,
On the other hand, the web can be a source in regulatory strategies vary with parenting style and
times of uncertainties and crises, through stabiliz- not with adolescents’ time spent online (ibid.;
ing the couple/family system: not only informa- Webb 2015). Parental worries about children’s
tion but also online social support communities contact with social media differ according to
are available for (expectant) parents on practically social class, gender, geographical region, and cul-
any relevant area. These might be particularly tural background (Chambers 2013), while ICTs
important if offline family support is not available have different effects depending on whether they
or perceived as intimidating. Couples/family are used in families mainly for educational or for
members struggling with stress, illness, or loss entertainment purposes (Carvalho et al. 2015).
can locate online venues for social support provi- Particular aspects of family functioning, such
sion. Family members may seek online help as communication (micro-coordination, i.e., man-
related to family concerns (e.g., medical informa- aging daily activities), cohesion (e.g., through
tion) as well as material about the family itself – sharing online activities between parents and chil-
online genealogical research is becoming increas- dren), roles, rules, intergenerational conflicts, and
ingly popular (ibid.). boundaries, are connected to ICT use. However,
Adoption websites and platforms for sperm the particular family’s developmental stage and
and egg donations as well as for surrogate mothers the geographical distance are powerful mediating
all over the world (even if they are not legal in factors on the effects ICTs have on family rela-
most states) support the pluralization of family tionships. Especially in geographically separated
formations and create more options for living or transnational couples and families, in empty
arrangements; this might happen under the condi- nest stage of the family life cycle or in crisis
tions of globalized neoliberal values and gives rise conditions, ICTs are significant in maintaining
to ethical issues. communication and strengthening existing bonds
To complement, online divorce education pro- (Carvalho et al. 2015; Webb 2015).
grams and online mediation seem to be a suitable The use of ICTs has the potential to influence
way for divorcing couples, especially if they do family roles due to the discrepancy of levels of
not want to meet each other physically – this is expertise. As these devices have appeared late in
also the case for “online parenting” after divorce their lives, today’s (grand-) parents act without a
(Eichenberg et al. 2017). reference model in media education, trying to
With regard to family dynamics, the influence establish rules which might in themselves have a
of ICTs is manifold, and research results are negative impact on the relationship with their
inconsistent (Jennings and Wartella 2013; descendants (Webb 2015; Eichenberg et al.
Carvalho et al. 2015). ICT use can impact family 2017). Conversely, through unmonitored use of
functioning in both positive and negative ways ICTs, family boundaries may be weakened,
and is associated with norms, values, and beliefs increasing vulnerability. These may lead families
of the family system. As the use of ICTs increases into hazardous situations like threat to privacy and
along with children’s age (through the develop- family safety, contact with inappropriate content,
ment of fine motor skills, increased ability to focus “happy slapping,” child grooming, and
involvement in situations of loss of control over Teenagers might be more confident with the use
virtual interactions such as cyberbullying or of digital means than support offered offline.
cybersex (Carvalho et al. 2015). Besides, the Online practices may destigmatize mental health
web may have a twofold role when used by ado- issues and facilitate the disclosure of difficult
lescents and young adults presenting mental experiences and feelings through anonymity and
health problems like eating disorders, depression, distance.
or self-harming: on the one hand, reinforcing the Among the psychotherapeutic approaches, C
risk behaviors and, on the other hand, preventing cognitive-behavioral therapy has a consolidated
them or offering support, advice, and experience history of implementing online activities, while
sharing (Campaioli et al. 2017). up to now a significant delay has been observed
Theoretical development toward understand- in couple and family therapy. One of the
ing the role of technology in couple and family best-developed approaches is Integrative Behav-
life is still scarce in the systemic field. Life course ioral Couple Therapy (IBCT), which has been
paradigm embeds family structures and family transformed to the web-based intervention
stages within social institutions and historical con- OurRelationship.com. A randomized control trial
text (Watt and White 1999). Hertlein and of 300 couples showed significant improvement
Blumer’s (2014) multi-theoretical model is an in relationship compared to a waitlist control (see
integration of a family ecology, structural- entry ▶ “Integrative Behavioral Couple Ther-
functional, and interaction-constructionist per- apy”); research was extended to a brief version
spective. The ecological impacts related to tech- of the program as well as on couples with specific
nology are described as anonymity, accessibility, characteristics such as intimate partner violence
affordability, approximation, acceptability, (IPV) (Roddy et al. 2017).
accommodation, and ambiguity. They are interre- In case studies, implementation of video tele-
lated with two types of changes in relationships: conferencing into therapeutic work is especially
changes in the structure of couples and families recommended for families in remote and rural
(in rules, boundaries, and roles) and changes in the areas (Dausch et al. 2009), couples living in
process of couple and family relations (intimacy, long-distance relationships (McCoy et al. 2013),
relationship initiation, formation, and mainte- transnational families (Bacigalupe and Lambe
nance). The framework, a valuable model for 2011), refugees (Mucic et al. 2016), active duty
research, helps also clinicians to address military members stationed in various areas and
technology-related issues in couple and family their families (Hill et al. 2001), as well as for
relationships, such as online dating, online por- family caregivers in pediatric and geriatric con-
nography, online infidelity, online video gaming, texts (Chi and Demiris 2015; Comer et al. 2017).
Internet addiction, cyberbullying, cyberstalking, Regarding contraindications, the same exclusions
etc. (ibid.; see also Borcsa and Pomini 2017). as in-person couple/family therapy apply (e.g.,
severe IPV, untreated substance abuse or psy-
chotic disorders in one or more family members,
E-Mental Health and CFT untreated high suicide risk in one or more family
members). The clinician should request in- person
The use of ICTs has been widely established by sessions or refer to outside providers when it is
health professionals with a growing acceptance of necessary to ensure safety (Wrape and McGinn
ICT use in mental health. E-mental health can 2018; see ibid. for further recommendations).
include videoconferencing, avatar chat, text chat, Settings may vary: the therapist sits with one or
virtual reality, e-mail, and others. Online practices more family members in the therapy room (in an
may offer resources and connections to special outpatient or an inpatient context), this system
populations, such as people living at geographical being virtually connected to the spouse or other
distance from services, presenting disabilities, or family members (for case examples see Shoe-
being impaired in reaching the services. maker and Hilty 2016). Another option is having
all members of the session (even other profes- relationships (Hertlein et al. 2014) but not neces-
sionals) at one or more screens, whereas the ther- sarily as a new therapeutic setting per se. Besides
apist is online at a different place. The respective age, personal attitudes and cultural values influ-
settings require attention to aspects of multi- ence the use of ICTs in clinical practice: whereas
directional partiality, especially if one person is family clinicians from Canada, Mexico, Spain,
regularly physically present with the therapist. and the United States, who used more ICTs them-
Particularly in this case, but also to ensure thera- selves, saw more benefits for families in general, a
peutic alliance in general, it is recommended to Turkish sample, despite using overall more ICTs
conduct the first one or two sessions conjointly in for nonclinical purposes than their English- and
person if possible (McCoy et al. 2013; Wrape and Spanish-speaking colleagues, turned out to be less
McGinn 2018). Further, the family home setting in favor of their use in clinical practice (Akyil
during online session could create some compli- et al. 2017).
cations like the intrusion of other family or non-
family members during the session or the pull to
multitasking – an aspect which should be Online Supervision
discussed before online meetings.
Connecting virtually to a (co-)therapist while Online supervision has been defined as a supervi-
being physically at a different place, e.g., in sion activity via digital tools, ranging from the use
another country, enables to create a therapeutic of cellular phones, texting, instant messaging, and
system in the language of the family, even if this e-mailing to encrypted online sharing of video-
is not the language of the country where part or the recorded material/sessions, videoconferencing,
majority of the family lives. This is especially and remote live supervision (RLS). In RLS, a
valuable when working with refugees and their supervisor watches a live psychotherapy session
families scattered over various countries, as the via the Internet and gives guidance to the therapist
implementation of translators might be waived in real time (Rousmaniere 2014).
(Mucic et al. 2016). Online supervision offers chances to clinicians
In summary, e-Couple and Family Therapy located in rural or remote zones; receiving online
(e-CFT) has to be considered as a new setting, supervision in those cases where no supervision
and further conceptualization and research are would otherwise be available enhances the quality
needed. of the services provided to patients and combats
Discussing ICT issues with couples and fami- the sense of professional isolation (Pomini et al.
lies is becoming increasingly important, not only 2016). Online supervision in the context of train-
when the presenting problem is related to ICTs, ing for licensure saves travel costs and time but
e.g., Internet addiction or online infidelity. Under- goes hand in hand with a higher degree of respon-
standing the role ICTs play in the couples’/fami- sibility for the supervisee and his/her client, mean-
lies’ everyday life is one significant aspect in ing, e.g., that a local backup supervisor should be
working with today’s families (Borcsa and Hille identified if possible (Rousmaniere 2014).
2016). As regards intervention, using websites for In order to establish a high-quality online
assessment or for psychoeducation, pointing out supervision process, preparation is needed:
online self-help resources, and giving technology- besides goal formulation and clarification about
based homework assignments (Piercy et al. 2015) roles and responsibilities, like in all supervisory
are examples of how CFTs can utilize digital tools. settings, discussing software affairs and the man-
With regard to couple and family therapists’ agement of technical problems which might occur
usage of ICTs, it has become slightly more of a during online supervision as well as the agreement
routine in the last decades, asynchronous means on clear shared rules regarding the time and
of use being mainstream at present. Distant com- spaces of the meeting (e.g., avoiding intrusiveness
munication is primarily seen as a way to improve by thirds or multitasking) are essential in this
availability in already established therapeutic context. Moreover, technology-related matters
are how and where data will be stored and deleted. online marriage and family therapy programs are
The monitoring and evaluation of supervision available in several countries, even though the
process and results are part of the quality assur- literature describing these practices is still poor.
ance. Issues related to diverse cultures between The advantage of providing e-learning platforms
supervisor and supervisee located in different in CFT training programs is in overcoming geo-
areas, countries, or even continents have to be graphical distance, offering training to profes-
taken into account to prevent negative side effects sionals settled in zones where there is no C
for all the participants in the supervisory system availability of similar training or to professionals
(client, supervisee, supervisor); further, supervi- who prefer to enter a specific training of
sors should learn about local laws and regulations their choice, e.g., because it is provided in their
in the supervisee’s location that are pertinent to native language. Distance training saves cost and
client care (ibid.). time and in many cases allows education, which
As in the case of online therapy, synchronous would otherwise be unaffordable (Blackmore
types of online supervision, like videoconferenc- et al. 2008).
ing, are by now less popular among couple and Nowadays, the use of ICTs in CFT training
family therapists, who seem to feel more comfort- activities varies in frequency and intensity: from
able with offline modalities, though some forms sporadic use to adopting ICTs as the main, if not
of asynchronous digital communication like the only, method of providing education. CFT
e-mailing are more frequently used (Twist et al. training courses use ICT tools to enhance not
2016). Online supervision is usually preferred as only dialogue, circulation, and exchange of infor-
an adjunct to offline supervision; compared to mation and didactic materials between teachers
supervisors, supervisees are usually more at ease and students but also peer interaction among stu-
with supervision conducted solely online (ibid.), dents (e.g., ad hoc web social forum, Pomini et al.
probably due to the generational difference 2016). Through the web, students can gain access
between most supervisors being “digital immi- to a plethora of didactic materials and become
grants” and most supervisees being “digital more autonomous, while teachers should provide
natives.” assistance in choosing relevant information in a
Nevertheless, professionals’ attention to online critical way.
supervision seems to be increasing, as couple and Digital technology offers support and new
family therapists express more interest in learning instruments for a wide range of CFT training
about its effectiveness in comparison with offline activities, from a simple task, such as constructing
supervision (Blumer et al. 2015). Research on this genograms to more complex ones, like rating of
aspect is still limited, particularly in the CFT field; psychotherapy sessions for training or research
however, early findings showed that the supervi- purposes and recording and evaluating therapeu-
sory working alliance was not impaired by the use tic alliance. An online program based on the Sys-
of videoconference supervision (reported by tem for Observing Family Therapy Alliances
Rousmaniere 2014). (e-SOFTA) is used to rate client(s) and therapist
working alliance on four conceptual dimensions:
engagement in the therapeutic process, emotional
Online Training and Training in ICT Use connection with the therapist, safety within the
therapeutic system, and shared sense of purpose
Along with therapy and supervision, training within the family (Escudero et al. 2011). The
practices have been rapidly changing under the program is available on the web for research,
influence of digital technology. Utilization of supervision, training, or self-supervision (http://
e-mailing, chat, texting, and similar tools has softa-soatif.com/).
become a routine; videoconferencing for educa- Advantages of the utilization of ICTs in train-
tional purposes and online lessons is also well ing programs as an adjunct to traditional class-
established in academic contexts. Accredited room teaching are generally approved; however,
the debate regarding the advantages or disadvan- Ethical and Legal Issues
tages of solely online training programs is still
controversial. Despite the fact that online technol- Ethical concern in providing online psychother-
ogy allows group interactions, which can enrich apy or other e-mental health interventions is one
classroom communication among trainees and of the main worries expressed by mental health
between trainees and teachers (Boe et al. 2017), professionals regarding the use of ICTs in clinical
the lack of “face-to-face” group communication in practice. Questions of professional responsibility
a solely online setting limits students’ as well as like difficulties in conducting a correct assessment
teacher/trainee’s interactions. Nevertheless, group or managing crisis intervention online, as well as
videoconference with trainees from multiple loca- the delivery of online therapy in case of severe
tions and the online sharing of clinical and didac- psychiatric disorders, are further pointed out as
tical material facilitate the distance group training ethical dilemmas (Hertlein et al. 2014; Wrape and
(Rousmaniere 2014). McGinn 2018). Since there is no total data safety
With regard to education, the second main in the cyber endeavors, confidentiality is also one
topic is to what extent training programs include of the main concerns among therapists as well as
teaching of the appropriate ICT use in profes- clients.
sional and personal life and offer expertise in Working with clients, be it with adults or chil-
(clinical) online practice, including the risks and dren and adolescents, implies knowledge of the
benefits of such practices. Nowadays, the use of national legislation on online practices; if clients
social media is common among trainees are living in a different state, those might be
(Williams et al. 2013). Students as well as trained different or not defined yet (Rousmaniere 2014).
therapists must be aware that colleagues and cli- Further, a liability insurance appropriate to online
ents may potentially view their posts on social practices has to be considered.
networks. Patients searching for online informa- Several mental health associations released
tion about their therapists (“therapist-targeted guidelines for working with the Internet (see
googling” – TTG) and therapists’ searching online Mucic and Hilty 2016). According to the Ameri-
about clients (“patient-targeted googling” – PTG) can Association for Marriage and Family Therapy
are practices presenting risks not only for the Code of Ethics, (Standard VI Technology-
therapeutic process. Thus, it is important to Assisted Professional Services; AAMFT 2015),
address these topics during training and to provide not only therapists but also supervisors need to
trainees with education and guidelines on the use be trained in the use of technology before provid-
of ICTs both for professional and personal ing any kind of online activities and be aware of
purposes. national legislation regulating those (i.e., not prac-
In this given situation, the insufficiency of ticing online therapy outside their legal jurisdic-
adequate education offered by CFT training pro- tion). In online therapy or supervision, assuring
grams to their students has been underlined confidentiality is crucial, not only regarding cli-
(Blumer et al. 2015). This is the case particularly ents’ personal data but also concerning super-
regarding (a) the influence of ICTs on human visee’s information and the supervisee’s/
relationships and family life, (b) the management supervisor’s professional interaction. Clients and
of ICTs misuse by their clients, and (c) the appro- supervisees must be made aware of the risks and
priate use of ICTs in therapy and supervision. responsibilities associated with technology-
Core competences on the use of ICTs in therapy assisted services in written form and of both the
and supervision should include the evidence- therapist’s and clients’/supervisees’ responsibili-
based effectiveness of CFT online practices, ethi- ties for minimizing such risks (ibid.).
cal and legal concerns regarding these practices, The AAMFT guidelines for online practice of
confidentiality and privacy matters, general infor- couple and family therapy (Caldwell et al. 2017)
mation on how to conduct CFT online practices, summarize existing knowledge: (a) what stake-
and measures of security and safety (ibid.). holders need and prefer with regard to online
practice (e.g., access to qualified and appropriate online therapeutic programs (e-CFT) to help
care, insurance reimbursement) and (b) which are people in need to whom other forms are not
the current realities and evolving dynamics of our available, as well as assessing their effective-
environment (e.g., utilization, research, legal rec- ness, is a plea. Sharing knowledge about and
ognition, licensing). Ethical implications are evaluating CFT online training programs is
discussed, and best practice guidelines for online another task. Last but not least, the need for
psychotherapy are suggested regarding (1) com- education, dissemination of information, and C
pliance, (2) infrastructure, (3) advertising best practices regarding ethical and legal issues
and marketing, (4) informed consent, (5) initial linked to the use of ICTs in therapy, supervision,
assessment, (6) ongoing services, (7) crisis man- and training is a crucial aspect for the present
agement, (8) failures and breaches, and and future. While national legislations regulat-
(9) accountability and review. ing these practices are developing in several
In the year 2017, 13 out of 50 state documents countries, the nature of the web and the global-
of professional organizations’ ethical codes and ized societies will need transnational regulation
state licensure laws/rules in the United States and globally acknowledged guidelines, addressing
failed to include any technology-related key e-mental health, counseling, and psychotherapy
terms (Pennington et al. 2017). Those mentioning practices.
them (California scoring highest) focused upon
six major themes: supervision, continuing educa-
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Comparative Family Studies 30, 1–15. • Divorce therapy
Webb, L. M. (2015). Research on technology and the family.
From misconceptions to more accurate understandings. In • Sex therapy C
C. J. Bruess (Ed.), Family communication in the age of • Marriage therapy
digital and social media (pp. 3–31). New York: Peter Lang. • Couple therapy as adjunct to the treatment of
Williams, L., Johnson, E., & Patterson, J. E. (2013). The major mental illness, substance abuse, and
appropriate use and misuse of social media in MFT
training programs: Problems and prevention. Contem- spouse and family abuse
porary Family Therapy, 35(4), 698–712. https://doi.
org/10.1007/s10591-013-9256-4. Peer Review Policy
Wrape, E. R., & McGinn, M. M. (2018). Clinical and ethical Each paper is first briefly reviewed by the editor for
considerations for delivering couple and family therapy
via telehealth. Journal of Marital and Family Therapy, adherence to our standards of science and APA
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jmft.12319. a journal, it is sent out for review to a minimum of
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Couple and Relationship
tion of reviews, the editor makes a decision about
Therapy (Journal)
publication.
Volker Thomas
The University of Iowa, Iowa City, IA, USA
Couple Distress in Couple and
Introduction
Family Therapy
Douglas K. Snyder1, Richard E. Heyman2,

The Journal of Couple & Relationship Therapy
Stephen N. Haynes3 and Christina Balderrama-
promotes a better understanding of what contrib-
Durbin4
utes to healthy adult relationships and how ther- 1
Texas A&M University, College Station, TX, USA
apy facilitates the process. Experts address key 2
Family Translational Research Group, New York
treatment issues for all types of adult relation-
University, New York, NY, USA
ships. Articles explore couple therapy from the 3
University of Hawaiʻi at Mānoa, Honolulu, HI,
perspectives of theory, research, and practice, as
USA
well as issues related to the supervision and per- 4
Binghamton University – State University of
sonal growth of clinicians. Special thematic issues
New York, Binghamton, NY, USA
address a single topic for the entire issue, allowing
a more significant focus on that particular
topic. Recent thematic issues studied clinical con-
Name of Concept
cerns with interracial couples, and research and
treatment models addressing trauma in couples.
Couple Distress in Couple and Family Therapy
Contributions
Synonyms
The Journal of Couple & Relationship Therapy
discusses important issues from a multiplicity of Couple distress; Relationship dissatisfaction;
therapeutic styles including: Relationship distress
636 Couple Distress in Couple and Family Therapy
Introduction briefly summarized. Implications of these findings

for the practice of couple and family therapy are
Couple distress has a markedly high prevalence, offered, along with a clinical case example.
has a strong linkage to emotional and physical
health problems in the adult partners and
their offspring, and is among the most frequent Theoretical Context for Concept
primary or secondary concerns reported by indi-
viduals seeking assistance from mental health Couple distress (also referred to as relationship
professionals. distress with spouse or intimate partner) is con-
In the United States, the most salient indica- ceptualized within formal diagnostic nomencla-
tor of couple distress remains a divorce rate of tures (e.g., the DSM-5 or ICD-11) as occurring
40–50% among married couples, with about when (a) the major clinical focus is the subjec-
half of these occurring within the first 7 years tive experience of problematic quality in the
of marriage. Independent of divorce, many, if relationship, or (b) the problematic quality is
not most, marriages experience periods of sig- affecting the course, prognosis, or treatment of
nificant turmoil that place partners at risk for a mental or other medical disorder. Criteria
dissatisfaction, dissolution, or symptom devel- regarding impaired couple functioning include
opment (e.g., depression or anxiety); roughly behavioral (e.g., conflict resolution difficulty,
one-third of married persons report being in a withdrawal, aggression), cognitive (e.g.,
distressed relationship. Couple distress covaries chronic negative attributions or dismissal), or
with overall life dissatisfaction even more affective (e.g., chronic sadness, apathy, or
strongly than does distress in other domains anger) domains.
such as health, work, or children. Persons in However, these diagnostic perspectives fail to
distressed couple relationships are overrepre- recognize subthreshold deficiencies that couples
sented among individuals seeking mental health often present as a focus of concern, including
services, regardless of whether or not they those that detract from optimal individual or rela-
report couple distress as their primary tionship well-being. These include deficits in feel-
complaint. ings of security and closeness, shared values,
Maritally distressed partners are significantly trust, joy, love, physical intimacy, and similar
more likely to have a mood disorder, anxiety positive emotions that individuals typically value
disorder, or substance use disorder. Moreover, in their intimate relationships. Not all such deficits
couple distress – particularly negative necessarily culminate in “clinically significant”
communication – has direct adverse effects on impaired functioning or emotional and behavioral
cardiovascular, endocrine, immune, neurosen- symptoms as traditionally conceived; yet, fre-
sory, and other physiological systems that, in quently, these deficits are experienced as insidious
turn, contribute to physical health problems. Nor and may culminate in couple distress or partners’
are the effects of couple distress confined to the dissolution of their relationship.
adult partners. Couple distress has been related to
a wide range of deleterious effects on children,
including depression, anxiety, withdrawal, poor Description
social competence, health problems, poor aca-
demic performance, and a variety of other con- Understanding couple distress for purposes of
cerns (Vaez et al. 2015). couple and family therapy requires extending
This entry reviews empirical findings regard- beyond global sentiment to consider construct
ing behavioral, cognitive, and affective compo- domains particularly relevant to couple distress –
nents of couple distress. Findings regarding the including relationship behaviors, cognitions, and
comorbidity of couple distress with individual affect – as well as individual and broader cultural
emotional and behavioral health disorders are factors.
Relationship Behaviors indicate that distressed couples often exhibit a bias

Research examining behavioral components of cou- toward selectively attending to negative partner
ple distress has emphasized two domains: (a) the behaviors and relationship events and ignoring or
rates and reciprocity of positive and negative behav- minimizing positive events. Compared with non-
iors exchanged between partners and distressed couples, distressed partners also tend to
(b) communication behaviors related to both emo- blame each other for problems and to attribute each
tional expression and decision-making. Regarding other’s negative behaviors to broad and stable traits. C
the former, distressed partners, compared with non- Initial negative attributions predict relationship dete-
distressed partners, (a) are more hostile; (b) start rioration over the first 4 years of marriage. Dis-
their conversations more hostilely and maintain it tressed couples are also more likely to have
during the course of the conversation; (c) are more unrealistic standards and assumptions about how
likely to reciprocate and escalate their partners’ hos- relationships should work and lower expectancies
tility; (d) are less likely to edit their behavior during regarding their partner’s willingness or ability to
conflict, resulting in longer negative reciprocity change their behavior in some desired manner
loops; (e) emit less positive behavior; (f) suffer (Epstein and Baucom 2002).
more ill health effects from their conflicts; and
(g) are more likely to show demand$withdraw
Relationship Affect
patterns (Heyman 2001). Findings suggest a stron-
Similar to findings regarding behavior exchange,
ger linkage for negativity, compared with positivity,
research indicates that distressed couples are dis-
to overall couple distress.
tinguished from nondistressed couples by higher
Given the inevitability of disagreements arising
overall rates, duration, and reciprocity of negative
in long-term relationships, numerous studies have
relationship affect and, to a lesser extent, by lower
focused on specific communication behaviors that
rates of positive relationship affect. Nondistressed
exacerbate or impede the resolution of couple con-
couples show less reciprocity of positive affect,
flicts. Most notable among these are difficulties in
reflecting partners’ willingness or ability to
articulating thoughts and feelings related to specific
express positive sentiment spontaneously inde-
relationship concerns and deficits in decision-
pendent of their partner’s affect. By contrast, part-
making strategies for containing, reducing, or elim-
ners’ influence on each other’s negative affect has
inating conflict. Expression of criticism and con-
been reported for both proximal and distal out-
tempt, along with defensiveness and withdrawal,
comes. From a longitudinal perspective, couples
predict long-term distress and risk for relationship
who divorce are distinguished from those who
dissolution (Gottman 1994). Distressed couples are
remain married by partners’ initial levels of neg-
more likely than nondistressed couples to demon-
ative affect and by a stronger linkage of initial
strate a demand$withdraw pattern in which one
negativity to the other person’s negative affect
person attempts to engage the partner in relation-
over time. Although much of the couple literature
ship exchange and that partner withdraws, with
emphasizes negative emotions, deficits in positive
respective approach and retreat behaviors progres-
emotions such as smiling, laughter, expressions of
sively intensifying.
appreciation or respect, comfort or soothing,
mutual support or coping, and similar expressions
Relationship Cognitions
are equally important to consider as elements of
Social learning models of couple distress have
couple distress.
expanded to emphasize the role of cognitive pro-
cesses in mediating the impact of specific behaviors
on relationship functioning. Research in this domain Comorbid Individual Distress
has focused on such factors as selective attention, There is growing evidence that couple distress
attributions for positive and negative relationship covaries with, contributes to, and results from
events, and specific relationship assumptions, stan- individual emotional and behavioral disorders.
dards, and expectancies. For example, findings Representative community surveys indicate that
638 Couple Distress in Couple and Family Therapy
maritally distressed partners, compared with non- findings across multiple assessment methods includ-
distressed persons, are between two to three times ing self- and other-report measures as well as inter-
more likely to have a mood disorder, anxiety view and observational methods (Snyder et al. in
disorder, or substance use disorder (Whisman press). Certain domains (communication, aggres-
2007). Hence, when considering couple distress, sion, substance use, affective disorders, emotional
additional assessment should be made of the or physical involvement with an outside person)
extent to which either partner exhibits individual should always be assessed either because of their
emotional or behavioral difficulties potentially robust linkage to relationship difficulties (e.g., com-
contributing to, exacerbating, or resulting in part munication processes involving emotional expres-
from couple distress. siveness and decision-making) or because the
specific behaviors, if present, have particularly
Cultural Differences in Couple Distress adverse impact on relationship functioning (e.g.,
Cultural differences may also influence the devel- physical aggression or substance abuse).
opment, subjective experience, and overt expres- Second, because the functional sources of couple
sion of couple distress. These include not only distress vary so dramatically, the critical mediators
cross-national differences in couples’ relation- or mechanisms of change should also be expected to
ships but also cross-cultural differences within vary – as should the therapeutic strategies intended
nationality and variations in nontraditional rela- to facilitate positive change. Although substantial
tionships including gay and lesbian couples. evidence affirms that various versions of couple
Important differences among couples may occur therapy produce moderate, statistically significant,
as a function of their race/ethnicity, culture, reli- and often clinically significant effects, findings also
gious orientation, economic level, and age. These indicate that nearly a third of couples fail to improve
dimensions can affect the importance of the cou- in couple therapy, and up to one-half may lose gains
ple relationship to a partner’s quality of life, their in relationship satisfaction in the first 4–5 years
expectancies regarding marital and parenting following treatment (Lebow et al. 2012). The
roles, typical patterns of verbal and nonverbal diverse patterns of factors contributing to couple
communication and decision-making within the distress may be addressed with differential efficacy
family, the behaviors that are considered by different treatment approaches specifically
distressing, sources of relationship conflict, the targeting these causal influences. That is, particu-
type of external stressors faced by a family, and larly complex or difficult couples may benefit most
the ways that partners respond to couple distress from a treatment strategy drawing from both con-
and divorce. Moreover, when partners are from ceptual and technical innovations from diverse the-
different cultures, cultural differences and con- oretical models relevant to different components of
flicts can be a source of couple distress. a couple’s struggles (Snyder and Balderrama-
Durbin 2012).

Family Therapy Clinical Example
Variations in the multiple sources, expressions, and Karen and David entered couple therapy following
impacts of couple distress have important implica- Karen’s miscarriage 2 months earlier. The trauma of
tions for both the assessment and treatment of cou- their loss compounded significant stressors the cou-
ple and family difficulties. First, because the ple had endured for the prior 2 years related to
composition of couple distress includes both subjec- David’s struggles in graduate school and Karen’s
tive elements (e.g., affective and cognitive compo- efforts to balance part-time secretarial work with her
nents) and objective or external elements accessible responsibilities as a mother to their 4-year-old son.
to direct observation (e.g., communication behav- They had managed to keep their marriage together
iors), assessment of couple distress should integrate despite financial hardships and growing emotional
distance between them. Karen longed for the emo- emotional expressiveness and in processing and
tional closeness she had anticipated her marriage then paraphrasing feelings that Karen disclosed.
would offer and that she had enjoyed with her sister Although emotionally more astute, Karen
growing up. Instead of drawing closer over the frequently felt overwhelmed by her own dis-
years, David seemed increasingly distant and tress; her desperate needs for soothing often
aloof. Karen’s efforts to draw him nearer and her escalated to a demandingness that precluded
complaints about his emotional detachment seemed the very comfort from David that she sought. C
to drive them further apart. David wished he could Learning to regulate her own affect more effec-
be more the kind of husband that Karen wanted, but tively and to approach David in a less
her unhappiness with him was apparent and his confrontive manner allowed him enough secu-
feelings of inadequacy in the marriage compounded rity to risk more emotional engagement from
the inadequacy he felt across most areas of his life. his end.
He had cried only briefly following Karen’s miscar- Examining their differences in assumptions
riage. David tried to invest more time and energy and expectancies about relationship intimacy
with their young son, but his efforts admittedly felt helped Karen and David to label their differ-
half-hearted. He empathized with Karen’s unhappi- ences in a less personalized, less blaming man-
ness, felt largely to blame, but found it difficult to ner. Adopting an alternative attributional
approach her given the increasing resentments she framework that emphasized cognitive processes
seemed to harbor toward him. rather than deficits in caring or commitment to
Initial interventions in couple therapy empha- their marriage helped to reduce the hurt that
sized providing a secure context for both partners accompanied their frustrations. As therapy pro-
to discuss their hurts and disappointments without gressed, Karen began to reexamine the criteria
attacking the other, deriving a formulation of their by which she judged David’s behaviors as an
difficulties that emphasized stressors outside as well expression of his caring, recognizing that these
as within their marriage, and identifying both indi- were so narrow and so rigid that she ended up
vidual and relationship strengths that had sustained dismissing or rejecting many of his efforts to
them through years of struggle and could be mobi- please her or show her that he cared. David also
lized to reverse the growing despair each had expe- benefitted from examining his own early rela-
rienced in the past few months. David became more tionship experiences, coming to recognize that
willing to hear Karen’s anguish when this was soft- emotional nonexpressiveness was the norm
ened by the therapist’s reflections, and gradually he throughout both his parents’ families for the
grew able to share his own grief and the immobili- last several generations. As therapy
zation he experienced when he thought about their approached its conclusion, both partners
loss. Both partners became better able to draw on reported experiencing greater understanding of
each other for comfort around this tragedy. Their themselves and each other, a stronger sense of
marital tensions diminished as the therapist helped commitment to their marriage, and less negative
each of them to confront individual and relational reactivity during times of external stress or rela-
challenges – David in managing responsibilities at tionship disagreements.
school and Karen in adjusting her work demands
and finding more reliable childcare for their son; and
the couple in blocking out one evening each week to Cross-References
engage in an activity outside their home and another
evening for discussing mutual aspirations and low- ▶ Affect in Couple and Family Therapy
conflict concerns. ▶ Four Horsemen in Couple and Family Therapy
Similar to most couples entering therapy, ▶ High Conflict Couples
Karen and David each demonstrated deficien- ▶ Pluralistic Approach to Couple Therapy
cies in their communication skills. David’s skill ▶ Snyder, Doug
deficits revolved primarily around difficulties in ▶ Training in Couple Therapy
640 Couple Therapy
Epstein, N. B., & Baucom, D. H. (2002). Enhanced Couple therapy is a concept that has been around
cognitive-behavioral therapy for couples:
since the twentieth century, but the practice of
A contextual approach. Washington, DC: American
Psychological Association. working with couples together in therapy is a
Gottman, J. M. (1994). What predicts divorce? The rela- much newer concept. Psychotherapy was origi-
tionship between marital processes and marital out- nally developed to focus on the individual. How-
comes. Hillsdale: Erlbaum.
ever, the first notions of couple therapy began in
Heyman, R. E. (2001). Observation of couple conflicts:
Clinical assessment applications, stubborn truths, and Germany in the 1920s as a part of the Eugenics
shaky foundations. Psychological Assessment, 13, 5–35. movement (Kline 2001) – a movement that
Lebow, J. L., Chambers, A. L., Christensen, A., & Johnson, attempted to improve the genetic qualities of man-
S. M. (2012). Research on the treatment of couple
kind. In the United States, “institutes for marriage
distress. Journal of Marital and Family Therapy, 38,
145–168. counseling” were first seen in the 1930s. The
Snyder, D. K., & Balderrama-Durbin, C. (2012). Integrative counseling was commonly offered to individuals
approaches to couple therapy: Implications for clinical separately, and treatment consisted of advice and
practice and research. Behavior Therapy, 43, 13–24.
information about values and obligations of mar-
Snyder, D. K., Heyman, R. E., Haynes, S. N., &
Balderrama-Durbin, C. (in press). Couple distress. In riage (Gurman and Fraenkel 2002).
J. Hunsley & E. Mash (Eds.), A guide to assessments Couple therapy, what was then called marriage
that work (2nd ed., pp. xxx–xxx). New York: Oxford counseling, continued with this format of treat-
University Press.
ment until psychoanalytic therapists began to con-
Vaez, E., Indran, R., Abdollahi, A., Juhari, R., & Mansor,
M. (2015). How marital relations affect child behavior: sider bringing each member of the couple into the
Review of recent research. Vulnerable Children and therapy room. This went against fundamental ana-
Youth Studies, 10, 321–336. lyst beliefs, and the practice never gained popu-
Whisman, M. A. (2007). Marital distress and DSM-IV psy-
larity (Gurman and Fraenkel 2002). It was not
chiatric disorders in a population-based national survey.
Journal of Abnormal Psychology, 116, 638–643. until the 1950s when psychiatrists began
experimenting with treating individual pathology
within the context of their families. Consequently,
therapists began to see the benefits of treating
relationships and couple therapy burgeoned.
Couple Therapy Today, couple therapy has developed into a
large body of psychotherapy theories grounded
Laura Sudano1,2, Jamie Banker3, Nicole Goren4 in a variety of theoretical backgrounds (Lebow
and Chloé E. Zessin5 2000). Couple therapy is considered a psychother-
1
University of California, Department of Family apy modality that focuses on the relationships
Medicine and Public Health, San Diego, between intimate partners and is no longer limited
CA, USA to married couples. Couple counseling theories
2
Winston Salem, NC, USA are considerate of cohort, culture, sexual orienta-
3
California Lutheran University, Thousand Oaks, tion, gender identity, and relationship style.
CA, USA
4
University of San Diego, San Diego, CA, USA
5
California Lutheran University, Port Hueneme, Prominent Figures
CA, USA
Neil Jacobson, Andrew Christensen, Robert
Weiss, Susan M. Johnson, John Gottman, Julie
Name of Theory Gottman, Harville Hendrix, Helen Hunt, Michael
Balint, William R. Fairbairn, Harry Guntrip,
Couple therapy Donald Winnicott, Melanie Klein, Henry Dick,
Couple Therapy 641
Edith Balint, Michael White, David Epston, Behavioral Couple Therapies

Milton Erickson, Steve De Shazier, Insoo Kim
Berg, Salvador Minuchin, Murray Bowen, Jay Integrative Behavioral Couple Therapy (IBCT).
Haley, Cloe Madanes, Milton Erickson, Don IBCT emerged when there was strong empirical
Jackson, and Stephen A. Mitchell support for traditional Behavioral Couple Ther-
apy, but there was also evidence suggesting its
limitations (Jacobson et al. 1984). IBCT focuses C
Description less on behavioral change and more on changing
the recipients’ views to acceptance (Jacobson
Couple therapy is more prevalent than ever and Christensen 1998). Acceptance is not resig-
before. There are a vast number of theoretical nation or a sign of weakness, but instead it is the
orientations, suited to fit many different relation- partner’s ability to keep their bond despite their
ship styles. These theories continuously gain issues. Acceptance comes when partners can
evidence-based research, proving their effective- understand the deeper meaning behind their
ness. Marriage and family therapists are more behavior, when they look at why it is there,
likely to see couples (as opposed to entire fami- and avoid thinking of the behavior in terms of
lies) in counseling, although spiritual counselors caring. The therapist must identify a theme for
and individual psychotherapists continue to the couple. IBCT also tries to facilitate a DEEP
become educated in couple therapy (Gurman and analysis of these themes (Christensen et al.
Fraenkel 2002). 2015). The therapist helps the couple look at
Numerous models informed by multiple theo- differences, emotional sensitivities, external
ries have been developed to guide the therapeutic stressors, and their patterns of interaction. The
work and to help therapists and couples hone treatment sessions focus on events that are hap-
specific aspects of the relationship (Gurman pening in the couple’s life. The therapist will
2011). This entry outlines the full range of couple look at patterns of interactions, events that may
therapy models and the theories that guide them. trigger conflict, negative events, and positive
The models are categorized based on the over- interactions. There are three main strategies:
arching themes for which these models were (1) acceptance strategies such as unified detach-
developed, and each category uses different theo- ment and empathic joining, (2) tolerance strate-
retical orientations to guide conceptualization and gies, and (3) change strategies.
intervention. These couple therapy models Behavioral couple therapy. Once named
include behavioral couple therapies, emotion- behavioral marital therapy (BMT), behavioral
centered, psychoanalytic and psychodynamic, couple therapy (BCT) is informed by operant
social constructionist, and systemic therapies. conditioning, positive reinforcement, punish-
Specifically, the models include Integrative ment, negative reinforcement, negative reci-
Behavioral Couple Therapy (IBCT), behavioral procity, shaping, extinction, functional
couple therapy, emotionally focused couple ther- analysis, discriminative stimuli, social learning
apy, Gottman Method Couple Therapy, integra- (social cognitive), social exchange, and nega-
tive problem-centered metaframeworks (IPCM), tive reciprocity. As is implied in the name, the
integrative couple therapy, brief relational couple theories informing this approach are behavioral
therapy, Object Relations Couple Therapy, psy- therapies. The original model included four pro-
choanalytic couple therapy, psychodynamic cou- cesses: (1) communication skills, (2) problem-
ple therapy, Imago relationship therapy, narrative solving skills, (3) relationship enhancement,
couple therapy, solution-focused couple therapy and (4) use of contracting to promote behavior
(SFCT), Bowen family systems therapy with cou- exchange. BCT broadened its focus in the 1980s
ples/intergenerational couple therapy, and Brief and included cognitions to include covert
Strategic Couple Therapy (BSCT). processes.
642 Couple Therapy
Emotion-Centered Couple Therapies meaning system. Gottman and Levenson (2002)

found that a 5:1 ratio of positive to negative com-
Emotionally Focused Couple Therapy. Emotion- ments during conflict was predictive of happy
ally focused couple therapy (EFT) holds that pri- couples, and thus, this has become part of the
mary emotions underlie vicious cycles that are therapy.
driven by the need for attachment (Johnson
2005; Johnson 2015). Based on attachment theory
(Bowlby 1969), EFT looks at the need for attach- Integrative Therapies
ment as the driving force behind distress. The
therapist encourages couples to access and display Integrative Problem-Centered Metaframeworks
their primary emotions. This restructures their (IPCM) Couple Therapy. IPCM is an integrative
interactional pattern and thus reinforces their approach that looks to maximize the success from
attachment. Treatment is experiential and includes many different models (Lebow 1997). The five
three stages: (1) cycle de-escalation, (2) change main theories that IPCM draws from are (1) partial
interactional patterns, and (3) consolidation and and progressive knowing, (2) systems theory,
integration. The nine steps in therapy are (1) iden- (3) theory of constraints, (4) differential causality,
tify relational conflict, (2) identify negative cycle, and (5) sequential organization (Breunlin et al.
(3) access underlying emotions, (4) reframe prob- 2011). The therapist follows the four phases of
lem in cycle terms, (5) identify disowned attach- hypothesizing, planning, conversing, and feed-
ment needs, (6) promote acceptance of other back (Breunlin et al. 2011; Pinsof et al. 2011).
partner’s experience, (7) promote expression of IPCM is an empirically based approach, and thus
needs, (8) help find new solutions to old problems, the Systemic Therapy Inventory of Change
and (9) consolidate (Johnson 2015). (STIC) (Pinsof et al. 2009) aims to bring this
Gottman Method Couple Therapy. John research into the room. Overall, IPCM looks to
Gottman’s research lead to the development of provide a new integrative model with a basis in
Gottman method couple therapy. Gottman found common factors.
that “masters” of relationships are relatively Integrative Couple Therapy: The Functional
happy and stable couples and “disasters” of rela- Analytic Approach (FACT). FACT maintains that
tionships are either unhappy or no longer together the ability to improve a couple’s relationship lies
(Gottman and Gottman 2015). What separates within them, and thus conjoint sessions are nec-
masters from disasters is the couples’ ability to essary (Gurman 2001). The therapist looks to the
handle conflict and lack of escalation of mild couple to bring up the focus of the session, typi-
negative affect. Gottman Method Couple Therapy cally an interpersonal issue, knowing that each
begins with a systematic assessment: a conjoint topic is most likely interconnected to the couples
interview, relationship history, conflict discussion, underlying issue. In early sessions, most conver-
individual interviews, and questionnaires. The sations are partner to therapist, progressing
therapist and the couple come up with agreed toward more partner–partner conversations as
upon goals, based on the assessment (Gottman the couple gets more comfortable with the pro-
and Gottman 2015). Since Gottman Method Cou- cess. There are three roles for the therapist in
ple Therapy is an experiential approach, the ther- FACT: (1) identify maladaptive patterns,
apist attempts to make sessions as dyadic as (2) teach the couple systemic awareness, and
possible, validating and aiding in communication (3) help the couple understand and overcome cen-
(Wile 1993). The five goals of Gottman Method tral “rules” that are keeping the problem (Gurman
Couple Therapy are to (1) downregulate negative 2015). FACT focuses on both individual change
affect during conflict, (2) upregulate positive and couple change (Gurman 2008), because they
affect during conflict, (3) build positive affect in work both ways. Because FACT relies on context,
nonconflicting times, (4) bridge meta-emotion there are no real techniques that are FACT
mismatches, and (5) create and nurture a shared specific. There are, however, three types of
Couple Therapy 643
clinically relevant behaviors (CRBs) that are crit- becoming a transitional object for expression of
ical in FACT: (1) problems in session, feeling (Fairbairn 1949). Therapists remain
(2) improvements in session, and (3) interpreta- impartial, communicating their feelings only
tions of behavior. The five rules of FACT are when it is relevant to their experience of the
(1) watch for CRBs, (2) evoke CRBs, (3) respond couple – therapist’s do not self-disclose. Goals
to CRBs, (4) watch for therapist effects on couple, of treatment are to identify and modify each part-
and (5) recognize variables that elicit behavior and ner’s unconscious transfer of his or her own C
generalize (Gurman 2015). desires or emotions to the other person (Scharff
and Scharff 2004). Therapists advance the capa-
bility of the couple’s ability to provide for one
Psychoanalytic and Psychodynamic another’s needs with regard to attachment, com-
Therapies munication, evidenced by empathy, and intimacy.
Therapists promote self-differentiation between
Brief Relational Couple Therapy. Brief relational partners and assist the couple in resuming their
couple therapy originates from object relations own stage of the couple life cycle with sureness in
theory and is informed by relational psychother- their abilities (Scharff and Scharff 2004). Object
apy. Specifically, brief relational couple therapy is relations couple therapy does not focus on indi-
informed by pieces of interpersonal psychoanaly- vidual client goals. Collaborating with clients on
sis, object relations theory, self-psychology, fem- their goals is considered to be obstructive to the
inist and postmodern thinking, infant–mother healing process, because symptoms are used as
developmental research, attachment theory, and guides to underlying anger and anxiety (Scharff
emotion theory. This approach investigates client and Scharff 2004).
relationship patterns that occur inside a couple’s Psychoanalytic Couple Therapy. Psychoana-
emotional world. The task of therapy is to work lytic couple therapy, rooted in psychoanalytic the-
collaboratively to recognize the themes of the ory, draws on the therapist’s experience of dealing
relationship between the therapist and client and with relationships in individual, group, and family
to look for the deeper meaning in everything that therapy. Techniques include therapists using
arises in therapy (Mitchell and Aron 1999). Tech- themselves as a tool to relate in depth with a
niques include examining responses to interven- couple to advance contact with a couple’s anxi-
tions and real-time client–therapist interactions. eties and defenses – therapists then interpret the
Therapists use rupture and repair as a healing anxiety to create change within the couple. Trans-
mechanism. ference and countertransference are used as ther-
Object Relations Couple Therapy. Rooted in apeutic tools. Goals of therapy are for couples to
Freud’s psychoanalytic theory, object relations pass through the stages they are stuck in, in order
couple therapy is a nondirective model in which to be authentic with one another and improve their
the therapist utilizes the anxiety in the room to emotional functioning (Dicks 1953).
build the therapeutic alliance. The therapist can Psychodynamic Couple Therapy. Psychody-
provide advice depending on the needs of the namic therapy comes from psychoanalytic theory
couple, but also relies on free association and which is influenced by Freudian theory, ego psy-
spousal reaction to track the unconscious and chology, object relations, and self-psychology.
explore countertransference (Scharff and Scharff Psychodynamic couple therapy is insight ori-
2004). Therapists explore a couple’s dreams and ented, concentrating on unconscious processes
fantasies, paying special attention to personal as they are exhibited in present behavior. Tech-
interpretation and reaction between spouses. The niques include assessing the unconscious in order
main technique of object relations couple therapy to reveal feelings that have been pushed out of
is for the therapists to use themselves as an object awareness, but are keeping people stuck. The goal
in the room. The therapist should aim to encom- of therapy is to foster self-awareness and under-
pass the hurt and anxiety between the couple, standing on how the past influences the present.
644 Couple Therapy
Unfulfilled needs of the past shape one or both of form of postmodern psychotherapy informed
the members of the couple’s behavior. Reality by the philosophical work of Michael Foucault.
becomes inaccurate, and expectancies between The idea behind narrative/social constructionist
the couple become excessive. With the help of a therapy is that if you separate a person from
therapist, functional patterns can be explored that his/her problem, he/she is able to externalize
encourage positive perception of reality (Scharff and therefore minimize the problems that exist
and Scharff 2014). in him/her lives (White 2009). A person’s expe-
Imago Relationship Therapy. Imago relation- rience becomes his/her dominant story, and this
ship therapy grew out of psychoanalytic theory, story gives meaning and shapes identity. Prob-
among many others. Imago relationship therapy lems occur when negative experiences shape a
comes from the idea that issues in adult relation- person’s story. Narrative therapy suggests that
ships are correlated to early childhood experi- people can change their stories, and therapists
ences and that most human problems stem from help them coauthor their new stories based on
a lack of connection (Hendrix and Hunt 2004). values that are discovered through the narrative
The main goal is to have each partner in a couple process. A primary technique is to externalize
become more self-aware and create a more problems from couples which stops blaming
empathetic connection. When one can learn to behaviors and allows for collaboration between
love his/her partner more fully, Imago relation- the couple and therapist on how the couple is
ship therapy believes that one can then begin to allowing the problem to flourish and ways in
heal the wounds from childhood (Hendrix and which to stop the outside problem from flooding
Hunt 2004). The main treatment method used to their relationship. Goals include engaging cli-
achieve these goals is “Imago Dialogue.” In this ents in making sense of their narrative, separat-
dialogue, couples are taught to lower their ing the person from the problem, externalizing,
defensiveness and to truly listen to each other. deconstructing problem-saturated stories, and
This helps foster clearer understanding both of finding exceptions (White 1993).
their own needs and the needs of the partner. Solution-Focused Couple Therapy (SFCT).
Couples will explore images of both their part- Inspired by Milton Erickson’s brief therapy,
ners and their early childhood caretakers. The SFCT searches for what is already working in
two techniques used are (1) parent/child dia- relationships. Techniques include miracle
logue and a (2) holding exercise. After this, questioning, scaling questions, and exception
Imago relationship therapy moves to question. Therapists assist in finding exceptions
behavioral techniques where partners are to when the relationship problems are occurring
encouraged to restructure their frustrations to and use those occurrences as a foundation for
desires. They come up with a list of behaviors solutions (de Shazer et al. 2007). Therapists are
that their partner can do to make them feel collaborative with their clients and set goals for
loved, and they are encouraged to do these. the couple, as well as the individuals within the
Lastly, partners are asked to develop a shared dyad. Moreover, therapists view clients as capa-
vision of their ideal marriage. It is important to ble of change and focus on strengths rather than
note that Imago only works if both partners are deficits. Therapists assist their clients in making
ready to both give and receive this love goals concrete, manageable, and clear (Berg and
(Hendrix and Hunt 2004). De Jong 1996). Small changes make a large
impact on the couple by creating a ripple effect.
Repetition of a couple’s success is imperative
Social Constructionist Therapies because this builds confidence and reinforces
positive coping skills for future problems.
Narrative Couple Therapy. Narrative couple Goals include instilling hope, managing
therapy originates from narrative therapy, a change, and “cheerleading” the small successes.
Couple Therapy 645
Because therapists focus on solutions rather intervention is brief, because when the positive
than fixing problems, the model is intended to feedback loop is interrupted, the problem
be short term/brief therapy. behavior stops (Haley 1963). Techniques
include reframing, symptom prescription, para-
doxes, ordeals, restraining techniques, and dou-
Systemic Therapies ble binds. Goals of treatment include
identifying feedback loops, discovering the C
Bowen Family Systems Therapy with Couples/ rules that govern the loop, and changing the
Intergenerational Couple Therapy. Bowen fam- loop/rules between the couple.
ily systems theory is a systemic approach that Since client and therapist are influencing one
works both for families and couples. The ther- another, therapists use enactments, which include
apy and theory proposes that a person with the therapist directing the family members to
increased anxiety and inability to separate speak as if the therapist was not present, to explore
thoughts from emotions (intra- and interperson- how their clients relate in the world. The enact-
ally) within his/her family of origin will have ments are indicative of repetitive relational pat-
increased levels of anxiety, particularly within terns between couples, which give insight into
future intimate relationships. Differentiation is personal history. The goal is to use these intrapsy-
defined as an ability to distinguish oneself in chic and interpersonal discoveries to assist the
relation to the family or intimate relationships client in acknowledging their ways of relating to
(Kerr and Bowen 1988). The lack of differenti- others. Then the therapist assists in helping the
ation can lead to or exacerbate issues within a client gain self-reflective skills to become aware
couple. Every couple has conflict as it is difficult and less reactive.
to remain an individual while attaching in an
emotionally intense relationship. The therapist
functions as a coach to help the individuals and Relevance to Couple and Family Therapy
the team achieve higher levels of differentiation
(Bowen 1978). This approach views the dyadic Theories in couple therapy approaches often over-
issues in the context of their extended families, lap but vary. The variety of approaches that are
and thus genograms are often used throughout informed by similar and differing theories offer
the treatment. The two main goals are (1) reduce varied conceptual understandings of working with
anxiety within the dyad and (2) increase levels couples.
of differentiation (Baker 2015). Bowenian ther- Models are created from modern and postmod-
apists focus on process as opposed to content, ern theories. That is, modern models are rooted in
avoid being triangulated, and expose the under- behavioral therapies, while postmodern theories
lying emotional processes to help clients think emphasize intersectionality of the human experi-
about their problems differently and deepen the ence. Despite how a therapist conceptualizes a
understanding of each other. case, each model’s intervention is informed by
Brief Strategic Couple Therapy (BSCT). theory.
BSCT was inspired by strategic family therapy
theory, which has its foundation in cybernetics
models. BSCT focuses on the theory of para- Clinical Example of Application of
doxical intervention and problem-maintaining Theory in Couples and Families
behaviors (Haley 1963). If a couple is using a
“solution” that is maintaining a problem Mark and Tom are in their late 40s and present
(positive feedback loop), the goal of therapy is with issues related to infidelity. Mark presents
to interrupt the problem/solution pattern with irritability and notes that he works tire-
(creating a negative feedback loop). The lessly as a litigation lawyer and often brings
646 Couple Therapy
work home where he stays up past when his a gay, married male couple raising an adolescent
family is asleep to complete his work-related female, there are varying stressors. For exam-
tasks. Tom, a stay-at-home dad who raises ple, Mark and Tom may confront their roles
their 13-year-old daughter, Arden, presents associated with life cycle and sexuality differ-
symptoms of depression. Tom notes that he ently. That is, Mark may experience what it
had an affair with a family friend, a woman, means to be a gay married, employed, older
for the past 8 years. Tom reports that the affair male raising an adolescent daughter differently
started around the same time that the couple from Tom, a gay married, stay-at-home dad,
adopted Arden. Tom reports feeling distant older male raising an adolescent daughter.
from Mark and stressed from raising Arden on A psychosocial and postmodern approach to
his own. Arden does well in school and has working with this couple may provide fruitful
friends, but she is withdrawn from both parents. therapeutic experience working within a Bowen
The therapist observes Mark and Tom blam- family systems and narrative therapy approach.
ing each other for Tom’s infidelity. Mark notes In essence, a patient-centered approach to
that he is the one who “wants to talk about understanding each partner’s family or origin
everything” as his family often discussed dis- and contextual experience can strengthen thera-
agreements openly. Tom reports “wanting to get peutic alliance and outcomes.
over things” and notes how his father worked
hard to support his family of six while his mom
Cross-References
was a stay-at-home parent. Tom further dis-
closes that his father abused alcohol and his
mother abused substances which caused divi-
▶ Bowen Family Systems Therapy with Couples
sion within the family that eventually led them
▶ Bowen Family Systems Therapy with Families
to divorce when he was 16 years old.
▶ Brief Relational Couple Therapy
The therapist determines that the couple is
▶ Brief Strategic Couple Therapy
struggling with family of origin issues related to
emotional processes, triangulation, and the life
▶ Gottman Method Couples Therapy
stressors of being a gay, male couple raising an
▶ Imago Enrichment Program
adolescent child. Therefore, Bowen family sys-
▶ Integrative Behavioral Couple Therapy
tems therapy with couples/intergenerational cou-
▶ Integrative Couple Therapy: The Functional
ple therapy and narrative therapy approach
Analytic Approach
would be ideal to address the couple’s issue
▶ Integrative Problem-Centered Metaframeworks
related to conflict. Therapy goals include
▶ Narrative Couple Therapy
increasing the couple’s level of differentiation
▶ Object Relations Couple Therapy
and exploring the dominant discourse of homo-
▶ Psychoanalytic Couple and Family Therapy
phobia. The therapist will use genograms to
▶ Psychodynamic Couple Therapy
highlight intergenerational patterns of triangula-
▶ Solution-Focused Couple and Family Therapy
tion, particularly in Tom’s family of origin, and
emotional process of avoidance, in Mark’s fam-
ily of origin, that will allow the couple to process
References
their different patterns. Furthermore, a genogram
will be helpful to identify multigenerational pat- Baker, K. G. (2015). Integrative behavioral couple therapy.
terns of triangulation to decrease the anxiety in In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.),
the relationship, particularly for Mark as he con- Clinical handbook of couple therapy (5th ed.,
sumes himself with work and Tom as he seeks pp. 246–267). New York: Guilford Press.
Berg, I. K., & De Jong, P. (1996). Solution-building
out another partner to decrease anxiety. conversations: Co-constructing a sense of competence
Lastly, patient in context is important to with clients. Families in Society, 77(6), 376–391.
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Bowen, M. (1978). Family therapy in clinical practice. Jacobson, N. S., & Christensen, A. (1998). Acceptance and
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Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. forming relationships. New York: Norton.
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(2011). Integrative problem centered metaframeworks G. (1984). Variability in outcome and clinical signif-
(IPCM) therapy: I. Core concepts and hypothesizing. icance of behavioral marital therapy: A reanalysis of
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648 Couple Violence in Couple and Family Therapy
to stay together. Gender-specific approaches to

Couple Violence in Couple treatment of IPV were introduced in the 1970s
and Family Therapy when the feminist movement began to challenge
dominant social beliefs that male violence in inti-
Chelsea Spencer, Marcos Mendez and mate relationships was a private isolated event. At
Sandra Stith that time, IPV was believed to occur solely in the
Kansas State University, Manhattan, KS, USA context of a patriarchal, male-dominated society
in which men exerted power and control over
women.
Synonyms Since then, four decades of research expanded
on the feminist view of the 1970s and integrated
Domestic violence; Intimate partner violence; this perspective into a more intersectional, multi-
IPV; Partner violence factorial perspective, which led to treatment alter-
natives for women and men who experience IPV
(George and Stith 2014). In addition to early clin-
Introduction ical studies which sampled women in shelters and
hospitals, nationally representative studies in the
Approximately 24% of all intimate relationships 1980s began to discover that rates of male vio-
experience some forms of violence, and between lence in the context of intimate relationships were
36% and 58% couples who are seeking therapy similar to rates of female violence (Straus 2005).
have experienced physical violence in their rela- These findings helped the research community
tionships (Jose and O’Leary 2009). However, not begin to shift the initial views of IPV resulting in
all couples who experience violence in their rela- almost exclusively of male perpetration and
tionships are the same, nor are they all appropriate female victimization, to a perspective that recog-
for couples therapy. Johnson (2008) identified nizes that both men and women can be perpetra-
different typologies of violent relationships, two tors and victims of IPV.
of the most commonly recognized being intimate Studies on IPV risk factors revealed that rela-
terrorism and situational couple violence. Intimate tionship factors, such as partner emotional abuse,
terrorism is characterized by asymmetric violence marital satisfaction, and attachment, are some of
that is used as a means to control one’s partner. the most important predictors of IPV (Stith
Couples experiencing intimate terrorism are genet al. 2004). Research has also made it clear that
erally not considered appropriate for couples some IPV perpetration result from a maladaptive
treatment (Stith et al. 2011). Situational couple response to conflict in relationships or from cou-
violence is characterized by less severe violence ples’ inability to resolve conflict in a non-violent
that is often bidirectional in nature and typically a matter (Johnson 2008). Since many couples want
response to a specific situation (Johnson 2008). to stay together, end the violence, and work on
There is some research evidence that conjoint their relationship, researchers have developed and
treatment with couples experiencing situational tested couple’s therapy treatment for IPV.
couple’s violence can be safe and effective in
reducing violence (Stith et al. 2012).
Description of Treatment Approach
Theoretical Context for Concepts Systemic treatment of IPV focuses on working

and Description of Concepts with both individuals in the relationship, as
opposed to traditional treatments that focused on
Couples therapy for IPV was developed as an working solely with the violent offender. A variety
alternative to gender-specific approaches to treat- of approaches have been developed and tested for
ment for carefully screened couples who choose working conjointly with couples, including
Couple Violence in Couple and Family Therapy 649
behavioral couples therapy (O’Farrell and Fals- to conduct conjoint therapy that week. If it is not
Stewart 2002). However, in this entry, we focus on considered to be safe, the co-therapist works with
one particular approach. each client (or each group) separately. If it is
Domestic violence-focused couples treatment determined that conjoint therapy is appropriate,
(DVFCT) is a manualized program for treating all clients and co-therapists meet conjointly. At
couples experiencing situational couple violence the end of each session, co-therapists again meet
(Stith et al. 2011). Its development began in separately with clients to determine if there is C
1997 at Virginia Tech using funding from the work to do before the couple leaves together.
National Institute of Mental Health; DVFCT can DVFCT is designed to be conducted using a
be conducted in a multi-couple group format or solution-focused framework in 18 sessions. In the
with one couple at a time, and treatment is pro- first 6 weeks, the therapist works primarily with
vided by two co-therapists. DVFCT is grounded men and women separately and helps them use
in solution-focused brief therapy (De Shazer and practice mindfulness exercises, develops and
1985). Therapist using this model seeks to avoid practices a negotiated time-out, begins to address
raising emotional intensity (that could possibly substance abuse issues (if necessary), and
trigger violence in the relationship) and promotes uses psychoeducation to help them understand
building on strengths in the couple’s relationship IPV. Psychoeducation that is important to address
(Stith et al. 2011). Research examining the effec- in therapy includes the definition of what consti-
tiveness of DVFCT has found that this treatment tutes IPV and the various types of abuse (i.e.,
for IPV has led to a decrease in both psychological physical, sexual, emotional, social isolation, etc.).
and physical violence in the relationship, as well In the final 12 weeks of the program, the same
as an increase in overall marital satisfaction for gender-specific pre- and post-groups are used, and
some couples (Stith et al. 2011). couples practice mindfulness activities at the
beginning of each session, but the issues
addressed by the couple or multi-couple group
Application of Concept in Couple are determined by client needs.
and Family Therapy
Prior to beginning DVFCT, a thorough assess- Clinical Example

ment is crucial in order to identify whether or
not the couple is appropriate for couple’s treat- James and Alicia, both in their late 30s, came to
ment. Couples who report severe violence, or therapy wanting to improve their relationship.
couples who have major discrepancies in the vio- James and Alicia had been experiencing more
lence that they do report, are not suited for couples and more conflict and reported that their conflicts
treatment (Stith et al. 2011). These couples should have escalated to the point where James would
be referred to other forms of treatment. It is also shove, push, or slap Alicia. During the first ses-
recommended that couples who are appropriate sion, the co-therapists separated James and Alicia
for couples treatment sign a “no violence con- in order to assess for violence in their relationship.
tract” which places ending violence as the center Through this assessment, the therapists learn that
of therapy. the violence in their relationship has not escalated
Therapists using DVFCT begin and end each past pushing, shoving, or slapping. James and
session meeting with each partner separately or Alicia both gave congruent accounts of the
with males and females separately if in a group amount and types of violence in their relationship.
format (Stith et al. 2011). Each week before begin- The situational nature of the violence in their
ning conjoint treatment, the therapist assesses for relationship, as well as the level of congruency
potential violence since the previous session and in their responses surrounding the type of violence
asks about successes. After the presession meet- and the extent of the violence in their relationship,
ing, the therapists concur to determine if it is safe makes James and Alicia suitable for couples
650 Couple Violence in Couple and Family Therapy
treatment. The therapists continued to assess for encouraged to practice at home, especially if feel-
violence and the possibility of violence at the ing triggered.
beginning of each session. Another tool that the therapists gave James and
One of the first things that was addressed in Alicia was a negotiated time-out. The negotiated
treatment (in separate sessions) was each partners’ time-out has seven steps that the therapists taught
view of the problem that brought them to therapy. them and asked them to practice. This intervention
Although DVFCT works from a solution-focused can be found in detail in Rosen et al.’s article
approach, it is important for both partners to talk (2003). The therapists taught James and Alicia
about the problems that brought them and espe- how to recognize when they are becoming dis-
cially for the victim of violence to express how the tressed and develop a signal that let the other
violence has impacted her. This gave Alicia partner know that a negotiated time-out is needed,
the chance to share her experience and to tell the separating from one another for a scheduled
therapists how emotionally hurtful it was for her period of time and then coming back together to
when the violence occurred. Alicia described the resolve the conflict without the conflict escalating.
fear and unsafety that she felt when James became In the session after the negotiated time-out was
angry. James, in a separate session, talked about discussed, Alicia came to session stating that she
his own disappointment that he had let himself thought it did not work. When asked to elaborate,
lose control and become physically violent. He Alicia reported that she felt as though James was
reported that he had grown up in a violent home using the time-out as a means to completely avoid
and had vowed never to become violent in his talking about things. The therapists had to reiter-
own marriage. The therapists made sure that ate the importance of setting a time to come back
Alicia and James felt heard and understood during to the conflict and that negotiated time-outs could
the first session. The therapists also had James and not be indefinite time-outs. After this, Alicia
Alicia agree to a non-violence contract during reported that this technique was more useful, and
their time in therapy. It was important for James James was able to come back and talk about
and Alicia to make this commitment, or they conflicts at a later time.
would not be suited for couples treatment if they After James and Alicia were equipped with
had declined making this commitment. Therapy tools that helped them to de-escalate conflict, the
also focused on how violence is a choice and that second part of therapy was more client led and
we are responsible for our own behaviors. The focused on what the couple needs from therapy.
therapists highlighted for James and Alicia how Continuing to use a solution-focused approach,
James is responsible for acting violently toward the therapists helped Alicia and James navigate
his partner, and Alicia is responsible for her own obstacles that they believe they will continue to
decision on whether or not she stays with James if face and focus on the strengths Alicia and James
he does not commit to remaining violence-free. currently have in themselves and in their
This first phase of treatment involved provid- relationships.
ing both James and Alicia with psychoeducation
about the different types of violence, the cycle of
violence, and anger management strategies. Some References
anger management strategies that the therapists
discussed with James and Alicia were recognizing De Shazer, S. (1985). Keys to solution in brief therapy.
New York: W.W. Norton.
triggers, understanding that anger is a secondary George, J., & Stith, S. M. (2014). An updated feminist view
emotion and that there are other emotions under- of intimate partner violence. Family Process, 53,
neath that anger, and the understanding that they 179–193.
have a choice as to how to respond to triggers. Johnson, M. P. (2008). A typology of domestic violence:
Intimate terrorism, violent resistance, and situational
Mindfulness exercises are also another important
couple violence. Lebanon: Northeastern Press.
part of DVFCT, and the therapists started sessions Jose, A., & O’Leary, K. D. (2009). Prevalence of partner
with mindfulness exercises that the couple were aggression in representative and clinic samples. In
Couples Coping Enhancement Training Enrichment Program 651
K. D. O’Leary & E. M. Woodin (Eds.), Psychological program for couples that aims to reduce martial
and physical aggression in couples: Causes and inter- distress and increase relationship satisfaction by
ventions (pp. 15–35). Washington, DC: American Psy-
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O’Farrell, T. J., & Fals-Stewart, W. (2002). Behavioral of stress and coping, and acquire relationship
couples and family therapy for substance abusers. Cur- skills. The program is based both upon stress
rent Psychiatry Reports, 4, 371–376. and coping theory and research on couples. As
Rosen, K. H., Matheson, J. L., Stith, S. M., McCollum,
E. E., & Locke, L. D. (2003). Negotiated time-out: everyday stressors can have a negative effect on C
A de-escalation tool for couples. Journal of Marital relationship quality and satisfaction (Randall and
and Family Therapy, 29(3), 291–298. Bodenmann 2009), and marital communication is
Stith, S. M., Smith, D. B., Penn, C. E., Ward, D. B., & especially affected by stress (e.g., Repetti 1989),
Tritt, D. (2004). Intimate partner physical abuse perpe-
tration and victimization risk factors: A meta-analytic the CCET focuses on building coping and
review. Aggression and Violent Behavior, 10(1), 65–98. communication skills with the aim of improving
Stith, S. M., McCollum, E., & Rosen, K., (2011). Couple the quality of their relationship (Halford and
therapy for domestic violence: Finding safe solutions. Bodenmann 2013). In addition to traditional ele-
American Psychological Association. Washington, DC.
Stith, S. M., McCollum, E., Amanor-Boadu, Y., & Smith, ments of couples programs (e.g., communication
D. (2012). Systemic perspectives on intimate partner vio- and problem-solving skills), CCET also addresses
lence treatment. Journal of Marital and Family Therapy, individual and dyadic coping (i.e., couples coping
38(1), 220–240. https://doi.org/10.1111/j.1752.0606.2011. together as a unit) in promoting relationship sat-
00245.x.
Straus, M. A. (2005). Women’s violence toward men is a isfaction, improving the quality of the couple’s
serious social problem. In R. J. Gelles & D. R. Loseke relationship, and reducing marital distress.
(Eds.), Current controversies on family violence
(pp. 55–77). Newbury Park: Sage.
The CCET program was developed by Dr. Guy

Couples Coping Enhancement Bodenmann (1997a).
Training Enrichment Program
Courtney K. Johnson-Fait1, Ashley K. Randall2 Theoretical Framework

and Guy Bodenmann3
1
Arizona State University, Tempe, AZ, USA The CCET is grounded in social learning theories,
2
Counseling and Counseling Psychology, humanistic theory, and communication theory and is
Arizona State University, Tempe, AZ, USA based upon the knowledge that communication
3
Department of Psychology, University of Zurich, competencies are among the most important
Binzmuehlestrasse, Zurich, Switzerland predictors of marital success (Karney and Bradbury
1995). In the conceptualization of dyadic coping
underlying the CCET approach, dyadic coping
refers to a systemic-transactional view of coping in
Name of the Model couples in which one partner communicates his or
her stress (verbally or nonverbally), and the other
Couples Coping Enhancement Training (CCET) partner responds to these signs in one of three ways:
program the partner becomes affected by stress also (i.e.,
stress contagion); the partner ignores the signals
entirely (i.e., display no coping reaction whatso-
Introduction ever); or the partner demonstrates positive or nega-
tive dyadic coping (Bodenmann 1997b).
The Couples Coping Enhancement Training Positive forms of dyadic coping include sup-
(CCET) program is a distress prevention training portive dyadic coping (e.g., helping with daily
652 Couples Coping Enhancement Training Enrichment Program
tasks or providing practical advice, empathic what makes the CCET different from other pro-
understanding, helping the partner to reframe the grams is its emphasis on stress and coping and the
situation, communicating a belief in the partner’s use of additional techniques related to the
capabilities, or expressing solidarity with the part- enhancement of individual and dyadic coping.
ner); common dyadic coping (e.g., joint problem
solving, joint information seeking, sharing of feel-
ings, mutual commitment, or relaxing together); Populations in Focus
and delegated dyadic coping (where one partner is
explicitly asked by the other to give support, and CCET is offered to various populations of couples
as a result, a new division of tasks is established, (universal prevention). This includes couples at
such as when one partner takes over chores for risk of high stress vulnerability, such as those
another). Negative forms of dyadic coping include transitioning into parenthood and dual-career
hostile dyadic coping (support that is accompa- couples (selective prevention), and couples who
nied by disparagement, distancing, mocking, sar- already realize first damages of continuous stress
casm, open lack of interest, or minimizing the exposure (indicated prevention). CCET is offered
seriousness of the partner’s stress), ambivalent to heterosexual as well as same-sex couples,
dyadic coping (when one partner supports the and couples at all ages and different cultural
other unwillingly or with the attitude that his or backgrounds.
her contribution should be unnecessary), and
superficial dyadic coping (support that is insin-
cere, such as asking questions about the partner’s Strategies and Techniques Used in the
feelings without listening, or supporting the part- Model
ner without empathy; Bodenmann 1997b).
The improvement of individual and dyadic The CCET focuses on the importance of commu-
coping skills is a major emphasis within the nication and ways in which couples can effec-
CCET. In learning about dyadic coping, partners tively cope with stress by teaching couples
learn how to communicate with each other (a) how stress can cause their communication to
more clearly about their own stress experiences. deteriorate, and (b) how they can protect their
Through this process and related emotional explo- communication and their relationship from the
ration, they also learn how to offer each other negative impact of stress by increasing their indi-
appropriate and matching support, how to pro- vidual and dyadic coping resources.
mote closeness and intimacy within the relation- A high degree of standardization of the pro-
ship, and how to create a synergy in their efforts, gram is ensured with a detailed and highly struc-
so each partner can deal with everyday stress more tured manual for trainers (training manual
effectively. Another key element of the CCET published in German by Bodenmann 2000 and
addresses fairness, equity, and boundaries within translated to English in 2004) and a thorough
the relationship, as lack of fairness, equity, or the instruction program for the trainers delivering
observance of insufficient boundaries can also the program. Each trainer receives 30 h of train-
give rise to stress and distress within the couple ing over a 4-day period, 20 h of group supervi-
and fairness/equity regarding dyadic coping sion and successful licensing before delivering
contributions is crucial. The CCET has elements the program. The program is 18 h and consists
of communication and conflict resolution in com- of modules varying from 1.5 to 5 h in duration.
mon with other programs (e.g., the Prevention and Because of the flexible modular structure, it can
Relationship Enhancement Program [PREP]; be offered in various formats. Typically, the
Markman et al. 1993) and shares with Compas- CCET is offered as a weekend workshop that
sionate and Accepting Relationships through begins Friday evening and ends Sunday eve-
Empathy (CARE; Sullivan et al. 1998) elements ning; although, the program can also be
of empathy and conflict resolution. However, conducted as a series of six weekly sessions,
lasting 3 h each. Another format allows the and how stress can be avoided, analysis of
program to be embedded into a weeklong cou- coping reactions in everyday life and what
ple’s retreat that includes vacation and adequate coping looks like, and relaxation
childcare. The content and effectiveness are techniques such as progressive muscle relax-
identical in all three formats. The CCET typi- ation. This module is intended to last 3 h.
cally is conducted in groups of four to eight The goals of Module three, Enhancement of
couples. Dyadic Coping, include increasing an under- C
The CCET consists of six modules: standing of the partner’s stress, enhancing
stress-related communication, and improving
Module one, Knowledge of Stress and Coping, is dyadic coping skills. This module provides an
focused on teaching couples about stress and introduction into the concept and utility of
coping. This module aims to help couples dyadic coping via a short lecture. Categories
improve their understanding of stress and dis- of dyadic coping are taught through video
tinguish between different types of stress. The examples. Couples complete a questionnaire
content of this module includes an overview of on how each partner communicates his or
the topic of stress – including its causes, forms, her stress and how they display dyadic coping.
and consequences, as well as how couples cope The core part of this module is the exercise of
with the stress. Via psychoeducation, couples stress-related self-disclosure and provision of
are taught that stress is a consequence of cog- dyadic coping in the three-phase-method
nitive appraisals and that emotions (e.g., sad- (Phase 1: communication of partner’s
ness, anger, anxiety) are shaped by these A stress; Phase 2: provision of dyadic coping
appraisals. The content in module one also by partner B; Phase 3: feedback of partner
aims to promote enhancement of situation A to B on satisfaction and effectiveness of
evaluation with exercises where aspects of the his/her support and further wishes). Simulta-
situation such as significance or controllability neously, both partners act in both roles (stress
are evaluated. This module also includes communicator and support provider). In
assessment of different areas of stress by ques- these exercises, the couples are supervised by
tionnaire. This module is intended to last 2 h CCET providers. This module is intended to
and 30 min. last 5 h.
In module two, Improvement of Individual Cop- Module four, Exchange and Fairness in the
ing, the objectives include preventing stress Relationship, objectives include improving
by anticipating stressful situations and pre- a couple’s awareness of the importance of a
paring in advance how to cope with the fair and mutual exchange within the context
stressor. This module focuses on improving of dyadic coping, enhancing the ability to
coping during the stressful event and pro- detect inequality and dependence in the rela-
cessing it in retrospect. It focuses on counter tionship, and improve sensitivity towards
stress by building up a repertoire of pleasant one’s own needs and the needs of the partner.
events as well as learning to reduce stress The content of this module is delivered
physiologically (e.g., progressive muscle through short presentation on the meaning
relaxation). This module is delivered through of fairness and boundaries in the relation-
short lectures on functionality of different ship. This includes diagnostic exercises to
coping strategies and includes a diagnostic help couples understand their views on the
exercise on one’s own coping style. Content exchange and fairness in their relationship;
is also delivered through exercises on differ- an assessment of personal needs for distance
ent examples on the link between adequate and closeness, as well as supervised commu-
copings according to different stress profiles. nication exercises that allow both partners to
Materials are planning sheets for defining explore their needs. This module also focuses
one’s own repertoire of pleasant activities on sensitization to the presence of over-
654 Couples Coping Enhancement Training Enrichment Program
involvement that may go along with depen- communication skills, individual and dyadic
dence, or selfishness, in relationships. The coping, psychological well-being, relationship
length of this module is 2 h. satisfaction, as well as on the well-being of
Module five, Improvement of Marital Communi- children.
cation, aims to improve speaking and listening
skills, detect inadequate communication
behavior, and learn to overcome deficits in Case Example
communication. These skills are taught
through a short presentation on the meaning Susan and Kim have been together for 8 years. They
of appropriate communication and a video are in their early thirties, fell in love during college,
demonstration of dysfunctional communica- and moved in together 4 years ago. They both work
tion (criticism, defensiveness, contempt, bel- hard in leading positions, and although they earn
ligerence, and withdrawal), according to well, their busy schedules do not allow much time
Gottman (1994). Each partner is asked to for each other, and the couple suffers from daily
assess problematic communication styles in stress and its spillover to their relationship. In the
his or her own behavior by means of a short evening, both are either still working or are tired and
questionnaire. Then the couples are introduced need time for themselves. Joint activities became
to more effective ways of discussing differ- rare, and Susan and Kim’s sexual life is affected.
ences through a widely used speaker-listener Susan is unhappy and realizes that they pay a high
technique and are trained in supervised com- price for their luxury life standard and that their high
munication where both partners act as speaker workload drives them apart. She feels alienated
and listener in two exercises. This module is from Kim, their communication has become super-
intended to last 4 h. ficial or conflictual, and love is fading out. She talks
Module six, Improvement of Problem Solving Skills, with Kim and proposes to attend a workshop for
focuses on strengthening the couple’s mutual couples focusing on stress management as a couple.
problem-solving skills. This module includes Kim agrees with Susan’s concerns and approves.
brief psychoeducation on the usefulness of They look up possibilities and decide to attend a
problem-solving in marriage and the need to CCET workshop.
resolve problems. It also consists of a supervised, In the CCET workshop, they meet five other
structured, five-step problem-solving approach couples, some in similar situations, one newly
involving: describing the problem, brainstorm- married couple wanting to keep love alive, one
ing possible solutions, choosing the best solu- couple transitioning into parenthood, and one
tion, planning to solve the problem in everyday lesbian couple. All are eager to learn more about
life by implementing this solution, and evaluat- the how stress affects their relationship and how
ing the solution. This module is intended to last to deal with daily stress more effectively.
90 min. A trained psychologist, licensed in CCET,
delivers the workshop starting with theoretical
inputs (psychoeducation), diagnostics (Stress
Research About the Model Management: How much stress do I have in var-
ious areas?), and explains what stress is and how
The efficacy of the CCET has been supported in it influences communication, cohesion, relation-
four randomized controlled trials as well as in ship satisfaction and stability.
different studies on effectiveness up to 2 years Kim and Susan learn how their love can get
after participation in the program (Bodenmann buried under daily stress and how alienation can
and Shantinath 2004; Bodenmann et al. 2001; pull them apart. As they learn about the role of
Cina et al. 2002; Widmer and Bodenmann individual and dyadic coping in buffering stress,
2009). Positive effects were found on couples engage in discussing examples of their
experiences coping with stress in their lives. References

Through their own discussion, other couples’ dis-
closures, and the facilitator’s teaching, Kim and Bodenmann, G. (1997a). Can divorce be prevented by
enhancing coping skills in couples? Journal of Divorce
Susan begin to appreciate how they can benefit
and Remarriage, 27, 177–194.
from shared stress appraisals and joint dyadic Bodenmann, G. (1997b). Dyadic coping – A systemic-
coping efforts. They begin understanding what transactional view of stress and coping among couples:
stress-related self-disclosure and dyadic coping Theory and empirical findings. European Review of C
Applied Psychology, 47, 137–140.
look like – learning rules for the speaker and
Bodenmann, G. (2000). Kompetenzen für die Partnerschaft
rules for the listener, and practicing effective [Competencies for marriages]. Weinheim: Juventa.
communication. Via individual supervision, the Bodenmann, G., & Shantinath, S. D. (2004). The Couples
trainers coach them in the application of rules Coping Enhancement Training (CCET): A new
approach to prevention of marital distress based upon
and communication skills.
stress and coping. Family Relations, 53, 477–484.
Through a three-phase-method, Susan and https://doi.org/10.1111/j.0197-6664.2004.00056.x.
Kim talk about continually upsetting situations Bodenmann, G., Charvoz, L., Cina, A., & Widmer, K.
and discover why the experiences are so hurtful. (2001). Prevention of marital distress by enhancing
the coping skills of couples: 1-year follow-up-study.
Both express a deepened mutual understanding,
Swiss Journal of Psychology, 60, 3–10.
closeness, and ability to see their partner’s stress Cina, A., Widmer, K., & Bodenmann, G. (2002). Die
reaction in a different light, and therefore an Wirksamkeit des Freiburger Stresspräventionstrainings
ability to be empathic and supportive. They (FSPT): Zwei Trainingsvarianten. [The effectiveness of
two versions of the CCET]. Verhaltenstherapie, 12,
learn about fairness, effective communication,
36–45.
and problem-solving through instruction and Gottman, J. M. (1994). What predicts divorce? Hillsdale:
exercises aimed at fostering their skills. Further- Erlbaum.
more, they find the individualized attention from Halford, K., & Bodenmann, G. (2013). Effects of relation-
ship education on maintenance of couple relationship
trainers particularly helpful in improving dyadic
satisfaction. Clinical Psychology Review, 33, 512–525.
coping, communication, and problem-solving Karney, B. R., & Bradbury, T. N. (1995). The longitudinal
skills. Susan and Kim, like other couples, espe- course of marital quality and stability: A review of theory,
cially appreciate the different exercises and their method, and research. Psychological Bulletin, 118, 3–34.
Markman, H. J., Renick, M. J., Floyd, F. J., Stanley, S. M.,
coaching by a trainer. At the end of the work-
& Clements, M. (1993). Preventing marital distress
shop, Susan and Kim, like the other couples, feel through communication and conflict management
motivated to apply these skills in everyday life. trainings: A 4- and 5-year follow-up. Journal of
While five couples leave the workshop in a very Consulting and Clinical Psychology, 61, 70–77.
Randall, A. K., & Bodenmann, G. (2009). The role of
positive humor and feel energized, one couple
stress on close relationships and marital satisfaction.
seems to have a harder time than before. One Clinical Psychology Review, 29(2), 105–115.
trainer talks with this couple discretely and sug- Repetti, R. L. (1989). Effects of daily workload on subse-
gests they seek of counseling or couple therapy quent behavior during marital interaction: The roles of
social withdrawal and spouse support. Journal of
for additional support. Susan and Kim leave feel-
Personality and Social Psychology, 57, 651–659.
ing more confident about their ability to recog- Sullivan, K. T., Pasch, L. A., Eldridge, K. A., &
nize the stress affecting the relationship, as well Bradbury, T. N. (1998). Social support in marriage:
as their ability to communicate, and to cope with Translating research into practical applications for cli-
nicians. Family Journal: Counseling and Therapy for
the stress in a more effective manner.
Couples and Families, 6, 263–271.
Widmer, K., & Bodenmann, G. (2009). The Couples Cop-
ing Enhancement Training (CCET): A new approach to
Cross-References prevent marital distress based upon stress and coping.
In S. Callan & H. Benson (Eds.), What works in rela-
tionship education? Lessons from academics and
▶ Dyadic Coping Inventory service deliverers in the United States and Europe
▶ Systemic-Transactional Model of Dyadic (pp. 98–107). Doha: Doha International Institute for
Coping Family Studies and Development.
656 Couples Financial Interview
and describe financial triggers which can create

Couples Financial Interview feelings of stress or anxiety, depression, and rela-
tional conflict.
Anne Brennan Malec
Symmetry Counseling, Chicago, IL, USA
Name of Strategy or Intervention The Couples Financial Interview is a method used

in Financial Therapy of gathering information
Couples Financial Interview. about a couples’ beliefs about money. Financial
Therapy (FT) is an emerging field focused on
evaluation and treatment of the “cognitive, emo-
Introduction tional, behavioral, relational, and economic
aspects of financial health” affecting one’s daily
The Couples Financial Interview has been used life (Britt et al. 2014). A main objective of FT is to
within the context of Financial Therapy (FT) in improve one’s relationship with money thereby
order to help a couple ascertain and express their improving quality of life. The Financial Therapy
beliefs and values about money. Association was founded in 2009 in order to pro-
Financial conflicts may stem from funda- vide a forum for financial professionals, mental
mental differences between partners. Families health professionals, and researchers to coalesce
of origin often shape one’s meanings of around a shared vision of financial therapy.
money – forming one’s money preferences and Financial therapists assist clients with a variety
beliefs, or what are known as, money scripts of issues related to money, such as: improving
(Klontz et al. 2011; Klontz and Klontz 2009). one’s financial knowledge, skills, and relationship
It is not uncommon for clients engaging in dis- with money; exploring, negotiating, and effec-
ordered money behaviors to be unaware of their tively applying financial knowledge to reduce
own money scripts. Money scripts are underly- anxiety and conflict; and gain a sense of empow-
ing “assumptions or beliefs about money that erment over their financial lives. Financial thera-
are typically only partially true, are often devel- pists also assist clients in introducing challenging
oped in childhood, and unconsciously followed financial conversations with family members.
throughout adulthood (Klontz et al. 2011). They are professionally trained in the mental
These schemas often derive from an emotion- health and financial fields. Financial therapists
ally triggering financial event in one’s child- act in the best interests of their clients and respect
hood that leaves a lasting impression, often the confidential nature of the client-service
until adulthood (Klontz and Klontz 2009). provider relationship (Financial Therapy Associ-
Money scripts are often multi-generational ation 2017).
within families and cultures and serve to signif-
icantly influence financial behaviors.
One clinical intervention for uncovering Rationale
money scripts or schemas is to engage in a Cou-
ples Financial Interview. The interview will pro- The American Psychological Association reports
vide needed insight into how client(s) views that since 2007 money has been a top cause of
money, and where he or she may develop prob- stress for Americans. The most recent survey
lematic financial behaviors. Through addressing found 72% of Americans stressed over money
a series of questions, the clinician and client(s) during the past month. Thirty-one percent of
will be able to understand long-held beliefs that adults with partners reported money as a major
have created the current difficulty, uncover source of conflict in their relationship. Seventy-
unexpressed financial expectations of a partner, seven percent of couples with children reported
Couples Financial Interview 657
money as a very significant source of stress in researchers have found that spending preferences,
their marriage (APA 2015). such as differences in gifting preferences, finan-
Turkel (1988) states that money is “One of the cial risk tolerance levels, and perceived power
richest fields in which to sow seeds of marital differentials can all lead to increased conflict in a
strife” (p. 225–226), as well as, “A symbol of relationship (Stolz 2009).
worth, competence, freedom, prestige, masculin- Dew and Dakin (2011) found disagreements
ity, control, and security, all of which can become about financial issues often lead to intense argu- C
areas of conflict” (p. 525). Trachtman (1999) states ments. Britt et al.’s (2010) research suggested that
that in our society an emotional taboo exists insufficient communication between couples is a
around money issues, making Americans “seclu- bigger predictor of arguments about money than
sive, embarrassed, and conflicted about discus- power or available resources. Falconier and
sion of money” (Kreuger 1986, p.vii). As a Epstein (2011) supported the value of practi-
society we may be comfortable talking about tax tioners’ awareness of how financial issues can
rates, health care costs, and social security, but affect a couple and the importance of understand-
rarely do people discuss their income, level of ing each partner’s role with family finances. The
debt, or thoughts and feelings about money. authors also stressed the importance of the clini-
Financial difficulties have been shown to pre- cian inquiring about partners’ satisfaction with the
dict increases in depression, marital conflict, and current status of their financial roles.
the likelihood of divorce, with a predicted Financial issues are different than other rela-
decrease in marital satisfaction (Dew 2008; tionship issues in that they cannot easily be
Amato and Rogers 1997; Conger et al. 1990; ignored (Papp et al. 2009). In addition to their
Gudmunson et al. 2007; Stanley et al. 2002). frequency and unavoidability, financial issues
The European Journal of Public Health found may be related to visceral emotions that can
that adults in debt were three times more likely act as triggers for negative conflict tactics. This
than those without debt to suffer from common is because individuals connect such powerful
mental health disorders. A study from Northwest- meanings as, “caring, security, success, and
ern (Sweet et al. 2013) found that consumers with esteem to money” (Shapiro 2007; Jenkins et al.
higher levels of debt had a 13.3% increase in 2002). Disagreements about money may have
depressive symptoms and an 11.7% increase in less to do with the actual financial and spending
perceived stress. For every 10% increase in per- choices and more to do with the underlying
sonal debt, the study found that depressive symp- meanings of money (Jenkins et al. 2002).
toms worsened by 14%. Research and practice have asserted that
In terms of financial and human capital, when “Money has symbolic potential unlike almost
resources are low, conflict is high. Dew anything else” (Stanley and Einhorn 2007,
(2007) found that net worth is an important pre- p. 294). Financial disagreements are often
dictor of partner conflict. Specifically, couples related to power, gender, and control issues.
with higher debt loads report greater levels of (Jenkins et al. 2002; Shapiro 2007).
stress and more conflict, as well as those with Rick et al. (2009) reported evidence of conflict
lower levels of income and education (Dew and being predicted by differences in spousal prefer-
Yorgason 2010). ences in spending behavior, specifically, a pattern
Money conflict between partners arises from of negative assortative mating (partnering based
different financial management strategies on dissimilar characteristics) when it comes to
(Lawrence et al. 1993), charitable giving prefer- spending behaviors. Negative assortative mating
ences (Andreoni et al. 2003), and spending per- has been found to be associated with increased
sonalities (Rick et al. 2009). A common theme in conflict. They found the highest levels of conflict
the literature is that money arguments are related when a chronic over-spender was married to a
to couples deciding how to allocate resources chronic under-spender. The researchers also
within the household. Practitioners and found that the greatest relationship satisfaction
developed when spending behaviors were • How will the financial situation change if the
the same. couple has children?
Lawrence et al. (1993) used financial manage- • Will one partner leave the workforce to care for
ment strategies to predict arguments about money. children? If so, is this a temporary or perma-
Couples who reported healthy financial manage- nent shift?
ment strategies, such as recordkeeping and goal • What are each partner’s expectations for how
setting, were less likely to argue in comparison to their family’s finances should work?
other couples. These findings suggest that for • Were finances discussed before the couple got
couples who prioritize seeking agreement on married or engaged? If not, why?
financial matters may have less to argue about. • How does a partner feel when the other partner
When working with couples in the context of questions spending or tries to place limits on
financial therapy, it is recommended that the cli- spending?
nician keep in mind that research findings indicate • Does one partner dominate financial decisions?
that there is a gender gap in the levels of financial • What are the expectations of income, freedom
knowledge demonstrated by men and women to spend, savings, retirement, etc.?
(Huston 2010; Lusardi and Mitchell 2008; • Does one partner value budgeting more than
Woodyard and Robb 2012; Xiao et al. 2011). In the other?
particular, as it relates to personal finance, women • Is there any resentment from past financial
are less confident, knowledgeable, and interested decisions?
than are men (Borden et al. 2008; Chen and Volpe • Does either partner have adult children from
1998, 2002; Lusardi and Mitchell 2007; Robb and this or a prior relationship? If so, what does
James 2009). each partner think about supporting children
into adulthood?
• Has either partner used joint assets without the
knowledge of the other?
Description of Intervention
• Has there been an increase in feelings of anx-
iety, depression, anger, increase in substance
After establishing basic rapport with the couple
use/abuse, increase in arguments, demand/
and discussing the goals and purpose of financial
withdrawal behaviors, psychological or physi-
therapy, the clinician can begin the Couples
cal aggression, or relationship distress? What
Financial Interview in order to ascertain the
role have finances played?
beliefs and money scripts of the individuals. It is
• How has the couple been trying to cope with
important to maintain an exploratory and non-
the financial/relational strain? What helps?
judgmental atmosphere in order to allow for
What hurts? Have there been attempts at
honest and vulnerable answers. When working
problem-solving? Has there been avoidance
with couples or individuals around issues related
of the topic?
to money or financial management, a therapist
may inquire about the following:
Further information can be gathered by asking
the following (adapted from Mumford and Weeks
• Each partner’s financial role in the 2003; Furnham et al. 2014):
relationship – is there a main provider, second-
ary provider, co-provider, only provider? • What is your earliest memory around money?
• Is money a frequent source of conflict? If so, • What is your most joyful money memory?
what aspects of money lead to conflict? Most painful?
• What are the client’s biggest financial fears? • What were you taught about the wealthy/poor?
• What money related cognitions shape each What are your memories of your parents
partner’s financial concerns and coping around financial issues?
strategies? • Was money openly discussed in your home?
Couples Financial Interview 659
• Do you recall there being financial honesty or budget considerations and that she resists his
were there secrets and hidden spending? attempts to control her spending. He reports feel-
• Were your parents’ savers or spenders? ing extreme frustration that he must be the family
• Were your parents anxious about money? financial manager while his wife seems oblivious
• Did they have consistent work? to family budget constraints.
• Were there periods of poverty or feelings of By conducting the Couples Financial Interview,
deprivation? the clinician is able to help the clients identify and C
• Were there frequent arguments about money? express their feelings and beliefs about money and
• Who made the financial decisions? how those beliefs have created the foundation for
• Were there any bankruptcies? Borrowing? their current financial distress. The couple is able to
Credit card debt? Gambling issues? talk about their finances without the conversation
• If one’s parents divorced, was money a conten- escalating to attacks or being shut down by a desire
tious issue? to avoid unresolvable conflicts. The wife can
• Did you determine at a young age that you explore how and why she came to believe it was
would “never” do certain things, or you her spouse’s responsibility to manage the family
would live differently? finances, and why she has been so resistant to live
• How did/are parents faring financially in retire- within a budget. The husband has the opportunity to
ment/older years? consider why he chose to hide debts from his spouse
• What plans have you made for retirement? and not address the family spending issues sooner.
• How much money and what lifestyle do you With the help of the clinician, the couple creates a
expect to have for retirement? budget and sets goals to alleviate their debt. They
• What resources are available to you in the meet separately with a financial planner who can
event of an emergency? provide an overview of their financial challenges
• How do your siblings live now? and help them chart a course for the future. The
• How do you think your family money history couple also learns strategies for engaging in positive
has affected you? and effective communication about money as well
• Does your financial situation cause you shame as other sensitive topics. Three months later, they
or embarrassment? report being on track to pay off their debt within a
year and that they are experiencing improved satis-
faction in their marriage.
Case Example
A heterosexual couple presented for financial

References
therapy after losing their home due to the hus-
band’s poor financial management and growing American Psychological Association Survey Shows
debt. The wife was unaware of the family financial Money Stress Weighing on Americans’ Health Nation-
strain in part due to the husband falsifying finan- wide. (2015, February 04). Retrieved 21 April 2017,
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money-stress.aspx.
have difficulty communicating effectively about Amato, P. R., & Rogers, S. J. (1997). A longitudinal study
money because the conversation escalates quickly of marital problems and subsequent divorce. Journal of
with mutual blaming, criticism, and defensive- Marriage and the Family, 59, 612–624.
ness. As it relates to spending, the wife reports Andreoni, J., Brown, E., & Rischall, I. (2003). Charitable
giving by married couples: Who decides and why does it
feeling criticized, controlled, “parented” by her matter? The Journal of Human Resources, 38(1),
husband and micro-managed. The husband 111–133.
reports feeling unappreciated for his financial con- Borden, L. M., Lee, S., Serido, J., & Collins, D. (2008).
tributions to the family, and resentful about Does participation in a financial workshop change
financial knowledge, attitudes, and behavior of college
unexpressed financial expectations. The husband students? Journal of Family and Economic Issues, 29,
states that his wife acts entitled to spend without 23–40.
Britt, S. L., Klontz, B. T., & Archuleta, K. L. (2014). In Financial Therapy, 3(1), 2. https://doi.org/10.4148/jft.
B. T. Britt, S. L. Britt, & K. L. Archuleta (Eds.), v3i1.1485.
Financial therapy: Establishing an emerging field. Kreuger, D. (Ed.). (1986). The last taboo; money as symbol
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Couples Group Therapy 661
the freedom for persons to individuate, and to

Couples Group Therapy increase personal and systemic creativity.
2. Adult intimacy involves taking responsibility
Judith Coché for one’s actions, thoughts, feelings, and
The Coche Center, Philadelphia, PA, USA behavior in relation to the other person.
Perelman School of Medicine at the University of 3. An emphasis on the positive and constructive
Pennsylvania, Philadelphia, PA, USA handling of human concerns is hope-inducing C
for clients.
Introduction
An Intergenerational Frame for Couples Work
Couples group therapy assumes that both couples
Couples group therapy is a treatment modality
and groups form a system and that treatment inter-
founded on integrating principles from group
ventions need to include multi-generation patterns
dynamics and family therapy. A small group
for both marital and family dynamics. A group
structure employing insight-oriented therapy is
operates like a family, and a family has the prop-
used to promote healing and growth for couples.
erties of a small group. Both are greater than the
Concepts are drawn from distinct but compatible
sum of their parts, and the subsystems of each can
sectors: family and couples therapy, group ther-
be fully understood only through knowledge of
apy, psychological assessment, and
the working whole.
psychoeducation. This combination of modalities
constitutes a unique approach which emphasizes
each individual and the couple as a unit. Systems Theory
Isomorphism states that similar structures and
processes occur on several levels in related sys-
Theoretical Framework tems (Coche and Coche 1990). Therapists need to
think on several levels simultaneously in order to
Couples group therapy has drawn on major contrib- respond with flexibility to the challenges of the
utors to group and marital therapy, including exis- group:
tential work by Irvin Yalom (1985), psychodynamic
work by Rutan and Stone (1984), attachment theory
1. Personal level: The group concentrates
by John Bowlby (1969), John Gottman’s commu-
intensely on one member, and therapy looks
nication model (1994), and Yvonne Agazarian’s
somewhat like individual therapy.
system model (1981). Conceptual origins in systems
2. Couples level: Interventions focus on the ver-
theory are drawn from the worlds of biology (Von
bal and nonverbal internal and interpersonal
Bertalanffy 1968) and social psychology (Lewin
behaviors, and dimensions of the behaviors,
1951). An intergenerational frame for couples
for each member of the couple and for the
work (Sullivan1953) is key.
couple as a whole. Patterns of affection, inter-
est, anger, and withdraw comprise some of the
Existential base: Three existential principles dimensions considered.
underlie the work: 3. Interpersonal level: The activity of the group
is directed to interpersonal relationships
1. Clients seek to be more of a person in an between members and couples in the group.
intimate context than they have been able to Many of Irvin Yalom’s (1985) curative factors,
achieve. Carl Whitaker and David Keith such as universality and altruism, come to full
(1981) stated that the goals of therapy should therapeutic power at the interpersonal thera-
be to establish a sense of belonging, to provide peutic level.
662 Couples Group Therapy
4. Group-as-a-whole level: At the group-as-a- Group size. A number of authors write that
whole level, the leader makes a statement that the optimal group size is three to five couples.
applies to everyone, such as the group is This size creates optimal opportunity to experi-
annoyed. Directional shifts, group decisions, ence the power of the dyadic and subgroup
norm enforcement, and explorations of partic- relationships between group members and
ipants’ roles in the group all are topics of allows member to identify with one another.
discussion that fall into the group-as-a-whole Length and frequency of sessions. Clinicians
category (Agazarian and Peters 1981). Group- vary in their preferred length and frequency of
as-a-whole work enables the group to progress group meetings. For example, one use of cou-
developmentally, from dependence on the ples therapy is within a medical setting. There,
leader to interdependence between members. heart attack victims and their partners may come
together weekly for 1 h to discuss common
concerns and solutions to ongoing problems.
Rationale for the Strategy In a different scenario, couples who want to
optimize intimacy and sexuality may benefit
Couples group therapy applies strengths from from a monthly group of three or 4 h. This
group, marriage, and family therapy. From group frequency allows couples to travel the distance
therapy, strengths include the feedback loop pro- needed to attend a group with trained coleaders
vided by other members and a spirit of group and encourages depth of clinical progress that
support that lives in each member between ses- can only be achieved with a group of this time
sions. From marriage and family therapy, there is duration.
an approach to the couple/family as a working Although actual time varies, it is crucial to
social system designed to protect the life and adapt the frequency and length of sessions to
well-being of each member. Research in couples meet the needs of members. In an institutional
group therapy (Coche 2010) underscores the find- setting, for example, where clients would find it
ing that intervention using this modality is at least difficult to concentrate for a longer period of
as effective as other therapeutic modalities. time, greater frequency and shorter sessions
would be necessary. Clinical success requires a
match between needs served and clinical
Description of the Strategy structures.
Structuring an Effective Treatment Package Group Organization and Functioning

In order to structure an effective treatment pack- A group is organized along time, content, and
age, it is necessary to decide if one is going to do a leadership dimensions. In structuring couples
closed or open group. One must also plan the group therapy, leaders consider the length of the
length of the sessions, set goals and do progress group and interventions concerning both content
reports, and consider whether to require out of and process levels of change.
group therapy. Finally, a decision about single or Optimal group length depends on the goal of
coleadership needs to be made. the group: support groups may meet for 1 h for
Closed versus open group therapy. There are 6 weeks, while depth groups may meet for six to
two ways of controlling the flow of patients in a 12 months for two to 4 h. Most members seek
group. In a closed group, patients begin and end change relating to difficult topics of being
therapy at the same time. For example, a group coupled: they want to improve their finances,
begins in September and ends at the end of June. decide about whether to have children, or manage
In an open group, patients begin and end as is sexual dissatisfaction. In addition to these content
optimal: one couple may begin in January and areas of focus, the couple needs to enrich and
end in April, while a different couple remains in deepen the emotional communication skills
the group for a second year. between them because this level of interchange
Couples Group Therapy 663
allows couples to deepen intimacy and sexuality. change, to the nodal work on attachment theory
Interaction between members focuses not only on in couples group therapy, and to the foundation
the content of the concern but on the way of work in the technology of neuropsychological
expressing this topic. and nonverbal aspects of couples group therapy.
Pre-training. Most pre-training programs
consist of brief informative sessions which
occur before a couples group begins. The func- Case Example C
tion of pre-training is to define the therapist’s
role and to explain the session format and other In the brief vignette that follows, readers can trace
important things such as confidentiality, goals, the concerns that brought a couple into treatment,
group purpose, contracting, and general group how couples group therapy addressed their con-
policies. cerns, and, finally, the benefits they received from
Therapy goals and progress reports. Treat- the treatment.
ment goals can focus on issues such as improved Donald carries an American passport and is of
communication skills; heightened awareness and Italian heritage; Jean is Australian. They married
openness; increased flexibility in intimacy, sexual- despite concerns about their competitive families.
ity, problem solving, clarification of role ambigui- Both families wanted the couple to move to their
ties, and conflicts; improvement of the couple’s country of residency and competed for the affec-
maladaptive defense styles; and increasing aware- tion of the grandchildren. After Jean finished
ness of intergenerational issues. Many types of cou- graduate training in economics, the couple settled
ples group therapy include goal setting at the in the United States. Jean found life empty in a
beginning of the group. In some models, goal setting society which she found materialistic and pre-
is done by the patients themselves: frequently ferred Australia’s laid-back lifestyle. A genetic
patients are given an assignment to set their goals predisposition toward depression exacerbated
and be ready to report on them at the next group Jean’s sense of feeling lost in her home. She
meeting. In other couples groups, goals may be sought treatment for depression and asked
jointly set by the therapists and the clients. Setting Donald to move “back home” with her. His career
goals helps clients to focus their energies on specific was deeply centered in their state residency. When
steps in achieving the change that they seek. individual and couples treatment proved inade-
quate, the therapists suggested that the special
Facilitating Therapeutic Change Within power of a group to create an environment that
a Couples Group Setting fostered change might help Jean become less
Two facets of facilitating change within a cou- depressed as well as help Donald be more flexible
ples group setting merit brief clinical attention. in meeting her needs.
First, group leaders must be comfortable han- The couple was screened to be members of a
dling both predictable problems and clinical general couples therapy group for relatively high-
emergencies in ongoing groups. Predictable functioning couples needing to make changes in
problems include ongoing lateness or absence one or more areas of their lives. The heterogeneity
of members, interpersonal difficulties between of the age of the members, combined with the high
group members that are hard to resolve, and motivation for clinical change, creates an optimal
members who interrupt the flow of the group learning environment for couples who need to
through extraneous comments. Clinical emer- change levels of intimacy and sexuality, learn to
gencies involve choices of treatment paradigms communicate more effectively, and find greater
for maximal therapeutic progress. In addition to life satisfaction together. This group offered a
recent developments in relational psychoana- safe and positive forum to treat issues necessitat-
lytic thinking and in cognitive-behavioral ing treatment. The group met twice a month for
approaches to therapy, particular attention is 150 min. Coleadership involved a senior therapist
devoted to positive psychology as a catalyst of skilled in both group therapy and couples therapy
664 Couples Group Therapy
and a junior therapist training to become a certi- to fit into their customs. Because Donald was
fied group therapist. Explicit confidential con- more flexible and quite excited about the freedom
tracts were signed by each member and kept on that Australia offered, the couple decided to move
file. The closed group began in the fall and ended with their two sons to Australia, where they
11 months later. The closed group format had the remain. They love living near the ocean, they
advantage of enabling members to grow trusting love the freedom of the country, and they find
of the leader and of each other, facilitating trans- meaning together raising their family in this soci-
formational change in a short time period. ety. As soon as they were able to agree on what
Groups started on time and ended on time, and would mean the most, they overcame the daunting
members were asked not to miss more than 25% of task of creating a meaningful culture for them-
the sessions during a 12-month contractual selves and their children. Treatment with the help
period. of other members of the group enabled substantial
Members sat on comfortable chairs and change: the group acted as a hall of mirrors,
couches in a circle. Leaders sat across from creating a microcosm of the world at large much
one another in order to maximize eye contact. more powerful than therapy for the couple and
Clinical notes were recorded by the less experi- one therapist. Couples practiced their work out-
enced coleader. Policies by which the group side the group and reported progress to other
operated were read by all members when they members. The feedback loop acted as a catalyst
entered the group: each member signed a con- to reach treatment goals. Donald and Jean
tract agreeing to the treatment as described in describe their experience in the group as trans-
the policies. The group therapy fee was charged formational, allowing them to connect with one
monthly and the bulk of the treatment was cov- another more deeply than they would have
ered by insurance. In addition to their partici- thought possible.
pation in the group, each group member
(including Donald and Jean) participated in
either individual or couples therapy. This com- Cross-References
bination of some targeted individual work and
some targeted group work acted as a catalyst ▶ Hold Me Tight Enrichment Program
enabling a level of change difficult to achieve ▶ Sexuality in Couples
without the power of a group. ▶ Strategic Family Therapy
The couples group therapy facilitated both ▶ Trust in Gottman Method Couples Therapy
personal and interpersonal change for Donald
and Jean. Members grew to care about each
other’s welfare. This ongoing source of honest References
feedback and deep caring facilitated necessary
and complex changes for each partner. Members Agazarian, Y., & Peters, R. (1981). The visible and invis-
of the group served as a hall of mirrors, reflecting ible group: Two perspectives on group psychotherapy
and group process. London: Routledge & Kegan Paul.
the behavior and comments of each member. Bowlby, J. (1969). Attachment and loss (2nd ed.). New
Feedback from members helped facilitate neces- York: Basic Books.
sary behavioral and attitudinal changes in the Coché, J. (2010). Couples group psychotherapy: A clinical
marriage, in Donald and Jean, and in the com- treatment model (2nd ed.). New York: Taylor and Francis.
Coché, J., & Coché, E. (1990). Couples group psychother-
munication style between them. apy: A clinical practice model. New York: Brunner/
As treatment for the couple progressed, Jean Mazel.
and Donald began to explore their respective Gottman, J. M. (1994). What predicts divorce: The rela-
reasons for marrying. Jean, raised in a highly tionship between marital processes and marital out-
comes. Hillsdale: Lawrence Erlbaum Associates.
self-contained British family culture, thought Lewin, K. (1951). Field theory in social science: Selected
that Donald’s high-spirited Italian family often theatrical papers. Chicago: University of Chicago
acted in bad taste and had no interest in learning Press.
Crane, D. Russell 665
Rutan, J. S., & Stone, W. N. (1984). Psychodynamic group Therapy Education, as well as chair of the Family
psychotherapy. New York: Macmillan. Therapy Section in the National Council on
Sullivan, H. S. (1953). The interpersonal theory of psychi-
atry. New York: Routledge. Family Relations.
Von Bertalanffy, L. (1968). General systems theory: Foun-
dations, development, and applications. New York:
George Braziller Inc.. Contributions to the Profession
Whitaker, C. A., & Keith, D. V. (1981). Symbolic-
experiential family therapy. In A. Gurman &
C
D. Kniskern (Eds.), Handbook of family therapy He spent the early years of his career conducting
(pp. 187–225). New York: Brunner/Mazel. research on measurement issues in CFT, but in
Yalom, I. D. (1985). The theory and practice of group the middle of the 1990s, he turned his attention
psychotherapy (3rd ed.). New York: Basic Books.
to exploring the economic effectiveness of CFT.
Although by that time the general effectiveness
of CFT had been established by numerous ran-
domized clinical trials, Crane believed that there
Crane, D. Russell was a need to demonstrate that CFT was also
cost-effective. Recognizing the research that
Richard B. Miller
demonstrated that clients who were seen in indi-
vidual psychotherapy experienced a subsequent
decrease in their use of health-care services,
Crane sought to see if a similar phenomenon
Name
was present in CFT. Termed the “medical offset
effect,” the idea was to see if the costs of mental
D. Russell Crane (1948–)
health treatment were offset by a reduction in
visits to doctors and hospitals after treatment
was terminated. Crane was able to obtain access
Introduction
to the health-care records from a major health-
care organization, and he found that clients who
D. Russell Crane was an influential couple and
attended couples therapy experienced a 21.5%
family therapy (CFT) researcher whose ground-
decrease in health-care utilization over the next
breaking research established CFT as a cost-
year (Law and Crane 2000). In addition, he
effective treatment modality for mental and
found that the “identified patient” in family
relational disorders. His research also demon-
therapy experienced a 9.5% decrease and that
strated that CFT resulted in decreased health-
other family members participating in family
care utilization of couples and families seen in
therapy experienced a 30.5% decrease in their
therapy.
use of health-care services. Thus, in addition to
demonstrating the applicability of the medical
offset effect to CFT, Crane, consistent with fam-
Career ily system theory, was able to establish family
therapy’s added economic benefit of reducing
Crane received his Ph.D. in 1979 in marriage and multiple family member’s health-care utiliza-
family therapy from Brigham Young University. tion within the same episode of treatment.
After spending the first 4 years of his career at Subsequent research by Crane showed an
Texas Tech University, he was a professor in the even larger medical offset effect among high
MFT program at Brigham Young University utilizers of health-care services, who account
for 34 years, before retiring in 2016. Throughout for a disproportionate amount of overall
his career, he provided important service to health-care costs. Crane found that high
the profession, serving as chair of the Commis- health-care utilizers (defined as patients with at
sion on Accreditation for Marriage and Family least four health-care visits in a 6-month period)
666 Creating Lasting Family Connections Program
who received CFT decreased their overall Law, D. D., & Crane, D. R. (2000). The influence of marital
health-care use by about 50% (Law et al. and family therapy on health care utilization in a health
maintenance organization. Journal of Marital and
2003). More specifically, they experienced sub- Family Therapy, 26, 281–291.
sequent decreases in medical use for urgent care Law, D. D., Crane, D. R., & Berge, J. (2003). The
visits (78%), illness visits (38%), and influence of marital and family therapy on high utilizers
laboratory/X-ray visits (56%) (Crane and of health care. Journal of Marital and Family Therapy,
29, 353–363.
Christenson 2008).
Following his seminal work on medical off-
set effects in CFT, Crane continued doing
research on the cost-effectiveness of CFT by
publishing a series of studies that used nearly Creating Lasting Family
one million medical records from CIGNA, a Connections Program
major health-care insurer. He was able to use
those records to compare the costs of using Ted N. Strader1,2, Christopher Kokoski1, David
conjoint therapy (either couple of family ther- Collins3, Steven Shamblen3 and Patrick
apy) with the costs of using individual therapy McKiernan4
to treat various mental and relational disorders. 1
Council on Prevention and Education:
For example, when examining the costs of Substances (COPES), Louisville, KY, USA
treating depression, he found that individual 2
CLFC National Training Center, Resilient
therapy was 58% more costly than conjoint Futures Network, LLC, Louisville, KY, USA
therapy (Crane et al. 2013). 3
Pacific Institute for Research and Evaluation
In recognition of his groundbreaking (PIRE), Beltsville, MD, USA
research on the cost-effectiveness of CFT, in 4
University of Louisville, Louisville, KY, USA
2007 Crane was given the Cumulative Contribu-
tion to Marriage and Family Therapy Research
Award by the American Association for Marriage Name of Model
and Family Therapy.
The Creating Lasting Family Connections ®
(CLFC) Program
Cross-References
▶ Meta-Analysis of Treatment Outcomes in Introduction

▶ Quantitative Research in Couple and Family Creating Lasting Family Connections (CLFC)
Therapy is a manualized, family focused program to
▶ Research About Couple and Family Therapy increase parenting skills and family-
relationship skills to build the resiliency of
youths aged 9–17 years, to increase alcohol
References and drug knowledge and attitudes, to reduce
the frequency of alcohol and other drug (AOD)
Crane, D. R., & Christenson, J. C. (2008). The medical
offset effect: Patterns in outpatient services reduction
use, and to increase family use of needed com-
for high utilizers of health care. Contemporary Family munity services. CLFC is designed to be
Therapy, 30, 127–138. implemented through community systems such
Crane, D. R., Christenson, J. D., Dobbs, S. M., as mental health centers, churches, schools, rec-
Schaalje, G. B., Moore, A. M., Pedal, F. F. C.,
Ballard, J., & Marshall, E. S. (2013). Costs of treating
reation centers, and court-referred settings.
depression with individual versus family therapy. There are three modules for parents and three
Journal of Marital and Family Therapy, 39, 457–469. separate modules for their children.
Creating Lasting Family Connections Program 667
CLFC Program Modules for Adults personal independence and responsibility for
Raising Resilient Youth. Participants learn and adulthood. Youth are asked to visualize them-
practice effective communication skills with selves in the future role of parents, coworkers,
their families, friends, and coworkers, including supervisors, or other adults responsible for setting
listening to and validating others’ thoughts and appropriate expectations and consequences for
feelings. Participants also enhance their ability their children or others they may need to supervise
to develop and implement expectations and con- in areas of responsibility (Strader and Noe 1998c). C
sequences with others, including children, Developing A Positive Response. This module
spouses, coworkers, and friends. This training helps young people to become aware of their
enhances a sense of competence, connectedness, deepest wishes for their own personal health,
and bonding between parent and children and their relationships with their peers and family
other meaningful relationships (Strader and Noe members, and their yearning for success. With
1998a). exercises designed and facilitated with sensitivity
Developing Positive Parental Influences. This to remain inclusive and nonjudgmental, partici-
CLFC training component helps participants pants examine information, facts, and feelings
develop a greater awareness of facts and feelings about alcohol, tobacco, marijuana, and other drug
about substance use, abuse, and dependency; exposure (and possible use) in family, peer groups,
review effective approaches to prevention; and community, and media. This module also helps
develop a practical understanding of intervention, youth develop an appropriate “worldview” of alco-
referral procedures, and treatment options. This hol and other drug issues with a focus on personal
module includes an examination of childhood and and family health (Strader and Noe 1998d).
family experiences involving AOD, personal and The six modules of the CLFC curriculum are
group feelings and attitudes toward AOD issues, administered to groups of parents/guardians and
as well as an in-depth look at the dynamics of their children in 18–20 weekly training sessions.
chemical dependency and its impact on relation- While the sessions are typically provided in the
ships and families (Strader and Noe 1998b). same facility at the same time, the parents and
Getting Real (Same content for both Adult and youth meet in separate training rooms with differ-
Youth Modules). The Getting Real training is pro- ent group facilitators. Youth sessions last 1.5 h
vided separately to groups of adults and youth. and parent sessions last 1.5–2.5 h. The curriculum
Participants examine their responses to the verbal focuses on (1) imparting knowledge about AOD
and nonverbal communication they experience use; (2) improving communication and conflict
with others. Participants receive personalized resolution skills; (3) building coping mechanisms
coaching on effective communication skills, to resist negative social influences; (4) encourag-
including speaking with confidence and sensitiv- ing the use of community services when personal
ity, listening to and validating others, sharing feel- or family problems arise; (5) engendering self-
ings, and matching body language with verbal knowledge, personal responsibility, and respect
messages. This promotes the skills of self- for others; and (6) delaying the onset and reducing
awareness and mutual respect while focusing on the frequency of AOD use among participating
helping participants combine thoughts, feelings, parents and youths. The program includes optional
and behavior in a way that leads them to generate individual, couple, and family case management
powerful, meaningful, and palatable messages to sessions to identify any need for specific therapeu-
others (Strader et al. 1998). tic interventions and specialized referrals to other
community services. A 6–9-day CLFC Certifica-
CLFC Program Modules for Youth tion Training for therapists (and other providers)
Developing Independence and Responsibility. In along with all materials necessary for implementa-
this component, youth are asked to examine their tion are available from the program developer.
current level of personal responsibility in their The CLFC Program is one of three programs
family life, with an eye toward developing comprising the Creating Lasting Family
Connections (CLFC) Curriculum Series. The participating families (youth and adult modules)
Series also includes the CLFC Fatherhood Pro- and community members. CLFC incorporates
gram and the CLFC Marriage Enhancement Pro- Experiential Learning Theory (Kolb 1975) by
gram. The CLFC Curriculum Series addresses the providing an interactive program with a strategic
intergenerational and chronic nature of addiction mix of role plays, games, brainstorms, guided
and the family’s role in both recovery and preven- imagery, reflective exercises, demonstrations,
tion. The CLFC Series represents the intersection and group discussions. Participants are invited to
of treatment and prevention services for families involve themselves in practicing or “experienc-
(Straderet al. 2013). Each of the three CLFC pro- ing” the ideas, concepts, and skills shared in the
grams is separately listed on the SAMHSA’s sessions and to engage in reflective thought and
National Registry of Evidence-based Programs group discussion (Johnson 1997; Satir 1983).
and Practices (NREPP). Risk and Resiliency Theory (Hawkins et al.
1992) serves as a major underpinning of the pro-
gram. Specific exercises are designed to build
Prominent Associated Figures resiliency across the domains of self, family,
school, and community (Benard 1991). Building
The Original CLFC Program was developed in from strengths, the program focuses on both intra-
the late 1980s by Ted N. Strader, M.S., a Certified and inter-personal skill development including
Chemical Dependency Counselor, a Certified Pre- verbal and nonverbal communication (with an
vention Specialist, and Executive Director of the emphasis on listening and validation), how to
Council on Prevention and Education: Sub- say no (refusal skills), and family management
stances, Inc. Dr. Tim Noe and Warrenetta practices to help prevent negative outcomes and
Crawford Mann provided notable assistance in mitigate known risk factors.
program development. Teresa Strader, L.C.S.W, Further, CLFC combines Social Learning The-
and Christopher Kokoski assisted with the devel- ory (Bandura 1977) and Therapeutic Alliance
opment of support materials. The CLFC curricu- (Bordin 1979) through the positive rapport
lum has been recognized on the National Registry established between staff and participants, and
of Evidence-based Programs and Practices through staff modeling of appropriate relationship
(NREPP) as an Exemplary Program by Healthy behaviors. Developing respected interpersonal
Canada’s Compendium of Best Practices, and a connections is key in promoting growth in both
four-time winner of the Exemplary Program personal and family behavioral dynamics.
Award provided by the National Association of For example, in the group “educational sessions”
State Alcohol and Drug Abuse Directors, two program staff served in roles often perceived
SAMHSA’s Center for Substance Abuse Preven- more as facilitators of information and role
tion, and the National Prevention Network. The models of new possibilities rather than as “thera-
John C. Maxwell Leadership Team named pists.” A range of nonjudgmental, inclusive, and
Mr. Strader one of the top 10 leaders in the USA positive facilitation skills (Strader and Stuecker
serving youth and families. 2012) result in a Therapeutic Alliance between
the CLFC trained facilitators and participants.
This alliance can be carried into private case man-
Theoretical Framework agement sessions that, when needed, can lead to
deeper personal work or other necessary referrals
The Creating Lasting Family Connections ® for more specific therapeutic interventions.
(CLFC) integrates an eclectic combination of per- Key elements of Cognitive Behavioral Ther-
sonal, couple, family, and community strengthen- apy (Beck 1993) are incorporated into group exer-
ing theoretical frameworks. These frameworks are cises. Participants are invited to participate in a
translated into a structured series of sequential, process of individualized coaching and personal
developmental, and experiential activities for reflection in order to self-correct unhelpful
Creating Lasting Family Connections Program 669
thinking and behaviors. CLFC integrates this sys- throughout the program sessions. The concept of
tem of established theories which are expressed in “influence versus control” is threaded throughout
the program design, exercises, activities, and the entire CLFC Program. Facilitators both role
implementation protocols. Each of these theories model and manage the program under the belief
relates to the central belief described in Building that participants learn best when they can volun-
Healthy Individuals, Families and Communities tarily choose their own preferred level of partici-
that “deep healthy connections build strong pro- pation (i.e., active discussion, interactive practice, C
tective shields to prevent harm and to provide both quiet listening, etc.) for each activity in each pro-
nurturing and healing support” (Strader et al. gram session. Throughout the CLFC Program,
2000, p. 17). The book refers to this concept as facilitators incorporate motivational interviewing
“connect-immunity.” and trauma-informed care techniques into interac-
tions with participants (Strader and Stuecker
2012). Culturally sensitive case management and
Populations in Focus ongoing support supplements the program con-
tent. Facilitators refer participants to appropriate
The Creating Lasting Family Connections ® service providers, as needed.
(CLFC) Program was designed for at-risk Cauca-
sian, African American, and Hispanic/Latino fam-
ilies (parents and youth) from urban, suburban, Research About the Model
and rural areas in the USA. The program is
implemented with universal, selective, and indi- In a large-scale study, the Creating Lasting
cated populations as designated by the Institute of Family Connections ® (CLFC) Program was
Medicine (IOM) Classification System. implemented in five communities in the
Louisville, KY, area (Johnson et al. 1998).
A community was defined as a group of people
Strategies and Techniques Used in who form a support system based on shared activ-
Model ities and interests. Families were randomly
assigned to the intervention group or control
The Creating Lasting Family Connections ® group. Participants were 183 high-risk youths,
(CLFC) Program incorporates a rich variety of aged 12 through 14, and their families (95 in the
strategies and techniques to appeal to the full intervention group and 88 in the control group).
range of adult and youth learning styles, Over half (58%) of the youths were female, with
cultural differences, personalities, and prefer- 16% of families identifying as African American.
ences. Learning strategies and techniques include Almost half (47%) had five or more family mem-
brief lectures, role plays, guided imagery, reflec- bers, and 30% were in low-to-medium-income
tions, discussions, brainstorms, facilitator demon- groups. There were no statistically significant
strations, storytelling, and interactive games. between-group baseline differences on key family
CLFC facilitators are trained and certified to and environmental characteristics (e.g., age, gen-
implement the program. CLFC provides facilita- der, youth access to marijuana, parent smoking
tors of differing gender, age, race, and experience behavior, and family participation in other alcohol
to relate to the largest number of participants. and other drug programs).
CLFC facilitators role model the skills of the Data on youth and family resilience and AOD
CLFC Program, therefore providing information use outcomes were collected before program ini-
within a relational and nonjudgmental context. tiation, after program services, and 1 year after
Facilitators listen and validate participant thoughts program initiation. Parents in the intervention
and feelings, provide clear and sensitive feedback, group reported statistically significant gains in
and express their own emotions as a means knowledge about AOD and enhanced beliefs
to manage group participation and interaction against using these substances, compared with
parents in the control group (Johnson et al. 1995, her thoughts, feelings, and verbal and nonverbal
1998). Both parents and youths in the intervention language. With a little practice, Doris began pro-
group reported a statistically significant increase viding more clear and compassionate messages to
in use of community services to help deal with others, including her children. Her children were
personal or family problems, compared with par- practicing similar communication skills of trust,
ents and youths in the control group (Johnson empathy, and saying “no” to others regarding
et al. 1995, 1998). The evaluation also found negative behaviors like alcohol and drug use
positive moderating effects on delayed onset and while learning to show respect for the other person
frequency of AOD use among youth. in the role play. In the alcohol and other drugs
module, Doris realized how deeply and perva-
sively her father’s alcoholism had affected her
Case Example and her family. As Doris recognized alcoholism
as a disease (rather than her father’s choice to
Doris (fictitious name used to protect her true abandon her), she expressed feelings of under-
identity), a single mother with five children, par- standing and forgiveness toward her father. She
ticipated in the CLFC Program. During the initial also recognized how her relationship with her
Screening and Program Placement Survey meet- father affected the choices she made for romantic
ing, she reported that she engaged in the program partners. She expressed openness and excitement
because the children’s fathers were “alcoholics for the possibility of bringing healing to herself
and drug addicts” who had abandoned her and and her children. As her children participated in
the children. She was frustrated with her constant the youth version of the alcohol and drug module,
need to “threaten, spank, and argue with her chil- two of her children expressed recognition of how
dren.” She particularly wanted to “prevent her they played certain roles in the family. The oldest
male children from turning out like their fathers.” child recognized that he alternated between
She and three of her children participated in the playing a “hero” role when he did well and a
program. “scapegoat” role when he made mistakes.
Early in the Raising Resilient Youth module, A second child recognized how she played the
Doris participated in an exercise to reflect on how “mascot” role by using humor to deflect attention
her own upbringing might have affected her from the family pain. Both of these children
approach to childrearing. Along with discovering seemed to particularly benefit from learning to
that her parents were not able to meet all of her express their emotions and from the closeness
needs as a child, she further became aware of how they felt with their mother when she could vali-
she was relying heavily on a series of “power and date them. The children made a connection that
threat” techniques that were unintentionally trig- not all hurtful situations needed to turn into angry
gering defensiveness and rebellion in her children. interactions. This reduced blame and fighting in
In another training room, her children were mak- the family.
ing their own discoveries about kind and compas- A year after participating in the program and
sionate relationships and developing empathy for several case management sessions, she and her
their mother in the corresponding Developing children reported less angry and disrespectful
Independence and Responsibility module. Next, behavior in the family and more communication
Doris learned and practiced skills of listening and support. Both Doris and her children were
and validating her children’s feelings, while beginning to listen and validate each other more
establishing clear, fair, and consistent expecta- and argue less. Doris stated with pride and satis-
tions and consequences. While she struggled faction that her children really improved atten-
with expectations and consequences, she also dance at school and she reported less family
responded to the interactive experience of the conflict, less school problems, and greater success
Getting Real module. Doris volunteered to receive in schoolwork. She said that her children appeared
personal coaching during role plays on integrating to have less interest in alcohol and other drugs.
Creativity in Couple and Family Therapy 671
She reported that she thought the entire program Strader, T. N., & Noe, T. D. (1998b). Developing positive
was very interesting and very helpful. She added parental influences training manual and participant
that it was really hard to be good at everything she program. Louisville: Resilient Futures Network.
learned in the classes. Because of the family’s new Strader, T. N., & Noe, T. D. (1998c). Developing indepen-
way of thinking and talking about alcohol, other dence and responsibility training manual and parti-
drugs, and emotions, Doris said she could see cipant notebook for the creating lasting family
her children doing better and that is what
connections program. Louisville: Resilient Futures
Network.
C
mattered most. Strader, T. N., & Noe, T. D. (1998d). Developing a positive
response training manual and participant notebook for
the creating lasting family connections program.
Louisville: Resilient Futures Network.
Cross-References Strader, T. N., & Stuecker, R. (2012). Creating lasting
family connections ®: Secrets to successful facilitation.
▶ Creating Lasting Family Connections Program Strader, T. N., Noe, T. D., & Crawford-Mann, W. (1998).
Getting real training manual and participant notebook
for the creating lasting family connections program.
Louisville: Resilient Futures Network.
References Strader, T. N., Noe, T. D., & Collins, D. (2000). Building
healthy individuals, families, and communities: Creat-
Bandura, A. (1977). Social learning theory. Englewood ing lasting connections. New York: Kluwer/Plenum
Cliffs: Prentice Hall. Publishers.
Beck, A. T. (1993). Cognitive therapy of substance abuse. Strader, T. N., Kokoski, C., & Shamblen, S. R. (2013, July
New York: Guilford Press. 25). Intersection of treatment and prevention: Prevention
Benard, B. (1991). Fostering resiliency in kids: Protective and recovery-informed care. SAMHSA Recovery to Prac-
factors in the family, school, and community. Portland: tice E-Newsletter, 14. Retrieved from http://www.
Western Center for Drug-Free Schools and npnconference.org/wp-content/uploads/2017/09/Strader-
Communities. Kokoski-Shamblen-ENewsletter.pdf.
Bordin, E. S. (1979). The generalizability of the psycho-
apy: Theory, Research and Practice, 16, 252–260.
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk
and protective factors for alcohol and other drug prob- Creativity in Couple and
lems in adolescence and early adulthood: Implications
for substance abuse prevention. Psychological Bulletin,
Family Therapy
112(1), 64–105.
Johnson, D. W. (1997). Reaching out: Interpersonal effec- Saliha Bava
tiveness and self-actualization. Boston: Allyn & Mercy College, New York, NY, USA
Bacon.
Johnson, K., Berbaum, M., Bryant, D., & Bucholtz, G.
(1995). Evaluation of creating lasting connections: Taos institute, Chagrin Falls, OH, USA
A program to prevent alcohol and other drug use
among high risk youth. Final evaluation report.
Louisville: Urban Research Institute.
Johnson, K., Bryant, D. D., Collins, D. A., Noe, T. D.,
Synonyms
Strader, T. N., & Berbaum, M. (1998). Preventing and
reducing alcohol and other drug use among high-risk Flow; Improvisation; Innovative; Play-oriented;
youth by increasing family resilience. Social Work, Unique linkage
43(4), 297–308.
group process. London: Wiley. Introduction
Satir, V. (1983). Conjoint family therapy. Palo Alto:
Science and Behavior Books. Family therapy originated as a creative resistance
Strader, T. N., & Noe, T. D. (1998a). Raising resilient youth
training manual and participant notebook for the cre-
to the existing dominant discourse of mental
ating lasting family connections program. Louisville: health in the early 1950s, which focused primarily
Resilient Futures Network. on locating problems within the individual
672 Creativity in Couple and Family Therapy
psyche. In family therapy’s cultural tales, the orig- pathways for going on together in the face of their
inators are often referred to as irreverential and differences. Creativity is the useful and meaning-
creative. The rise of family therapy as a creative ful unique linkages* between two “points,” where
activity was a social process in and of itself. the points can be ideas, values, beliefs, practices,
Montuori (1992) states “evolving human sys- differences between people, etc. The social con-
tems are. . .creative human systems” (p. 193). The structionist approach to creativity as a social, rela-
importance of creativity for meaningful living has tional process rather than an individual
been emphasized by a number of authors across achievement has important implications for how
traditions (Allman 1982; Gergen 2009; Keith we engage in family therapy.
2014; Montuori 1992). Though from a modernist Family therapy’s growing culture of models,
epistemological position, Allman (1982) states that theories, and treatment plans (Imber-Black 2014)
“When we help the family see themselves as a increases the quest for certainty while not concep-
system and teach them to play with their meanings, tualizing the process of creative engagement
we open each member to his [sic] own poetry and within the therapeutic context. The sole reliance
twinke [sic]” (p. 43). on theories and plans potentially reduces the gen-
Postmodernists view creativity as a social rather erative possibilities of clients’ and therapist’s cre-
than an individual phenomenon (Gergen 2009; ative interactive process. Family therapy historian
Montuori 1992). Northern-American individualistic Lynn Hoffman’s (1998) statement “models are
culture and reductionist methodological approaches heuristic fairy tales, holders of complex realities”
have shaped the construct of creativity by limiting it (p. 98) can be interpreted to mean that theories
to the study of the creative individual while failing to should be held lightly. All plans, like the models
look at its relational nature – interactions and con- they depend on, are possible road maps that
texts (Montuori and Purser 2011). Gergen states should not predetermine the outcome but create
“one comes into creativity through participation in space for emergent possibilities yet to be realized.
a history of relationship” (2009, p. 92). Creativity, By taking risks and adopting the stance of a curi-
“born within relationships,” is not “prior to rela- ous learner, therapists and clients can cocreate
tional life” (Gergen 2009, p.95). meaningful ways to engage their plans, as
required by their intersectional context. Thus,
engaging therapeutic plans and relationships
Theoretical Context for Concept require creativity. Creativity in family therapy is
being oriented to the theories and models as pos-
Creativity, a relational process that emerges in sibilities for unique creative linkages in people’s
dialogue and collaboration, is a flexible and adapt- lives rather than being predetermined by the
able response to living in “liquid times” where “right” outcome as per our theories.
lives are more fragmented with increased uncer- The bridge from theory to the discursive activ-
tainty (Bauman 2007). From a social construction ity of therapy is a performative dialogic relation-
(Gergen 1999, 2009) perspective, creativity is ship (Anderson 1997; Levin and Bava 2012)
defined as co-creating contextually relevant, between the therapist and the clients and their
unique ways of going on together in our ordinary words. Bakhtin (1981) notes that “the word in
everyday lives that emerges from the activity of living conversation is directly, blatantly, oriented
relating. Shotter speaks to the notion of emer- toward a future answer-word: it provokes an
gence when he states “indeed, every response we answer, anticipates it and structures itself in the
make to another’s activity is, often, a poetic answer’s direction” (Kindle Location 3952).
response, in the sense that it is a uniquely new, Therapy, one such living conversation, is a pro-
creative linking of familiar utterances into unfa- cess of understanding and meaning-making
miliar” (2011, p.45, emphasis added). Creative (Anderson and Goolishian 1988; Anderson
linking is the means by which couples, parents 1997) where words take on an anticipatory and
and children, and families and communities create future forming act by the interlocutor’s creative
utterances. It requires coordination and creativity the stance of not-knowing helps to engage emer-
to make meaning. Such anticipatory, future gence of that which is being cocreated among the
forming conversational utterances are not to be conversational interlocutors.
confused with the theoretically predetermined
outcomes. The distinction lies in the relational
process. By attending to how we are spontane-
Application of Concept in Couple and C
ously relating to each other, to the context, and to
Family Therapy
what we want to accomplish together, we cocreate
a unique, resourceful, performative activity that is
Bava (2016) states that a play-oriented*
defining of the relationship and the conversations.
approach is “a way of being by which we impro-
Drawing on social constructionism, communica-
visationally act into the situation, attend to our
tive action (Anderson 1997; Pearce 2007), and com-
context, relatedness, and what is being created
plexity thinking, I have created a play-oriented*
(emergence) while exploring the meaningfulness
approach (not to be confused with play therapy)
of what is being created within the relationship
which fosters creativity in therapy and teaching/
without a predetermined outcome leading the
training. The approach consists of relational pro-
way” (p. 13). There is no prescriptive way of
cesses that foster conditions for creative coordina-
improvising into the situation for creative
tion and spontaneous responsiveness as action
engagement. Rather, it calls for accepting every-
(Gergen 2009; Shotter 2011). The play-oriented*
thing as offers (Poynton 2008) and listening curi-
approach to relationships not only opens up space
ously while being in synch with the client
for creative emergence but also makes one agile and
(Anderson 1997). Through our listening, hear-
ready to engage with uncertainty and the emergent
ing, and speaking (Anderson 2003), we position
(that which is being created in the turn-by-turn
ourselves to create space for the spoken and the
interactions). In play*, as children we learn how to
unspoken, the yet to be spoken, and the unspeak-
act, be, and become; preparing for the social inter-
able and in the process creating unique linkages*.
actions of adult life (Brown 2010). Since life is
Attending to the relatedness (McNamee 2004) is
dynamic, as adults we are constantly making up
the focus we bring to how we are relating, not just
ways of being and becoming. We do not stop
in our roles but to the relationship and context
playing, yet we stop calling it play. Instead, we
that is being jointly created. As we engage with
may call it being improvisational* or creative in
our spontaneous responsiveness (Shotter 2011),
challenging and/or new situations. In play* we cre-
new possibilities emerge, and staying open to the
ate our social worlds (Bava 2016; Pearce 2007).
emerging ideas without rushing to categorize and
label it requires comfort with uncertainty and
adoption of a not-knowing stance. As the process
Description
of mutual inquiry continues, it leads to coordina-
tion of meaning about the emergent. What gets
Creativity in therapy emerges when we engage
created between the client and therapist is part of
with clients in a collaborative relationship and
the “circle of meaning” (Gadamer as referred in
dialogue focused on generativity. Such a process
Anderson 1997, p. 114).
invites what Anderson (1997) identifies as
connecting, collaborating and constructing under-
standing and possibilities. Creativity is not a tech-
nique but a way of being in relationships; it is a Clinical Example: The Man Who Seeks
relational process of engagement. Creative Pathways for the Unknowable
engagement in therapy increases uncertainty and
ambiguity because the future is undetermined, yet Rafi (to protect client confidentiality a composite
to be cocreated. Adopting Anderson’s (1997) case is used) came to therapy because Sheila, the
stance of curiosity and shared inquiry along with woman he had dated for nine months and wanted
674 Creativity in Couple and Family Therapy
to marry, had ended their relationship abruptly and I adopted a not-knowing stance and stayed
had cut-off all contact with him. And though they curious of each possibility that Rafi would bring
lived in the same neighborhood, he rarely saw her. to therapy. We would engage in conversation and
Rafi and Sheila were living in New York City. mutually explore his options from multiple
Both were born and raised in Bangladesh where lenses – his, hers, cultural, family (his parents),
marriages are arranged by family elders. The rea- etc. as he introduced them. As an Indian,
son for the breakup of the relationship was ambig- I spontaneously used a shared contextual refer-
uous. Rafi initially thought it was because his ence point since he liked Bollywood movies,
family had not responded to the marriage proposal I would make reference to the hero with a jilted
from her family in a timely fashion. But with time, heart as a way to introduce lightheartedness into
he felt there were other factors at play, and he felt the conversation, and to explore the storyline he
that unless he was able to unearth the reason for wanted to create for his life’s movie. I would enter
the breakup he would not be able to move each session not sure what aspect he would bring
forward. to therapy – his broken heart, lack of sleep, night-
When Rafi started therapy, he was unsure of mares, work performance, a visit to his home
how he would move forward with his life. He was country and/or how to face his family, dating
sure the relationship was not over and that he and trusting other women, etc. Over the course
could still influence Sheila to change her mind. of six months, he came up with unique creative
But after repeated attempts to contact her with no solutions to his dilemmas. For instance, Rafi was
response, he started to feel very sad. He spoke of interested in hiring detectives to unravel Sheila’s
the possibility that he might not be able to get an family life in Bangladesh as a way to make sense.
answer from her, as she had not only blocked all So, he hired a detective and then called it off as
contact with him but also he couldn’t track her on there was not much information. He reflected that
social media, where she used to be very active. in spite of the information, the ambiguity of the
Rafi who saw himself as smart and successful in breakup might still linger. He was not sure if it was
business, could not fathom the way to move for- the influence of her parents, the delay in his par-
ward in his personal life. In my attempts to ents confirming the match, or him not pushing his
cocreate possibilities, I stayed open to his creative parents to confirm the match or other factors that
solutions to contact her while being curious of resulted in the breakup. In the midst of uncertainty
how his approaches might be viewed from her and unfinishedness, there was a sense of play
perspective (given her history, which he had (movement) and flow*.
shared). As I improvised* my way through our conver-
Our conversations further focused on his sations, I continued to listen and check-in with
attempts to make sense of the situation, espe- Rafi on how he needed me to listen, how our
cially the abruptness and the lack of response for relationship was working for him, and how the
the breakup. Later, the focus was on how sad he direction of therapy was meaningful for him. As
felt and how he had dreams of her. With each his ideas emerged, I spontaneously explored them
turn in therapy, Rafi would identify the steps he from a place of curiosity and with a perspective of
would want to take. Some steps would look like learning by doing (play*), and we would discuss
he was potentially pursuing her or would only each of their potentials in light of Rafi’s hopes.
lead to more pain instead of making a clean Sometimes, he would go further with some ideas
break and moving on in the face of what was a and come back and discuss the results and then
dead end. But I attended to the unique linkages* decide to drop them while with other ideas he took
he was making rather than the perceived out- them further, and they took on a life of their own.
comes. We explored those linkages in terms of For instance, Sheila loved the outdoors, so he
the possibilities that would be created for the decided that the way to move forward was to
future of their relationship together. honor her spirit of outdoors and take to activities
such as hiking and traveling. We discussed how References

that would be helpful for him, how would it not
make him pine for her or keep hope alive (if that is Allman, L. (1982). The aesthetic preference: Overcoming
the pragmatic error. Family Process, 21(1), 43–56.
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with the intent to resolve but to understand and bilities: A postmodern approach to therapy. New York:
publicly hold them as paradoxical responses of Basic Books. C
Anderson, H. (2003). Some notes on listening, hearing and
being human. And I invited him to play, engage,
speaking and the relationship to dialogue. Paper pre-
and discover his preferred options. He continued sented at the Eighth Annual Open Dialogue Confer-
to hike and realized that he loved it, and by the end ence: What is Helpful in Treatment Dialogue? Tornio,
of the therapy, he was doing it because he liked it Finland. Retrieved from http://harleneanderson.org/arti
cles/newbatch/Dialogue-listeningspeakinghearing.pdf
rather than for any symbolic meaning. The emer-
Anderson, H., & Goolishian, H. (1988). Human systems as
gence of such an activity and the final meaning it linguistic systems: Evolving ideas about the implica-
took on is an illustration of how I held all ideas as tions for theory and practice. Family Process, 27,
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Bakhtin, M. M. (1981). The dialogic imagination: Four
meaning rather than naming any single idea as
essays. Austin: University of Texas Press. Kindle Edition.
denial or (not) letting go, etc. Over the course of Bauman, Z. (2007). Liquid times: Living in an age of
hiking, he also met a couple of women and dis- uncertainty. Malden, MA: Polity Press. Kindle Edition.
covered he was not yet ready to date and that Bava, S. (2016). Play-oriented pedagogy: Liberating
emergence and uncertainty in couples and family ther-
opened up the conversations about how to trust
apy training. Manuscript submitted for publication.
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The role creativity played in this process was imagination, and invigorates the soul. New York:
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Gergen, K. J. (1999). An invitation to social construction.
was emerging by noting the creative linkages Rafi
Thousand Oaks: Sage.
made for how to go on in the face of an abrupt Gergen, K. (2009). Relational being: Beyond self and
ending to his romantic relationship. In holding community. New York: Oxford University Press. Kin-
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Keith, D. (2014). Continuing the experiential approach of
Carl Whitaker. Phoenix: Zeig, Tucker & Thiesen. Kin-
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676 Cultural Competency in Couple and Family Therapy
Poynton, R. (2008). Everything’s an offer: How to do more one’s ancestry. Although the classification of
with less. Portland: On Your Feet. individuals on the basis of external markers
Shotter, J. (2011). The dance of Rhetoric: Dialogic selves
and spontaneously responsive expressions. In C. Meyer (racial categorization) has been established by
& F. Girke (Eds.), The rhetorical emergence of culture scientists as not having a biological basis, and
(pp. 37–51). New York/London: Berghahn Books. race is widely accepted as being a social con-
struct, the salience of race in individual, social,
and political discourse dictates that it be
included in this discussion of cultural compe-
Cultural Competency in tency. In everyday conversation, the terms race
Couple and Family Therapy and ethnicity are often used interchangeably.
However, in this document, they are intended
Christiana I. Awosan1, Yajaira S. Curiel2 and to refer to different concepts.) (e.g., Blacks,
Mudita Rastogi3 Whites), ethnicity (e.g., African-American,
1
Seton Hall University, South Orange, NJ, USA Latino-American), social class, (e.g., poor and
2
Palo Alto University, Palo Alto, CA, USA working-class), sexual orientation (e.g., LGB),
3
Illinois School of Professional Psychology, and religion (e.g., Muslims). Furthermore, in
Argosy University, Schaumburg, IL, USA the past two decades there has been a push to
train clinicians to not only critique the overall
lack of cultural and gender-sensitivity in family
Name of Entry therapy theories, but also the awareness of ther-
apists’ own cultural identities, ideologies, and
Cultural Competency in Couple and Family values on their work with their clients (Hardy
Therapy and Bobes 2016). In recent years, the work of
cultural competency in the field of CFT has
included the notion and practice of Social Jus-
Synonyms tice* (McDowell and Shelton 2002).
The concept of Social Justice within the prac-
Contextual factors; Cultural attunement; Cultural tice of cultural competency requires awareness
awareness; Cultural consciousness; Cultural and sensitivity from clinicians and researchers
humility; Cultural literacy; Cultural multi- regarding the ways in which issues of gender,
dimensionality; Cultural responsiveness; Cultural race, class, sexual orientation, religion, national-
sensitivity; Diversity; Intersectionality and social ity, etc., influence power, privilege, and oppres-
justice; Multicultural perspective sion in the lives of clients and the therapeutic
process. It also includes thorough consideration
of the negative impact of these issues on their
Introduction mental, emotional, and relational well-being.
Essentially, cultural competency is the ability of
Over the past four decades, the field of Couple the mental health professional to “consider the
and Family Therapy (CFT) has attempted to broader ecology of families, [couples and individ-
move from a broader focus of gender and cul- uals, and widen their] lens to take history, context
tural awareness to a more specific emphasis on and community into account” in their work
ways to train clinicians and researchers to focus (McGoldrick and Hardy 2008, p. 7).
on particular groupings such as gender (e.g.,
females), race (The authors distinguish and pre-
sent the categories of race and ethnicity as sep- Description
arate but related concepts. Race is categorized
as the phenotypic presentation of one’s skin Cultural competency in the field of CFT
color and ethnicity as a cultural heritage of includes the ability of a therapist to take into
Cultural Competency in Couple and Family Therapy 677
account the cultural histories of a client through- The History of Cultural Competency in the
out the process of clinical assessment, diagnoses, Field of CFT
implementing clinical interventions, as well as Cultural competency vaguely appeared in the field
research and clinical training. Further, it encom- of CFT in the later 1970s and 1980s when female
passes therapists’ awareness of their own culture therapists such as Rachel Hare-Mustin, Betty Car-
as well as a recognition and acknowledgment of ter and Peggy Papp begun to critique the field’s
clients’ cultural differences in order to engage definition of family, the invisibility of women’s C
in and cultivate therapeutic relationships, pro- lives with regards to lack of power in relation-
cesses, and interventions that are culturally sen- ships, and the privilege of two parent, middle-
sitive and responsive to the needs of the clients class, patriarchal, heterosexual, White families in
(Sue et al. 1992). many of the family therapy theories (Walters et al.
Culture is defined as the ways in which gen- 1991). The era of the 1980s in the field of family
der, race, ethnicity, class, sexual orientation, therapy was associated with the “feminist critique
religion, nationality, etc., shape individuals’, of family therapy.” However, many noted that this
couples’, and families’ ideologies, values, and period mainly focused on the voices of White
relationships. Cultural competency points to the female therapists without privileging the experi-
need of the therapist to hold the perspective and ences of women of color or those from the Global
practice that every family, regardless of its cul- South.
tural background is like “all other families, Raising awareness of and sensitivity to gen-
some other families and no other families” der inequalities and male dominance largely
(Hardy 1989, p. 22). Therapists must take into ignored the topic of ethnicity and work with
account the larger contextual issues, such as families of color. Simultaneously, from the late
race, gender, ethnicity, sexual orientation, spir- 1960s and throughout the 1970s, the invisibility
ituality/religion, nationality that inevitably of ethnicity and general attention to race in
impact the therapeutic relationship, process, family therapy theories, writings, and clinical
and treatment. In other words, cultural compe- works were highlighted by prominent scholars
tency calls therapists to be appreciative, knowl- such as Harry Aponte, Braulio Montalvo, Sal-
edgeable, and attend to the cultural similarities vador Minuchin, and Carlos Sluzki. In these
and differences with regards to gender, race, family therapist scholars’ work, they empha-
sexual orientation, class, religion, nationality, sized and advocated for the broad understanding
etc., that exist in all the couples, families, and of diverse cultures and cultural influences rather
individuals they work with, and the impact of than a specific embracement of understanding of
their own cultural differences and similarities a specific cultural group. For instance, in their
with clients. work as Structural Family therapists, Minuchin
The ideas of and training in cultural compe- and others focused on specific families of color
tency in the field of CFT emerged as scholars who lived in impoverished neighborhoods
and clinicians began to critique the Eurocentric, (McGoldrick and Hardy 2008). These scholars
middle class, heterosexual, male, relational contended that it was more effective to attend to
standards, and perspectives that were imbedded the broader sociocultural context of families’
in all the family therapy models and clinical class and ethnic backgrounds rather than the
interventions. Even though the field of CFT specifics of the ways their social class and eth-
prided itself in the ability to view individuals, nicity informed their presenting problems and
couples, and families within the context of their vice versa (Goldenberg and Goldenberg 2013).
social environment and relationships, family According to Doherty and Baptiste (1993),
therapists were being trained to be objective to widespread interest on the issues of race and
the issues of gender, race, class, sexual orienta- ethnicity was generated by the landmark publi-
tion, religious, etc., in working with families cation, Ethnicity and Family Therapy
(McGoldrick and Hardy 2008). (McGoldrick et al. 1982).
In an attempt to focus on the specific family there was a lack of clinical and training focus in
structure and dynamics of ethnic groups and their working with families of color, particularly with
presenting problems, some scholars described regards to race.
these families in generalized terms. Although the According to Hardy, the “neglect of [cultural]
McGoldrick et al. (1982)’s text, Ethnicity and context” created and promoted a “theoretical myth
Family Therapy, played a pivotal role in moving of sameness (TMOS)” in working families of
the field of CFT forward in cultural awareness color. To challenge the narrow and linear view,
training, it was also critiqued for perpetuating a which is antithetical to the systems epistemology
monolithic view of specific ethnic family groups that “all families are virtually the same,” regard-
(e.g., the African American family, the Irish fam- less of their racial background, a definition of
ily, the Jewish family) (Hardy 1989). Differences TMOS, Hardy called for “training programs to
between families of color and White families were [not only] adopt a view and practice that empha-
highlighted at the expense of differences within size the importance of theory comprehension and
families with regards to variables such as gender skill acquisition [but] also punctuate differences
performance, influence of socio-economic status, that might be attributable to race, culture, ethnicity
geography. It is important for couple and family and/or gender” between the therapist and the cli-
therapists and researchers to have an awareness of ent which may impede the therapeutic relation-
the impact of the historical and current sociocul- ship and process (p. 20). Laszloffy and Hardy
tural context of the specific couple and family they (2000) stated that in order to be culturally compe-
serve. Just as questions were raised about the lack tent, trainees need to become aware of and sensi-
of accountability in family therapy theories tive to the ways race and racism influence the lives
regarding gender-sensitivity, the issue of training of clients and the presenting problems they bring
clinicians to be racially aware and sensitive in to therapy. Further, their need to learn how to
clinical and research work became a major topic address these contextual factors in therapy has
in the field by late 1980s. been the focus of cultural competency training in
During the 1990s and 2000s, the topic of race the field since 1990s (Hardy and Laszloffy 1992;
became a critical issue in the training of Couple Laszloffy and Hardy 2000; Hargrave and Pfitzer
and Family Therapists. Family therapists such as 2003). Additionally, to develop cultural compe-
Kenneth V. Hardy, Marlene F. Watson, Monica tency around the issue of race, scholars emphasize
McGoldrick, Celia Falicov, Tracey Laszloffy, the importance of exploring the ways in which the
Elaine Pinderhughes, Nancy Boyd-Franklin racial differences between the therapist and client
highlighted the significance of addressing race inform the therapeutic alliance and process
when working with families of color (Laszloffy (Awosan et al. 2011; Rastogi and Wieling 2005).
and Hardy 2000). These scholars and others had to This continues to be a critical topic in the training
contend with the fact that virtually all the major of culturally competent couple and family thera-
family therapy theories (e.g., Bowen, Strategic, pists and researchers (Dee Watts Jones 2016;
and Symbolic Experiential) did not highlight the Watson 2016).
influence of race on the lives and problems that Similarly, much work is still needed in training
clients present in therapy. Nor did the theoreti- CFTs to be sensitive and competent when it comes
cians emphasize the interplay of race within the to sexual orientation. By the early 2000s, scholars
therapeutic relationships and processes. In an arti- raised questions about the influence of hetero-
cle, “The Theoretical Myth of Sameness: normativity in the theories and training in the
A Critical Issue in Family Therapy Training and field of CFT, and lack of lesbian, gay, and bisexual
Treatment,” Hardy (1989) emphasized the (LGB) affirmative content in CFT training pro-
“neglect of [cultural] context” in both the thera- grams (Hudak and Giammattei 2010; Green
peutic relationships and throughout family ther- 2003). Cultural competency with regards to sex-
apy training programs. In calling family therapy’s ual orientation calls for decentering hetero-
attention to cultural competency, Hardy noted that normative definitions of family and couple
relationships and the ways in which clinicians and trained to be aware of the values, assumptions,
researchers are trained to work with LGB com- and prescriptions that they attach to cultural issues
munities. Pivotal writings on sexual orientation of class, spirituality/religion, ability, immigration,
awareness and sensitivity such as Stone Fish and and nationality. Culturally sensitive* profes-
Harvey’s (2005) Nurturing queer youth: Family sionals in mental health need to be open to the
therapy transformed have expanded the cultural ways in which their lack of awareness of their own
consciousness of CFTs. Authors have stressed values, assumptions, and prescriptions may nega- C
training CFTs to be aware and understand the tively influence and undermine the therapeutic
lives and societal stressors that LGB individuals relationship, process, and treatment outcomes
experience, as well as increasing consciousness (Hardy and Bobes 2016).
around clinician’s biases, attitudes, and feelings A further issue needs attention. Many of the
with working with this population* (Bernstein theoretical and empirical writings on cultural
2000; McGeorge and Stone Carlson 2011). Others competence largely focus on highlighting
have argued that CFTs must engage in and proac- diverse social identities or contextual factors
tively practice LGB affirmative therapy (Rock such as gender, race, ethnicity, sexual orienta-
et al. 2010). Even with the recent advances within tion, social class, spirituality/religion and immi-
the field on sexual orientation awareness and sen- gration, to name a few, rather than on the
sitivity, there is a gap in CFTs’ training on cultural multidimensionality* and intersectionality* of
competency around transgendered individuals these social identities. Intersectionality refers to
(McGeorge and Stone Carlson 2011). According the notion that all of us occupy multiple niches
to Coolhart et al. (2013), there has been less com- simultaneously and define ourselves via an inter-
petency training and development in the field of weaving of these categories. Further, our identi-
CFT when working with transgender youth and ties can be fluid, with different variables being
adults. Thus, more writings and research are highlighted in different contexts (Rastogi and
needed in the field of CFT with regards to cultural Thomas 2009). An understanding of the ways
awareness and sensitivity in working with this in which multidimensional social identities/
community. selves inform the therapeutic relationship, super-
The literature on the timeline of cultural com- visory relationship, and conceptual as well as
petency scholarship indicates a substantive explo- executive skills of CFT clinicians is greatly
ration and articulation around contextual factors needed (Hardy and Laszloffy 2002; Hardy
such as gender, ethnicity, race, and sexual orien- 2016). Additionally, the above authors argue
tation. Albeit, more work in the development that contextualizing CFT cultural competency
of tangible cultural competency clinical and within the framework of social justice,* power,
research skills around these factors are gravely privilege, oppression, and marginalization in the
needed in the field. In recent years, scholars have larger society and on the lives of individual cli-
highlighted the need for more scholarship on cul- ents, the therapeutic relationships, processes, and
tural awareness and sensitivity with regards to outcomes needs to be one of the major next steps
other diversity* issues such as social class, spiri- to further cultural competency in the field. CFT
tuality/religion, ability, immigration and national- needs to attend to not only “WHO is included
ity (Allen-Wilson 2016; Daneshpour 2017; Hardy (diversity) but also HOW one is included (social
et al. 2016; Platt and Laszloffy 2013; Seedall et al. justice)” in our therapy models and training pro-
2014). Knowledge of the influences of social grams (Hardy 2016, p. 7). He further argues that
class, spirituality/religion, ability, immigration one cannot truly be competent (i.e., be an expert)
and nationality on the mental health, and emo- on someone else’s culture, especially if one is not
tional and relational well-being of clients are aware and sensitive to the ways in which his or
essential to become a culturally attuned* therapist her own multidimensional cultural identities/
or researcher. Similar to the other contextual fac- selves dictate the relational and power dynamics
tors* mentioned above, it is critical that CFTs are in interactions with others.
Thus, cultural competency is not only about can raise consciousness of larger contextual issues
training CFTs to be cognitively aware of the cul- related to race, culture, gender, power, religion,
tural similarities and differences between them and its impact on clinical work.
and their clients or even among their clients. It is Moreover, addressing cultural competence
also about equipping CFTs in practical ways to within the supervision context has been supported
become affectively and relationally sensitive to by many family therapy scholars (Christiansen
the ways in which their multidimensional identi- et al. 2011; Hardy 2016; Killian 2001; Lappin
ties/selves and those of their clients may trigger and Hardy 2002; Todd and Rastogi 2014). Hardy
issues of power, privilege, oppression, or margin- (2016) espouses a Multicultural Relational Per-
alization that may impede culturally responsive* spective (MRP) to highlight a variety of core
therapeutic engagement and process. competencies that promote culturally sensitive
training and supervision. In these core competen-
The “How To’s” of Cultural Competency and cies, trainers and supervisors are required to
Its Current Status in CFT embody several key elements such as recognizing
The foundational texts pertaining to cultural com- that all relationships are cross-cultural. Trainers
petency have focused on obtaining content rele- and supervisors must be able to engage in a pro-
vant to the “culturally different.” However, an cess of critical self-interrogation and self-
integral aspect of cultural competency is for the reflection. A steady gaze inwards would assist in
therapist, researcher, and/or scholar to also be the process of acquainting oneself with our cul-
aware of her/his own cultural context. Thus, the tural being. Through the process of self-
cultural genogram (Hardy and Laszloffy 1995) is interrogation and critical self-reflection, one
an essential tool in the training of culturally com- would be better equipped to remain engaged in
petent family therapists. The purpose of the cul- intense conversations that often arise during con-
tural genogram is to raise cultural awareness and versations of diversity. The ability to highlight,
increase cultural sensitivity. Through the process deconstruct, and make visible the persistent expe-
of constructing a cultural genogram, family ther- riences of oppression and its effects also promotes
apists identify and explore their perceptions and an “oppression sensitive lens” to critically under-
feelings toward their cultural identities, encourage stand the interplay between power, privilege sub-
candid discussions that reveal and challenge cul- jugation and trauma (Hardy 2016). Hardy also
turally based assumptions and stereotypes, and outlines why the prospect of being “culturally
lastly, discover their culturally based triggers and sensitive” is not an endpoint that is easily
how these may impact their therapeutic effective- obtained; rather it is a lifelong process that
ness (Hardy and Laszloffy 1995). requires time, commitment, intentionality, and
Additionally, numerous authors contend that effort.
experiential learning is a critical part of enhancing
cultural sensitivity and have identified other strat-
egies to increase cultural sensitivity in clinical Relevant Research
training. In order to address accreditation stan-
dards relevant to cultural competence, Laszloffy In a content analysis of three family therapy
and Habekost (2010) present a model of experi- journals between 2004 and 2011, Seedall et al.
ential tasks to help educators promote both cul- (2014) indicated that there is far greater theoretical
tural awareness and sensitivity. These experiential than empirical scholarship on diversity,
tasks are designed to help students move beyond intersectional and social justice approaches in
cultural awareness and promote meaningful, the field of CFT. In previous years, the research
empathic clinical sensitivity. Esmiol et al. (2012) on cultural competency has focused on evaluating
concur that a combination of theoretical issues training programs and professional organization
alongside students’ exploring and discussion such as AAMFT incorporation and interaction of
their own stories of privilege and marginalization diversity issues in their curricula and programs
(Wieling and Rastogi 2003). Although these competency, the field’s research development
empirical studies have been helpful in moving and design needs to move towards studying and
the field forward in terms of emphasizing diver- understanding the unique experiences of specific
sity issues in CFT training programs, little is cultural groups. This type of empirical work will
known as to how the development of cultural provide data to build diverse therapy approaches
acknowledge of trainees is transmitted/translated from the ground up. In recent years, CFT
into cultural and clinical skills and competencies. researchers have engaged in research studies that C
More research is needed on how issues of diver- focus on the unique experiences of specific cul-
sity, intersectionality, and social justice are taught tural groups (Beitin and Allen 2005; Parra-
and integrated in training programs’ curricula and Cardona et al. 2009; Coolhart et al. 2013). This
within supervisory environments. Additionally, it research endeavors to provide factual and experi-
is important for the field to have better awareness ential knowledge on the variant cultural identities,
and understanding of the evaluative methods and values, and experiences of groups within their
processes of determining trainees’ cultural com- familial and societal contexts.
petency. Empirical work is lagging due to the To move beyond diversity research, the field of
difficulties that the field has in clearly defining CFT needs to incorporate social justice inquires in
and operationalizing concepts and constructs its empirical agenda. Scholars have indicated that
such as cultural competency. More research is cultural competency within the frame of social
needed to aid the field in defining and understand- justice should be able to address the impact of
ing what constitutes a culturally competent thera- sociocultural oppression or the trauma of sexism,
pist and/or researcher and the outcomes of this racism, heterosexism, classism, Islamophobia,
training and practice. and other forms of domination and issues of
Several authors have recently proposed that equity on clients’ mental, emotional, and rela-
clinicians, researchers, and scholars focus on cul- tional lives (Hardy 2016; McDowell and Shelton
tural responsiveness and humility as compared to 2002). Together, diversity and social justice
cultural competency (Bernal and Domenech- research will help the field develop better con-
Rodriguez 2009; Seponski et al. 2013). Particu- structs and concepts to aid trainers in assisting
larly, within a research paradigm, these authors trainees to acquire culturally aware and sensitive
contend that simply adapting models of CFT that skills and competencies as family therapists and
were normed on White heterosexual, patriarchal researchers. Additionally, this research will be
middle-class families is insufficient for use with beneficial to the field’s development and imple-
families, couples, and individuals who do not hold mentation of clinical interventions that are cultur-
mainstream Eurocentric values and norms. ally and socially just for specific groups, thus
Seponski et al. (2013) proposed the development enhancing trainers and supervisors’ abilities to
of culturally responsive therapy (CRT) and effectively evaluate trainees’ cultural competency
research by using a responsive evaluation and responsive skills (McGeorge et al. 2006).
(RE) approach. Culturally responsive therapy
and research within a responsive evaluation
framework allows CFT researchers and clinicians Special Considerations for CFT
to develop models of therapies that are “theoreti-
cally and technically responsive to the needs Schmonburg and Prieto (2011) indicated that the
unique to a certain population” rather than adapt recent emphasis in the field of CFT on diversity
and utilize current therapy models such as Emo- training has been helpful in terms of enhancing
tionally Focused Therapy to all couples, under the trainees’ knowledge of social cultural issues
premise of universality of emotional and interac- through didactic training format. A didactic train-
tional processes of partners regardless of their ing format may increase trainees’ cognitive under-
cultural identities and coupling context (p. 28). standing and the complexity of the similarities and
In order to advance CFT research on cultural differences of cultural identities among their
clients as well as between them and their clients. perspectives and practical applications (pp. 16–24).
We also believe that incorporation of experiential New York: Routledge.
Doherty, W. J., & Baptiste, D. A. (1993). Theories emerg-
training format (exercises) intertwined with didac- ing from family therapy. In P. Boss, W. Doherty,
tic training will aid trainees in becoming more R. LaRossa, W. Schumm, & S. Steinmets (Eds.),
culturally aware and sensitive by assisting in Sourcebook of family theories and methods:
ways in which to develop and apply clinical con- A contextual approach (pp. 505–524). New York:
Plenum.
ceptual and execution skills as well as research Esmiol, E. E., Knudson-Martin, C., & Delgado, S. (2012).
skills within the framework of cultural compe- Developing a contextual consciousness: Learning to
tency (Nixon et al. 2010; Esmiol et al. 2012; address gender, societal power, and culture in clinical
Hardy and Bobes 2016). Thus, an integration practice. Journal of Marital and Family Therapy,
38(4), 573–588.
of both didactic and experiential training formats Goldenberg, H., & Goldenberg, I. (2013). Family therapy:
allow for critical self-awareness and attunement, An overview. California: Cengage Learning.
which are major components of being a Green, J. R. (2003). When therapists do not want their
culturally competent and responsive therapist clients to be homosexual: A response to Rosilk’s arti-
cle. Journal of Marriage and Family Therapy, 29,
and researcher. 31–40.
Hardy, K. V. (1989). The theoretical myth of sameness:
A critical issue in family therapy training and treatment.
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cultural case conceptualization ability and couple family therapy
684 Cultural Competency in Supervision
Introduction status and the intersectionalities of one’s power

differentials, privileges, marginalizations, gender,
Cultural competency in supervision is not only sexual orientation, race, ethnicity, rank, service
an embodiment of cultural awareness and under- location, political climate, etc.
standing but a core competency of a supervisor in The lack of dialogue acknowledging the inter-
the field of marriage and family therapy. Culture play of privilege, power, and oppression sets a
competency in supervision encompasses aware- precedence of limited awareness and unwittingly
ness surrounding one’s own values, assumptions, reinforces previously set power and privilege
and biases as these serve as the foundation dynamics through defining and stereotyping.
from which one views the world including that The current model aims to shift focus away from
of culturally diverse clients. Cultural competency the belief that cultural differences are the source
in supervision is imperative to providing all- of inequities to understanding that it is the mean-
encompassing therapists that not only own their ing a particular culture construct and practice that
own power, privilege, and oppression but can creates a norm and defines and labels the domi-
facilitate this awareness within their clients nant, the marginalized, the accepted, and the
(Hernández et al. 2005). Cultural competency is unaccepted (Hernandez-Wolfe and McDowell
a lens which supervisors, supervisees, clients, and 2014). This model, to some degree, utilizes iso-
the interwoven connections to each can be morphism by calling attention to various dynam-
empowered to own contributions and take action ics that play out in supervision that parallel
to help alter the larger discourse taking place the supervisee and client process. The goal of the
within therapy and supervision. model is to foster awareness, not only with
the supervisee but also their client, surrounding
the interconnectedness of power, privilege, and
Theoretical Context for Concept oppression experienced by, and between, the indi-
vidual, their family, community, cultural group,
The current model of cultural competency and global institution. From this need, a founda-
evolved from a more rigid, singular perspective tion for cultural competency within supervision
inclined to compartmentalize people based on was devised using cultural equity, cultural humil-
gender, race, ethnicity, sexual orientation, class, ity, and intersectionality.
etc. The focus surrounded the “otherness,” the
differences, of the individual and not the
interplay between power and privilege and not Description
only of living in general but the role of the
therapist, supervisee, supervisor, and other Hernandez-Wolfe and McDowell (2014) empha-
power positions involved in the therapeutic size the use of cultural equity, cultural humility,
alliance, including the client (Hernandez-Wolfe and intersectionality to provide a foundation to
and McDowell 2014). A subsequent effect is help supervisees conceptualize their clients in
being the belief that one can understand a totality. The use of cultural equity ensures that
person and their experiences based merely on a supervisors reflect upon their own privileges,
few select descriptives of their identity and that power, and marginalizations and vice versa
these pieces of identity were static rather than while also embodying an awareness surrounding
fluid and interwoven with other vast aspects of the multifaceted interaction between personal,
identity, experience, and a larger societal institu- social, and institutional locality that directly or
tion. For example, a supervisor working from the indirectly interface with relationships of power,
previous model might encourage a supervisee to privilege, and oppression (Hernandez-Wolfe
learn all she could about working with clients that and McDowell 2014). Cultural humility, as
identify as veterans without helping the super- defined by Tervalon and Murray-Garcia (1998),
visee conceptualize the impact of having a veteran is the embodiment of lifelong learning and self-
Cultural Competency in Supervision 685
reflection which continuously fosters awareness as the supervisee allowing the supervisee to
and flexibility instead of becoming complacent help their client enhance their power within their
with cultural awareness. Through utilizing cul- context. Part of this process includes the supervisee
tural humility, one stays curious about culture acknowledging their own contributions toward
and is able to admit to times of unknowing. therapeutic gains as well as their own gain from
Of course, it is gravely important to know as the therapeutic relationship. In this aspect, the
much as possible about various cultures, disabil- supervisor garners special attention to the growth C
ities, and experiences, but utilizing humility of the supervisee as well as the growth of the client.
allows for the navigation of times of unawareness Similarly, accountability is the emphasis placed on
through engaging in honest dialogue. The last acceptance of one’s actions and the effect they have
foundational piece is intersectionality which on others, particularly when the actions have neg-
refers to how each person is positioned in multiple ative consequences; as well as utilizing reparative
systems of privilege and oppression including action to right wrongs that have been committed. In
race, gender, sexual orientation, religion, and this process supervisors gently guide supervisees’
social class (Crenshaw 1989). For example, a awareness surrounding the consequences their own
person who was born and raised in America and actions have had for their client and the client’s
identified as African American may have a very systemic relationship as well as for their self-of-
different conceptualization than another who the-therapist development.
identified as African American but only recently Throughout this process the supervisor
obtained citizenship. Understanding that there shares their own accountability and actions that
are multiple interactional levels based on the have contributed negatively to the supervisory rela-
various pieces of identity, cultural and systemic tionship as well as the therapeutic relationship. This
interactions and intersections allow for the super- process is also fluid in allowing for owning and
visor to help the supervisee to reflect upon as accepting actions that have negatively impacted
many dimensions as possible. others, as well as accounting for one’s privilege.
Lastly, empowerment is utilized to help the super-
visee guide their client in gaining power through and
Application of Concept in Couple and within their own lives. The supervisor facilitates this
Family Therapy process by helping the supervisee acknowledge
their own standing in society as well as their contri-
The framework for providing culturally compe- bution and gains from the therapeutic process. Once
tent supervision utilizes three components: the supervisee has foresight over their own experi-
(a) critical consciousness, (b) empowerment, ences, they can help their client be empowered
and (c) accountability (Freire 1971; Hernandez- through owning their own positive contributions in
Wolfe and McDowell 2014). This framework their own life and the lives of others.
focuses on understanding lived experiences
as well as empowering through creating action
within one’s own reality; this process allows Clinical Example
room to understand and appreciate actions
that had previously been taken for granted. Amir, an identified Muslim immigrant from Great
To start, supervisors need to maintain reflective Britain, came to the United States and is a prac-
questioning and processing to continue enhancing ticing marriage and family therapist trainee.
the supervisee’s awareness and raise critical Recently, Amir started working with Ehsan, an
consciousness, since critical consciousness is American-born Muslim who was referred for ther-
formed through the use of dialogue, curiosity, apy by his college guidance counselor for anger
and language (Hernandez-Wolfe and McDowell and depression. In supervising Amir shares that
2014). Critical consciousness is a multifaceted he is having a difficult time connecting with his
construct in applicability to the client as well client outside of a shared commonalty of religion.
686 Cultural Competency in Supervision
Amir told his supervisor that he has attempted Throughout the supervision process, Amir’s
to be transparent with his client and shares some supervisor has continuously reflected his own
of his own experiences and struggles in America accountability through acknowledging when his
as a Muslim in order to connect with him, but this own actions have had a negative impact on Amir
only seems to push Ehsan away. and has taken action to repair any damage caused
to the supervisory relationship.
Previous Model Through the supervisor’s encouragement
Amir’s supervisor advises him to dichotomize and role modeling, Amir decides to have a
Ehsan’s experiences as separate pieces and focus dialogue with his client and holds himself
on his experiences of oppression and marginali- accountable for his inability to find ways to further
zation as a Muslim American which eventually connect with and understand Ehsan’s experiences.
alienates Ehsan making him feel disempowered Conceptualizing Ehsan’s life through
and hopeless. Ehsan soon feels therapy is a waste intersectionality, cultural equity, and humility
of time as he is not getting the support he needs allows Amir to genuinely connect with Ehsan
and subsequently, feeling defeated, quits therapy and foster a space of awareness and understand-
and has no intention in finding another therapist. ing. Through this experience Ehsan feels honored
and heard and has a sincere desire to continue the
New Model therapeutic alliance.
Utilizing intersectionality, culture equity, and humil-
ity, Amir’s supervisor helps him to foster self-
awareness around his own power, privilege, and Cross-References
oppression. Utilizing critical consciousness, the
supervisor encourages Amir to examine his own ▶ Cultural Competency in Couple and Family
lived experiences in the United States as well as in Therapy
Britain, including the effects of the various commu- ▶ Culture in Couple and Family Therapy
nal, social, and political climates of each and the ▶ Supervisor-Supervisee Relationship in Couple
aspects of his experiences that he has taken for and Family Therapy Supervision
granted. This allows for Amir to recognize where
he may have more privilege as a Muslim British
immigrant than a Muslim American born and raised References
in United States post-9/11. This process helps Amir
understand that Ehsan’s experiences are heavily Crenshaw, K. (2018). Demarginalizing the intersection
shaped by his geographical location, politics, and of race and sex: A Black feminist critique of anti-
discrimination doctrine, feminist theory, and antiracist
economics as well as psychological conditioning politics [1989]. In Feminist legal theory (pp. 57–80).
and oppression. Furthermore, Amir’s supervisor Chicago, Routledge.
encouraged the use of empowerment as a way to Freire, P. (1971). Pedagogy of the oppressed. New York:
help Amir construct his own awareness of power Seaview.
Hernández, P., Almeida, R., & Vecchio, D. D. (2005).
within his reality and the reality of his client’s life. Critical consciousness, accountability, and empower-
Through this process the supervisor helps Amir ment: Key processes for helping families heal. Family
acknowledge his own standing in the world, be it Process, 44(1), 105–119.
race, gender, ethnicity, class, sexual orientation, and Hernandez-Wolfe, P., & McDowell, T. (2014). Bridging com-
plex identities with cultural equity and humility in sys-
the implications these have on Amir. Amir is also temic supervision. In T. C. Todd & C. L. Storm (Eds.),
encouraged to acknowledge his contributions to the The complete systemic supervisor: Context, philosophy,
therapeutic relationship, for instance, he was able to and pragmatics. New England: IUniverse.
connect with Ehsan through a shared religious expe- Tervalon, M., & Murray-Garcia, J. (1998). Cultural humil-
ity versus cultural competence: A critical distinction in
rience on how comforting that might be to Ehsan to defining physician training outcomes in multicultural
not have to explain Muslim morals and values to education. Journal of Health Care for the Poor and
someone. Underserved, 9(2), 117–125.
Cultural Identity in Couples and Families 687
Recognition of these issues has occurred

Cultural Identity in Couples across disciplines that include couple and family
and Families therapy specialties, and they developed guidelines
for cultural competence in order to address these
Shalonda Kelly and Yasmine Omar disparities in therapy. For example, the American
Rutgers, the State University of New Jersey, Psychological Association (APA) recognized the
New Brunswick, NJ, USA importance of multiculturalism*: C
Multiculturalism, in an absolute sense, recognizes the
broad scope of dimensions of race, ethnicity, lan-
Name of Theory guage, sexual orientation, gender, age, disability,
class status, education, religious/spiritual orientation,
and other cultural dimensions*. All of these are criti-
Cultural identity cal aspects of an individual’s ethnic/racial and per-
sonal identity, and psychologists are encouraged to be
cognizant of issues related to all of these dimensions
Synonyms of culture. In addition, each cultural dimension has
unique issues and concerns. (APA 2002, pp. 9–10)
Cultural dimensions; Diverse; Diversity; Individ- Similar to other psychological and allied organi-
ual and role differences; Minority; Multicultural zations, APA has continued to recognize the impor-
theory (MCT); Multiculturalism tance of understanding cultural identity and
multicultural competence (e.g., APA 2002). The
APA Ethics Code’s Principle of Respect for People’s
Introduction Rights and Dignity highlights awareness and respect
for all sources of “individual and role differences”*
Since the colonial era, a predominately Eurocen- based on age, gender, gender identity, race, ethnicity,
tric Western cultural lens has been imposed culture, and so on. Many APA divisions focus on
widely, with adverse consequences for minority* cultural identity, APA holds an annual multicultural
couples and families. Despite increasing diversity, summit, and APA also has developed guidelines
treatment approaches tend to adhere to Eurocen- around psychologists’ responsibilities to people
tric cultural values like rationality and individual- having diverse cultural identities.
ity, resulting in misperceptions that these values In the field, therapists’ multicultural competence
are universal. Similarly, Western treatment has most often been defined as multicultural knowl-
research values internal validity provided by ran- edge, skills, and awareness. This means that they
domized controlled trials over external validity must have the knowledge of the cultural identities
that focuses on whether or not findings generalize and associated experiences and worldviews of the
to couples and families with diverse cultural iden- clients that they treat, culturally relevant and sensi-
tities who remain underrepresented in studies. tive skills to address client concerns, and awareness
These narrow, rigid definitions of normalcy often that their own biases and values, as well as those of
do not consider collectivist and extended family the dominant Western culture, impact treatment.
values or the varied family structures, gender The need for therapist cultural competence under-
roles, socialization, discrimination experiences, scores the need for multicultural theory as a fourth
and environmental influences of diverse* couples force in psychology to improve the relevance and
and families. Instead, they are marginalized and usefulness of other theoretical paradigms.
perceived as culturally and genetically inferior.
Correspondingly, minorities are less apt to seek
Western mental health services, more likely to Prominent Associated Figures
drop out before treatment is completed, and
receive less quality care than other Americans Here is an alphabetized sample of prominent
(USDHHS 2001). authors who write about therapeutic work with
688 Cultural Identity in Couples and Families
diverse couples and families for several of the multicultural theory legitimizes liberation of con-
many important areas of cultural identity. In sciousness and social justice as therapeutic goals,
regard to race, ethnicity, and immigration, Nancy as they ground people in context and in relation to
Boyd-Franklin, Celia Falicov, Kenneth Hardy, other groups and empower them to transcend the
Shalonda Kelly, Kyle Killian, Monica Western individualist paradigm.
McGoldrick, and Mudita Rastogi are prominent. Multicultural theory can include a narrow or
Prominent gender and LGBTQI authors include broad definition of cultural identity, and each
Beverly Greene, Robert-Jay Green, Carmen aspect of these definitions has its own set of
Knudson-Martin, and Michael Lasala. Those frameworks and associated micro-theories. The
prominent in working with religious families narrow definition refers to race, ethnicity, immi-
include Froma Walsh and Mark Yarhouse. grants of different nationalities, and sometimes
sexual orientation, while the broad definition
adhered to within this entry includes many more
Description aspects of a person’s cultural identity. These
approaches are consistent with the second tenet
Multicultural theory* (MCT) has brought a fun- of MCT regarding how the self is experienced
damental paradigm shift to the field of psychology within multiple contexts that are important to a
by acknowledging and addressing the fact that all client’s cultural identity, including the couple and
psychological phenomena occur and are learned family, and the fourth tenet of MCT that states the
in a highly influential cultural context. Sue et al. need for multiple frameworks to ensure that these
(1996) describe MCT as a metatheory that supple- contexts are considered. First, ecological models
ments each of the major theoretical orientations, are examined, which normalize and emphasize the
such as psychoanalysis and behaviorism, and they need to consider cultural and other contexts within
present the six theoretical propositions on which treatment, without specifying the role of culture.
multicultural counseling and therapy are based. Next, key structural theories about concepts that
First, the multicultural framework clarifies how are essential to the development and expression of
all theoretical orientations are grounded in a cul- cultural identity are identified. Then information
tural context that is biased in favor of the world- and theories about some of the cultural identities
view of the population on which they are that are experienced by many individuals, cou-
developed. Second, the totality, fluidity, and inter- ples, and families in treatment are presented.
relatedness of layers of individual, family, group,
cultural, and universal experiences and contexts Ecological and Structural Models
must be considered in the development and Ecological models such as the biopsychosocial
change of identities for both therapists and clients. model and Bronfenbrenner’s bioecological
Third, for therapists and clients, cultural identity model help in understanding the impact of culture
development influences attitudes toward their on human behavior. Consistent with tenet two of
own group, the dominant group, and other groups MCT, they identify microlevel influences such as
and the relationships between them. Fourth, ther- a person’s biological makeup and increasingly
apists can enhance treatment by using modalities, distal contexts, such as family and interpersonal
frameworks, and goals consistent with the life contexts, and the dominant cultural values of the
experiences and cultural values of their clients. society as being influential on behavior. For
Fifth, multicultural theory encourages the use of example, the context of ongoing arguments with
multiple useful helping roles developed by many family members about cultural identity factors
cultural groups that go beyond the therapist-client like religious values, LGBT status, or differences
relationship, such as those involving prevention, in acculturation levels between teens and parents
traditional healing methods, and community- and might lead a teen to run away from home or
system-level resources and interventions. Sixth, in engage in risky behavior. Moreover, contexts
drawing on these other roles and methods, that span history and the life span, such as the
impact of the legacy of slavery and immigration, been developed to explain the impact of these
influence behavior within couples and families, individual differences, their intersections, con-
such as with spouses having differing perspec- flicts, and the beneficial aspects of cultural identi-
tives on their own heritage or a family living in ties. Next, some of the most well-known and
an ethnic enclave. influential theories about culturally related indi-
Oppression is a structural system that confers vidual differences are detailed.
unearned power and privilege on the dominant C
group and stigmatizes, dehumanizes, and disen- Racial and Ethnic Identities and Stage
franchises minority groups having nondominant Theories Racial and ethnic identity theories
cultural identities and demographic backgrounds. are at the forefront of our understanding of indi-
Oppression includes but is not limited to racism vidual differences and cultural identities
and White privilege and supremacy, heterosex- (e.g., Jernigan et al. 2017). Racial groupings are
ism, classism, sexism and patriarchy, and ableism. assigned on the basis of physical characteristics,
These “isms” are enacted in widespread policies, such as skin color, facial features, and hair texture.
practices, and social norms and customs based Despite refuted claims that there is a biological
upon the cultural identities of privileged groups, racial hierarchy, racial group designations change
consistent with the first MCT tenet that therapy is over time and across countries, and biologically
grounded in a biased cultural context. The “isms” there is just as much diversity within as across
form interrelated structural power systems that racial groups. Thus racial groupings are social
systematically create and maintain social inequal- constructs that become a significant aspect of a
ities. For example, McIntosh’s (1998) seminal person’s identity. Dr. William Cross developed a
primer shows social norms regarding how White stage theory of Nigrescence, a French term for
privilege is manifest. Another example involves becoming black, to describe African Americans’
two widely held mainstream values in the United development of racial identity in the United States
States; the Protestant work ethic states that one under the conditions of oppression. Dr. Janet
should work hard, and meritocracy states that Helms developed the first scale to measure it. Dr.
people get ahead in life based upon their own Robert Sellers developed a multidimensional the-
merits, such as intelligence and skills. Both con- ory of racial identity and an associated measure
cepts imply a level playing field in which oppres- that focused on key dimensions of race, such as its
sion does not exist, and the result is blame of those salience and centrality. Similar to racial identity,
with diverse cultural identities for their subordi- ethnicity refers to the common ancestry and his-
nate status. Oppression also can be internalized, tory of a group of people and a shared sense of
wherein those with diverse cultural identities may belonging to the group. Dr. James Marcia devel-
believe in the negative portrayals of them that are oped theory regarding the process of exploration
propagated by the dominant group. Overall, the and commitment as important to the development
minority stress that results from oppression harms of a personal identity, which Dr. Jean Phinney
the well-being and relationships of those with applied to the development and measurement of
diverse cultural identities. one’s ethnic identity, rather than explicitly consid-
ering race or racial oppression. Racial and ethnic
Identity Models identity began to be applied to all racial and ethnic
Identity models refer to the individual differences groups. While there are notable differences
among people that can be the basis for the devel- among measures of racial identity across racial
opment of their cultural identities, which yield groups, and between measures of racial and ethnic
value and meaning to their group membership identity, they all reveal important associations of a
and are associated with their well-being. Such positive racial and ethnic identity with key life
differences include but are not limited to racial outcomes such as mental health, achievement,
and ethnic identity, sexual orientation, gender, in-group and out-group interactions, and couple
religion, and immigrant status. Theories have relationship quality.
The developmental stage theories of racial and affect family relationships, such as with partner
ethnic identities have been applied broadly to differences in the level of coming out to others,
other aspects of cultural identity. Like the experi- having to develop supportive “families of choice,”
ence of those having a stigmatized racial identity, or having children in ways that all family mem-
people with other stigmatized cultural identities bers are not biologically related.
are thought to begin their identity development by
believing the negative things about their identity Gender Research and theory on gender differ-
that society promulgates. This perspective ences and the lower status of women in society
becomes challenged through their life experi- have focused upon evolutionary theory, social con-
ences, and they discard the dominant perspective structionist theory, postmodern feminist theory, and
to immerse themselves in understanding their biosocial theory (e.g., Wood and Eagly 2002). For
identity and eventually develop a positive view example, evolutionary theory states that men
of their identity and an acceptance of other iden- compete and experience sexual jealousy to control
tities (e.g., Jernigan et al. 2017). As with general paternity and yield reproductive advantages.
and ethnic identity theory, as they develop, people Social constructionist theories suggest that sex
go through a process of exploring and committing differences vary with power relationships within
to their cultural identity, and the final healthiest societies, such that in paternalistic societies, men
stage is committing to a cultural identity after control the context of child-rearing, and there is
having explored it (Yip et al. 2014). sex-typed socialization into gender roles. For
example, men may step back from parenting
LGBTQI Identities In addition to the applicabil- roles, and women may step back from career
ity of the foregoing racial identity theory stage building due to socially constructed societal dis-
model to sexual orientation, several key theories course suggesting that women are the natural
and concepts apply to the experiences of those in caregivers and belong in the home (Knudson-
the lesbian, gay, bisexual, transgender, queer and Martin 2017). Postmodern feminist theory also is
questioning, and intersex (LGBTQI) community. a type of social constructionist theory. Consistent
They all lack societal acceptance where they do with tenet six of MCT, it liberates consciousness
not fit the dominant conceptions of gender, gender by deconstructing the dominant paradigms and
identity expression or roles, and sexual orienta- highlighting how the most prominent discourses
tion. The dominant conceptions are that all per- are tied to the power structure, such as “tradi-
sons fit a gender binary of male or female, in tional” conceptions of gender being supported
which men adhere to traditional masculine gender by laws governing relative pay of men and
roles and expression, women adhere to traditional women, maternity leave, alimony, child support,
feminine gender roles and expressions, men are custody, and minimum income. It also asserts that
solely attracted to women, and vice versa. Con- the dominant discourses about gender and other
versely, it is well documented that these factors all oppressed groups portray dominant views and
are more accurately conceptualized as fluid con- values as universal rather than fluid and situated
tinua rather not belonging solely to one gender. in contexts. Biosocial theories combine evolution-
The social stigma of homophobia occurs when ary and social constructivist models; there are
LGBTQI community members are seen as defi- influential biological factors like hormones and
cient, and heterosexism occurs when they are nursing children that contribute to sex-typed divi-
expected to fit the dominant conceptions, such as sion of labor, and environmental and social cir-
when a girl is regularly asked which boy she likes cumstances influence the degree of patriarchy in
in school. Moreover, each subgroup of this com- societies.
munity has its own uniqueness. For example,
bisexual persons sometimes are pushed by gay Spirituality and Religion Religion is an integral
and heterosexual communities to choose between part of many cultural identities, and it is particularly
them. Issues faced by the LGBTQI community salient within couples and families. For example,
religions may vary in their emphasis on individual- intersectionality often is complex (e.g.,
ism prioritizing the individual or collectivism prior- Schwarzbaum and Thomas 2008), such that identi-
itizing the group, such as with Protestant ties are neither exclusive nor discrete, and the whole
Christianity and Judaism, respectively, which deter- of one’s intersectional identity often is greater than
mine priorities and values and moral judgments of the sum of each individual aspect of cultural identity.
couples and families. Many use their religion as a In addition, each person tends to have one or more
source of moral guidance, strength, and resilience to privileged identities, such as being White, male, C
turn to in times of trouble, such as with the experi- American, Christian, rich, etc., as well as one or
ence of oppression (e.g., Walsh 2016), and they more oppressed identities, such as being part of a
often practice their spirituality and religion with visible racial or ethnic group, a woman, an immi-
others having the same cultural identity, thus grant, adhering to a non-Christian religion or no
increasing those bonds. In the context of couples religion, poor, etc. These privileged and oppressed
and families, many religions view marriage as identities interact with each other, but do not negate
sacred, and lust and adultery vary in their moral each other. Importantly, the most marginalized
standing and attribution based on religious culture. groups in society tend to have multiple oppressed
stigmatized identities, each facing its own stressors.
Immigration and Acculturation Immigration
and acculturation are powerful forces that shape Risk and Resilience Models
cultural identities and impact couples and families. Risk and resilience models are useful for specify-
Key factors prior to immigration may include ing which factors are helpful and hurtful to indi-
traumas experienced by refugees, or the process of viduals, and these models have important
serial migration, in which one person may emigrate implication for cultural identity within diverse
first to prepare the way for other family members, couples and families (e.g., Walsh 2016). Protec-
resulting in potentially long periods of separation. tive and resource factors are positively influential,
Once immigrants have arrived, they experience while vulnerability and risk factors are negatively
many practical challenges, such as learning English influential. Similarly, resilience models focus
and obtaining legal citizenship. Also, they experi- upon identifying those individual, family, and
ence acculturation or the many cultural and psycho- school or community factors that help children
logical changes of living in a culture that can be and families to thrive even in adverse circum-
radically different than the culture from which they stances, such as poverty and stigma.
came, such as those coming from collectivist cul- For diverse couples and families, their cultural
tures to individualist cultures. Moreover, family identities bring strengths of resource and protec-
members may differ in these identifications, partic- tive factors, such as the parental socialization of a
ularly across generations, which may cause family positive racial and ethnic identity, religious cop-
strife due to clashes in cultural identities. ing, and extended family support (e.g., Walsh
2016). It is important for couple and family ther-
Intersections of Identities While each of the fore- apists and researchers to consider the strengths
going cultural identities was discussed separately, it and resilience derived from the cultural identities
is important to recognize that each person’s own of diverse couples and families, rather than just
cultural identity includes aspects of most of them their challenges, to avoid deficit models, further
(e.g., Jernigan et al. 2017). For example, everyone stigmatization, and the internalization of negative
has a gender, race, ethnicity, national status, perspec- cultural identities.
tive on religion and spirituality, etc., and the term
intersectionality describes the confluence of multi-
ple identities within each person. Consistent with Relevance to Couple and Family Therapy
MCT, each identity has its own influence on an
individual’s in-group and out-group attitudes and Cultural identity and its associated values impact
relationships. Moreover, one’s felt experience of the definition and structure of a couple or family.
For example, in the United States, the nuclear limited to stigma and discrimination, socioeco-
family is prioritized, consisting of a heterosexual nomic status, and neighborhood context. For
male provider, his wife who stays at home or example, within neighborhoods, there are pre-
tailors her career to enable raising children, and vailing attitudes and tendencies toward corporal
their children who are taught traditional gender punishment, religion, level of violence, attitudes
roles and see this modeling inside and outside of toward immigrants and non-English speakers, and
the family. Juxtaposed against this false norm or more, which shape the cultural identities of all of
false social expectation of what a family looks like the members of the couple or family.
and how it functions, all other couple and family Conversely, some couple and family members
types have been deemed deficient and have been may not share all of the same identities, and many
stigmatized. These include couples who do not may not share the same stance toward their own
have children, LGBTQI couples and families, and others’ cultural identities. The same experi-
interracial couples and families, three-generation ences may lead to differing values and coping
extended family households, families with differ- styles for each member. For example, within the
ent life cycle phases, and more (e.g., McGoldrick same immigrant family, two children may differ in
and Hardy 2008). Each has undergone extensive acculturation levels, including their adherence to
legal and social battles to be seen as legitimate, traditions, choice of social groups, and preferred
such as the fight for interracial marriage and gay languages. Couple and family members’ struc-
marriage and the fight to overcome some thera- tures, values, environmental contexts, and cultural
pists’ confusion and assumption of deficiency identities interact with and shape each other. Con-
when a grandparent and child present for sistent with MCT tenet five, which identifies the
treatment. need for multiple types of helping roles, these
Couples and families are known to be the con- variations require therapists to be culturally com-
veyors of culture, consistent with the second tenet petent. They need to assess cultural identities,
of MCT, which states that many contexts, such as better understand their roles in couple and family
family, cultural, and universal contexts, shape members’ lives, and tailor treatment to address the
cultural identities. Couples and families help strengths, challenges, and impacts of cultural
their members with the issues that all Americans identity.
face when establishing their cultural identities and Couple and family therapists have many prac-
values, including all of the foregoing cultural tical reasons to attend to cultural identity within
identities (Kelly 2017). For example, with racial, couple and family therapy. First, diverse couples
ethnic, and gender role socialization, parenting and families are one of the fastest-growing
styles, and choices of spiritual or religious prac- populations in the United States. Second, cultural
tices often linked to their cultures, couple and competence is essential in enabling accurate
family members interact daily and develop and cross-cultural assessment of health and pathology,
model shared worldviews, attitudes, and actions use of norms related to the specific population
toward various cultural identities. Often, couples’ being treated, and the ability to efficaciously tailor
and families’ socialization is consistent with their treatment to the diversity found in most couples
environmental and social context, but at other and families (e.g., Benish et al. 2011). This
times, those with diverse cultural identities pro- involves helping couples and families to address
vide a buffer against prevailing social attitudes, their unique concerns such as structural disparities
such as when one or more of the family’s cultural and discrimination and incorporating their
identities are stigmatized (e.g., Kelly 2017). untapped strengths and resilience. Third, attend-
Family members often have the same backing to diversity is complementary with the role of
grounds, and thus many share powerful culturally couple and family therapists, who often adhere to
relevant formative experiences that shape their systems principles. They tend to understand that
cultural identities and associated worldviews and couple and family dynamics play vital roles in
values in similar ways. These include but are not individual family members’ lives and shaping
their identities. Thus, they are uniquely trained partner left him. His mother and sisters know that
and well equipped to begin learning cultural com- he is gay and are supportive of it, but he does not
petence toward supporting diverse couples and talk to his father, and he is out with other family
families. and close friends, but not professionally. Tony’s
parents also had a hard life, to the extent that he
did not know his father and his mother became
Clinical Example of Application of addicted to drugs. But his aunt and uncle obtained C
Theory in Couples and Families custody of him at 3 years old and raised him in a
solid middle-class, professional home. Still,
Mark and Tony, an African American gay couple Tony’s family relationships are strained, and he
in their mid-twenties, met at school and began says they are homophobic. Tony is fairly sure that
seeing each other without overtly agreeing to his family “knows” about his sexual orientation,
being a couple. Six months later, Tony found out but they never talk about it. Tony is a serial
that Mark was seeing other guys and broke off monogamist, and most of his relationships ended
their romantic relationship. They continued to badly due to infidelity and trust issues. In addition,
hang out together, and after a few months, they both Mark and Tony share a deep commitment to
reunited as an official couple. Soon after that, the African American community and being role
Mark’s financial hardships led to him losing his models within it.
apartment, and thus Tony invited him to move The therapist’s cultural competence was used
in. While the couple is monogamous, they some- to tailor treatment to address key aspects of the
times enjoy threesome sexual encounters with couple’s cultural identities within a cognitive
other men. Finding out that one of those men behavioral and systems approach. The therapist
was Mark’s past sexual partner caused Tony to joined with the couple by being authentic and
question Mark’s honesty about his romantic his- overtly warm, and she oriented them to treatment
tory and Mark to feel mistrusted. Also, Tony procedures, given that they never had been in
sometimes wonders if Mark is with him just treatment. Because of Mark’s financial status,
because of his financial stability, while it bothers and Tony’s desire not to be used by Mark, she
Mark that he has to be the “friend” when they increased access to treatment by negotiating with
attend Tony’s family gatherings. Their strengths them for each to pay half of the fee and advocating
are that they really enjoy each other’s company, with her agency to lower it so that Mark could
they admire and respect each other’s values and afford his half. As a cultural broker who labels and
striving, and they like to host parties and go to negotiates differences in cultural identities, she
bars together. had them discuss their differing life experiences,
A cultural genogram revealed important simi- with a focus on socioeconomic-related factors and
larities and differences between the partners rele- levels of being out with family and community in
vant to their cultural identities. Mark grew up in a ways that invoked mutual support, understanding,
low SES household, with a family history of and labeling of these “isms.” Then she helped
drugs, crime, and multiple relationships, and said them to develop shared standards in their relation-
it led him to rely only on himself and to act tough ship surrounding issues of cultural identity. She
in order to not feel helpless. At 18, financial pres- had awareness that her clinic’s intake and couple
sure led him to criminal behavior resulting in relationship questionnaires were unfairly geared
2 years of incarceration, after which he joined a to heterosexual couples, and so she bonded with
community reentry program, turned his life them over discussing it as one of their regular
around, and entered college. He reported no pos- experiences of oppression and changed the
itive couple role models, other than TV shows. He forms accordingly. She had knowledge that three-
had two heterosexual relationships as a teenager somes and other aspects of non-monogamy can be
before dating only men, with one serious relation- healthy choices, particularly with the small circle
ship that ended with his devastation because his of those with whom they could feel comfortable
694 Cultural Values in Couples and Families
sharing their sexual orientation. She also drew Knudson-Martin, C. (2017). Gender in couple and family
upon their strength of role flexibility to address life: Toward inclusiveness and equality. In S. Kelly
(Ed.), Diversity in couple and family therapy: Ethnici-
their preferences about penetration and who does ties, sexualities, and socioeconomics (pp. 153–180).
it and negotiated the boundaries between them- Santa Barbara: Praeger.
selves and their circle, including exclusion of MinicGoldrick, M., & Hardy, K. V. (Eds.). (2008).
past partners from their threesomes to build Re-visioning family therapy: Race, culture, and gender
in clinical practice (2nd ed.). New York: Guilford Press.
trust. The couple reported satisfaction with treat- McIntosh, P. (1998). White Privilege: Unpacking the invis-
ment and a more rewarding and bonded ible knapsack. In M. McGoldrick (Ed.), Re-visioning
relationship. family therapy: Race, culture, and gender in clinical
practice (pp. 147–152). New York: The Guilford Press.
Schwarzbaum, S. E., & Thomas, A. J. (2008). Dimensions
of multicultural counseling: A lifestory approach.
Cross-References Thousand Oaks: Sage.
Sue, D. W., Ivey, A. E., & Pedersen, P. B. (1996). A theory
▶ African Americans in Couple and Family of multicultural counseling and therapy. Pacific Grove:
Brooks/Cole.
Therapy
U.S. Department of Health and Human Services. (2001).
▶ Biopsychosocial Model in Couple and Family Mental health: Culture, race, and ethnicity: A supple-
Therapy ment to Mental Health: A report of the Surgeon Gen-
▶ Cultural Competency in Couple and Family eral. Rockville, MD: Author. Retrieved from http://
www.surgeongeneral.gov/library/reports.
Therapy
Walsh, F. (2016). Applying a family resilience framework
▶ Cultural Values in Couples and Families in training, practice, and research: Mastering the
▶ Culture in Couple and Family Therapy art of the possible. Family Process, 55, 616–632.
▶ Ethnic Minorities in Couple and Family https://doi.org/10.1111/famp.12260.
Wood, W., & Eagly, A. H. (2002). A cross-cultural analysis
Therapy
of the behavior of women and men: Implication for the
▶ Ethnicity in Couples and Families origins of sex differences. Psychological Bulletin, 128,
▶ Feminism in Couple and Family Therapy 699–727.
▶ Gender in Couple and Family Therapy Yip, T., Douglass, S., & Sellers, R. M. (2014). Ethnic and
racial identity. In F. T. L. Leong, L. Comas-Diaz,
▶ Oppression in Couple and Family Therapy
G. C. N. Hall, V. C. McLoyd, & J. E. Trimble (Eds.),
▶ Resilience in Couples and Families APA handbook of multicultural psychology, Theory and
▶ Social Constructionism in Couple and Family research (Vol. 1, pp. 179–205). Washington, DC:
Therapy American Psychological Association. https://doi.org/
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▶ Socialization Processes in Families
▶ Spirituality in Couple and Family Therapy
Cultural Values in Couples and

References Families
American Psychological Association. (2002). Ethical Kiran Arora
principles of psychologists and code of conduct.
Washington, DC: Author.
Long Island University, Brooklyn, NY, USA
Benish, S. G., Quintana, S., & Wampold, B. E. (2011).
Culturally adapted psychotherapy and the legitimacy of
myth: A direct-comparison meta-analysis. Journal of Introduction
Counseling Psychology. https://doi.org/10.1037/
a0023626. Advance online publication.
Jernigan, M. M., Green, C. E., & Helms, J. E. (2017). Cultural values play a role in the everyday lives of
Identity models. In S. Kelly (Ed.), Diversity in couple couples and families. These values reflect a broad
and family therapy: Ethnicities, sexualities, and socio- context of individual behaviors and are consid-
economics (pp. 363–392). Santa Barbara: Praeger.
Kelly, S. (Ed.). (2017). Diversity in couple and family
ered expressions of people and communities.
therapy: Ethnicities, sexualities, and socioeconomics. Falicov (1995) defines cultural values as shared
Santa Barbara: Praeger. worldviews and meanings, which develop from
Cultural Values in Couples and Families 695
membership and participation in numerous con- worldview on how to understand self in relation
texts. These contexts can include but are not lim- to another. They list several overarching goals that
ited to religion, gender, race, ethnicity, language, can help facilitate treatment while considering
customs, and migration. These values create var- culture as a thread of understanding with all peo-
ied environments for family life. Therapists must ple. These goals are: (1) To develop an under-
be sensitive to values as they have implications for standing of the specific ways in which clients
understanding and organizing couple and view the world and their corresponding values C
family life. and beliefs; (2) To challenge segregated thinking
by promoting a fuller understanding of the ways
in which all aspects of existence are
interconnected. This includes encouraging aware-
ness of the ways in which experiences at the
individual, family, and cultural levels are all
Culture is a broad based and multidimensional
related; (3) To respectfully challenge beliefs and
concept (Hardy and Laszloffy 2002). No one
dynamics that support domination and oppres-
value adequately captures the essence of culture
sion; (4) To identify and individual wounds of
in its’ entirety. Cultural values are the components
oppression; (5) To rehabilitate each partners
that make up one’s cultural experience. Therefore,
(or family member’s) view of the other; (6) To
examining the various dimensions of cultural
work actively to achieve justice and; (7) To pro-
values (gender, sexual orientation, class, etc.) is
mote intimacy. These goals can assist in
critical in truly understanding the experiences of
uncovering and understanding cultural values
couples and families. Culture is an influential
that individuals hold in a family, while promoting
organizing principle and individuals can simulta-
healing and transformation.
neously hold two different positions, one which
maybe subjugated and the other privileged (Hardy
and Laszloffy 2002). People from the same cul-
tural group may have different cultural experi-
Family Therapy
ences depending on their overall participation in
all dimensions of culture. For example, two sisters
When working with couples and families, it is
may share cultural values in regards to race, gen-
imperative that therapists explore the importance
der and, sexual orientation but may differ on reli-
of cultural values with each client by not only
gion, age, and geographical location. Each of
identifying the values but also creating space to
these differing cultural variables presents oppor-
explore them deeply. Identifying, strengthening,
tunities for uniqueness within their shared cultural
and validating cultural identity is a useful tech-
groups. An awareness and curiosity of similarity
nique in helping family members ward off stress
and difference is essential so that therapists can
and find sites of resiliency. Becoming familiar
understand the nuances between family members
with various support systems from a cultural per-
as it relates to cultural values (Hardy and Bobes
spective is key in assisting with healing. Many
2016)
people become disconnected from traditional sup-
port systems. Being curious about the ways in
which older generations dealt with challenges
Holding a Cultural Perspective can uncover values that specific cultures hold in
regards moving through difficulties. Therapists
It is recommended that therapists examine couples can assist in helping couples and families work
and families through a cultural lens (Falicov through cultural based value conflicts or any cul-
1995; Hardy and Laszloffy 2002; McGoldrick ture based pride/shame issues (Hardy and
and Hardy 2008). Hardy and Laszloffy (2002) Laszloffy 2002). These value conflicts can occur
created a multicultural perspective, which is a both within a person and interpersonally. Moving
696 Cultural Values in Couples and Families
away from polarizing conversations and towards a of her life with her father undermining her abil-
both/and position can alleviate any stuckness cli- ities. He recently passed away without resolving
ents may feel and open conversations for alternate the tensions he had with his daughter. She was
possibilities (Hardy and Laszloffy 2002). Validat- looking forward to having her life with Alex
ing multiple perspectives from multiple cultural with a fresh start, somewhat away from the
values and perspectives can encourage a greater tensions her nuclear family has lived with for
tolerance and acceptance of the various cultural years. Although Alex understood Sarah’s posi-
values one may hold. tion, he was thinking ahead about raising a fam-
ily and wanted his future children to be close to
his parents and siblings, so they could grow in
Clinical Example an extended family. Over a period of seven
sessions, the couple became fluid in each other’s
Alex (35) and Sarah (34) entered couple therapy cultural values. Sarah’s initial perceptions of
following their engagement. Alex is Black and Alex’s stubbornness of wanting to eventually
from Uganda. He moved to the United States go back to Uganda were now more relatable.
10 years prior on a work visa. Sarah is White She too wanted to raise her future children in
and Scottish. She was born and raised in Ver- community; however, her community consisted
mont and moved to New York City 5 years ago of her women friends who had supported her
where she met Alex. The couple has a history of during her challenges with her family. Alex
feeling stalled when communicating their needs could appreciate Sarah’s sense of community
to the other person. Specifically, now that they and, his own feelings of isolation and distance
are engaged they are having difficulty deciding from his family were validated by Sarah.
where to live after marriage. Alex has a strong Defenses were softened when each partner
desire to move back to Uganda. Sarah is not could listen to the cultural values the other part-
directly opposed to it yet has hesitations. They ner held. They each understood that there was a
have made two trips as a couple to Uganda and greater contextual backstory to their partner’s
frequently travel to Sarah’s parents home to positions and that their positions were closer
Vermont for the holidays. than what first appeared to be the case.
Initial therapy sessions were focused on
assessing the couple both individually and rela-
tionally (Taibbi 2015). A cultural genogram was
used to assess the couple’s cultural values (Hardy References
and Laszloffy 1995). Through the exercise, Alex
Falicov, C. J. (1995). Training to think culturally:
shared that his family values hard work, persever- A multidimensional comparative framework. Family
ance, and having an active role in raising children. Process, 34, 373–388.
For Sarah, there was value placed on being inde- Hardy, K. V., & Bobes, T. (Eds.). (2016). Culturally sensi-
pendent, standing up for those less fortunate, and tive supervision and training. New York: Routledge.
Hardy, K. V., & Laszloffy, T. A. (1995). The cultural
staying out of others’ relational business. Through genogram: A key to training culturally competent fam-
further inquiry the therapist learned that Alex and ily therapists. Journal of Marital and Family Therapy,
Sarah had a number of cultural values in common, 21(3), 227–237.
such as their Christian religion and their families’ Hardy, K. V., & Laszloffy, T. A. (2002). Couple therapy
using a multicultural perspective. In A. S. Gurman &
middle class status. N. S. Jacobson (Eds.), Clinical handbook of couple
In an effort to work through the tension of therapy (3rd ed., pp. 569–593). New York: Guilford.
where the couple is going to live after marriage, McGoldrick, M., & Hardy, K. V. (Eds.). (2008).
the therapist focused on looking at the cultural Re-visioning family therapy: Race, culture, and gender
in clinical practice (2nd ed.). New York: Guilford
values that might be driving their divergent Publications.
positions. Sarah valued independence and a Taibbi, R. (2015). Doing family therapy (3rd ed.).
nuclear family. Further, she had struggled most New York: The Guildford Press.
Culture in Couple and Family Therapy 697
a multicultural society (McGoldrick 2003). With-

Culture in Couple and Family out frameworks or theory guiding culturally sen-
Therapy sitive practice, models of therapy may lack
essential components to conceptualizing issues
Laura Sudano1,2 and Rachel M. Carter3 and interventions when working with diverse cli-
1
University of California, Department of Family ents. Incorporating such theoretical frameworks is
Medicine and Public Health, San Diego, helpful to assess, diagnose, and intervene with C
CA, USA individuals, couples, and families.
2
Winston Salem, NC, USA Multicultural competence is essential to inform
3
University of Rochester, Rochester, NY, USA therapy. Theoretical frameworks that inform
Couple and Family Therapy include social con-
structionism or the presence of multiple realities
Name of Theory and the influences that shape them (Papert 1980).
Social constructivism also influences this field as
Culture in Couple and Family Therapy it emphasizes meaning making, forming self-
identity and the social connectedness through
which individuals interpret their world and expe-
Introduction riences and create patterns and order (Mahoney
and Granvold 2005). These tenets, then, can guide
Incorporating culture into therapy is integral to therapists to explore how contexts, such as race
work with others. Each individual is influenced and ethnicity, can affect a person’s thoughts, feel-
by the culture in which they live and the subcul- ings, behaviors, and construction of reality.
ture created within their own family. Aspects of
culture include religion/spirituality, race, ethnic-
ity, socioeconomic status (SES), gender, sex, sex- Relevance to Couple and Family Therapy
ual orientation, as well as other aspects of identity.
These facets are essential in conceptualizing the Cultural concepts can be seen in the various
human experience as it influences individual approaches used in Marriage and Family Therapy.
beliefs about the self and others, and the rules In Experiential Family Therapy, the natural orders
that govern these beliefs. and patterns of families play an integral role in the
therapeutic process. Each family member is con-
sidered to be an agent of change and that change
happens through experiencing the change in the
therapy room (Gladding 2015). Specifically, the
John Dewey, Lev Vygotsky, Jean Piaget, Seymour
order and processes within a family can be
Papert, Harlene Anderson, Peggy Penn, Harry
addressed in the therapy room through a technique
Goolishian
called family choreography in which family mem-
bers show the patterns in their family, the family
Description dance, by placing the family members in a posi-
tion according to their ways of relating to each
The field of Marriage and Family Therapy incor- other (Gladding 2015).
porates culture into models of therapy to help Family dance shaped by culture can explore
guide therapists to work effectively with individ- loss and meaning making (Mitchell 2016). It is
uals, couples, and families through issues for evident that the culture of where one grows up,
which they present. Often times, therapists who one grows up with, and how one is raised
attempt to move clients from maladaptive shapes the meaning of the word family and what
(unhealthy) to adaptive (healthy) patterns that one’s relationship with them should look like.
helps the individual, couple, or family living in This application of family sculpt and dance can
698 Culture in Couple and Family Therapy
be used to understand the culture of a family and approach can address social inequity and its
modified to be culturally sensitive based on fam- effects on family schemas and behaviors, and,
ily/individual characteristics. ultimately, the health of the family (Parker and
Bowen Family Systems Therapy focuses on McDowell 2016). CBFT acknowledges each per-
the patterns in families as well as the boundaries son individually within the family and how
within them that can either lead to or prevent the his/her/their socialization within their culture
differentiation of self in the individuals within the developed his/her/their schemas while increasing
family system (Bowen 1978). This approach the family members’ understandings of the
focuses on how the family members connect and schemas that were influencing their dysfunctional
disconnect from one another and how each mem- behaviors (Parker and McDowell 2016). Family
ber can maintain his/her/their individual identity therapists help the family members create health-
while still being emotionally close to others. Cul- ier alternative schemas that are both functional
ture plays a prominent role in the formation of and beneficial to the health of the family and
boundaries, levels of self-differentiation, and incorporated social justice (Parker and McDowell
structures within families. For example, a family 2016). Cognitive-Behavioral Family Therapy
in the United States may value individualism, demonstrates that therapists can use a cultural
while a family in China where the culture is col- lens to explore how individuals understand the
lectivistic may not value self-differentiation as world, what he/she/they are taught to believe
a goal in therapy (Epstein et al. 2014). about their self, their family, and others, all of
Research has shown that the goals of family which is shaped by the culture.
therapy and the therapeutic alliance differ Structural Family Therapy (SFT) focuses on
between cultures. Additionally, culture plays a the way families interact with each other. Its pre-
role in the language individuals use to communi- mise is addressing the structure of families and the
cate within their families (Epstein et al. 2014). relational systems (e.g., the parental and sibling
When using therapeutic approaches developed in systems), and coalitions that uphold the family’s
Western countries with families of other cultures, patterns of interaction (Gladding 2015). Culture
therapists should consider taking an inventory of plays an important role in SFT as the boundaries,
the culture and its specific cultural values so as not systems, and subsystems that create the structure
to impose one’s own cultural values on the family of families are shaped by culture. For example,
(Epstein et al. 2014). A therapist, then, may since SFT focuses on the executive subsystem, or
need to modify the view of “healthy” levels of the generation that is above the sibling subsystem,
differentiation when working with non-Western it is important to consider that executive subsys-
families. tems can consist of one parent, step-parents,
Cognitive-Behavioral Family Therapy (CBFT) and/or extended family members (e.g., grandpar-
focuses on the way the individuals within families ents) which changes the way that subsystems
make meaning that is built around his/her/their and boundaries look within a family and can
own personal beliefs and how that meaning influ- require an altered application of Structural Family
ences family behavioral patterns which are largely Therapy.
shaped by culture. CBFT encourages the individ- Cultural changes have occurred since the
ual members of families to think for themselves original development of SFT. Family therapists
about what is going on in their family instead of must recognize and address the cultural barriers,
adopting beliefs that may be maladaptive and oppression, discrimination, socialization, and
unhelpful (Gladding 2015). In other words, the familial roles that may be affecting nontraditional
therapist is responsible for eliciting the family systems to ensure that treatment effectively
patient’s/client’s perspective and exploring how helps build functional and healthy family systems
these beliefs affect family patterns. (Williams et al. 2016). Specifically, family thera-
Cultural concepts are used within Cognitive- pists who want to unbalance a family system and
Behavioral Family Therapy (CBFT) as the create change within a family must identify if
Culture in Couple and Family Therapy 699
there is oppression and issues of social justice and more adaptive stories about themselves and
within the community, political, and/or familial their relationships with each other to enhance
environment (Williams et al. 2016). family functioning (Suddeath et al. 2017). NFT
Strategic Family Therapy utilizes cultural con- addresses the ways in which family members
cepts in the way that it emphasizes the importance interact with one another and their social sur-
of how order is created and patterns are estab- roundings, by exploring how they construct
lished, as well as the importance of what upholds meaning together through the language they use C
them (Gladding 2015). Strategic Family Therapy and the stories they tell (Suddeath et al. 2017).
views family rules and the often-limited interac- Cultural concepts play an integral role in this
tional patterns of families as sources of family model as the therapist places great emphasis on the
dysfunction (Gladding 2015). Families learn way that society, and clients’ personal interactions
such limited interactional patterns and establish with it, affect the way that they make meaning and
rules largely due to the culture that they are form the beliefs they hold about themselves and
surrounded by and that which they have created others. NFT therapists also address cultural issues
together. by working with clients to gain a greater under-
When using Strategic Family Therapy, it is standing of how they interpret the stories they are
important to consider the needs and issues of told by society and the contexts they live
each individual family and how those are in. Furthermore, NFT therapists incorporate culture
informed by culture. For example, a family thera- into their approach as they shift the focus of
pist can consider ways that detrimental gender meaning-making with their clients by encouraging
roles are perpetuated by culture and society and them to focus on the strengths within their families
may limit the interactional patterns between fam- and helping co-construct strengths-based narratives
ily members of different genders and, thus, con- (Suddeath et al. 2017).
tribute to family dysfunction. Family rules such as Collaborative Therapies, which involve dia-
when and how to externalize emotions and what logical conversation or a mutual exchange of
topics are and are not allowed to be addressed in ideas and understanding by more than one indi-
families are also influenced by cultural norms and vidual, attempt to generate new meaning and
can contribute to unhealthy family patterns. In ideas. The family therapist’s role is to facilitate
order to be relevant when doing strategic family meaning-generating conversation by which the
therapy, it is critical that family therapists are client can make new assumptions and meaning
aware of the cultural customs, roles, and rules which includes maintaining space for the client
that affect the interactional patterns of families to bring their values to the conversation
and how they can be used to either help and hinder (Anderson 1997). This social constructionist
relational change. framework aids the client to re-negotiate a client’s
Narrative Family Therapy (NFT) is a theoreti- reality and “truth.” These “truths” are embedded
cal approach that focuses on the stories that fam- in the dominant narratives of the culture in
ilies, and the individuals within them, construct which the client grew up and deconstructing, or
(Suddeath et al. 2017). Social constructionism unpacking, these narratives or “truths” are essen-
plays heavily into this approach as it is centered tial to explore assumptions in therapy.
on the multiple realities that the family members
have created and the validation and investigation
of those realities (Suddeath et al. 2017). Thera- Clinical Example of Application of
pists using this approach help their clients see Theory in Couples and Families
their “realities” as “internalized stories”
(Suddeath et al. 2017, p. 119) that have been Jen and Marie present to therapy with issues of
shaped by the systems and culture that they are intimacy. Jen is a 47-year-old white, lesbian,
a part of (Suddeath et al. 2017). In this approach, woman who is a manager at a bank. Marie is
families are encouraged to consider alternative a 40-year-old African-American, lesbian, woman
700 Culture in Couple and Family Therapy
who is a grief counselor for young children. Jen curious stance, explore their thoughts/ideas of
states that she and Marie have been together for how they view contextual factors as mentioned
10 years and never had issues related to sexual in prior sessions.
encounters until 5 years ago, when they were
legally married. Jen notes that she pursues Marie Cross-References
and feels like Marie is closed off from Jen. Jen
states that she is “fed up” with pursuing Marie and ▶ Bowen Family Systems Therapy with Couples
feels like she doesn’t care. Marie states that she is ▶ Bowen Family Systems Therapy with Families
tired from her work and feels like she has no ▶ Cognitive-Behavioral Family Therapy
energy to engage with her wife sexually. ▶ Collaborative and Dialogic Therapy with
The therapist observes that Jen is quick to cut Couples and Families
Marie off when she starts expressing her levels ▶ Collaborative Couple Therapy
of energy. When this happens, Marie stops ▶ Experiential Family Therapy
talking about her feelings and explodes, “You ▶ Narrative Family Therapy
always do this! You don’t let me finish at all!” ▶ Primary Emotions in Emotionally Focused
Jen becomes defensive and says that Marie is, Therapy
“Making excuses.” Marie, then, becomes upset ▶ Secondary Emotions in Emotionally Focused
and is inconsolable. The therapist asks if this Therapy
exchange in the office is similar to at home, ▶ Structural Family Therapy
which both endorse that it is.
The therapist conceptualizes the case as the
couple struggling with issues related to power References
and assumptions. The therapist may utilize an
Emotionally Focused Approach (Johnson 2004) Anderson, H. (1997). Conversations, language, and
to facilitate an enactment. In the traditional EFT possibilities: A postmodern approach to therapy.
enactment, the therapist instructs one partner to
turn towards the other partner to describe their New York: Jason Aronson.
primary emotion about the situation. In a cultur- Epstein, N. B., Curtis, S. C., Edwards, E., Young, J. L., &
ally sensitive approach using EFT, the therapist Zheng, L. (2014). Therapy with families in China:
Cultural factors influencing the therapeutic alliance
may help each partner to access primary emo-
and therapy goals. Contemporary Family Therapy, 36,
tions about their experience of varying contex- 201–212. https://doi.org/10.1007/s10591-014-9302-x.
tual variables which each partner can share with Gladding, S. T. (2015). Family therapy: History, theory
each other. The therapist can use the information and practice (6th ed.). Hoboken: Pearson Education.
to identify the negative cycle where the conflict
couple therapy: Creating connection (2nd ed.).
is expressed, access unacknowledged emotions, New York: Brunner/Routledge.
and reframe the problem by incorporating the Mahoney, J. M., & Granvold, D. K. (2005). Constructivism
couple’s perspective using facilitative questions and psychotherapy. World Psychiatry, 4, 74–77.
McGoldrick, M. (2003). Culture: A challenge to concepts
of how these experiences have influenced their
of normality. In F. Walsh (Ed.), Normal family
view of the current problem which started when processes (3rd ed.). New York: Guilford Press.
they were married. The therapist is cognizant of Papert, S. (1980). Mindstorms. Children, computers and
maintaining neutrality and staying close to the powerful ideas. New York: Basic Books.
Suddeath, E. G., Kerwin, A. K., & Dugger, S. M. (2017).
individual’s words. That is, the therapist will Narrative family therapy: Practical techniques for more
maintain a two-way exchange of ideas while effective work with couples and families. Journal of
also respecting the experience of the individual. Mental Health Counseling, 39(2), 116–131.
Final phases of therapy may include promot- Williams, N. D., Foye, A., & Lewis, F. (2016). Applying
structural family therapy in the changing context of the
ing acceptance of each other, creating new
modern African American single mother. Journal of
cycles, and new solutions to issues. This process Feminist Family Therapy, 28, 30–47. https://doi.org/
is similar to early phase which is to maintain a 10.1080/08952833.2015.1130547.
Curiosity in Couple and Family Therapy 701
moved from psychoanalytic to systemic per-

Curiosity in Couple and Family spectives in working with troubled families
Therapy (Selvini-Palazzoli et al. 1980). Mara Selvini-
Palazzoli, Giuliana Prata, Luigi Boscolo, and
Donna Baptiste, Kaitlyn Bellingar and Gianfranco Cecchin were scholars who became
Incia Rachid known as the Milan Group. The Milan Group
The Family Institute at Northwestern University, advanced three concepts related to therapeutic C
Evanston, IL, USA curiosity. These concepts were neutrality, circu-
larity and hypothesizing (Selvini-Palazzoli et al.
1980). The Milan Group recommended that
Name of the Strategy/Intervention therapists display curiosity through neutrality,
described as a capacity to remain unaligned with
Curiosity. any family member’s opinions and positions, as
validation of each person’s point of view. Cir-
cularity referred to the therapist’s gathering of
Introduction
data on family patterns, including nonverbal
feedback read through body-language, and
Some argue that curiosity is one of humankind’s
using such data to articulate hypotheses.
deepest preoccupation, which leads to exploration
Hypothesizing was defined as the therapist’s
about how, when, and why things work. This results
articulation of systemic formulations around
in problem-solving and creativity (Kunst 2012). The
family concerns. The Milan Group’s framework
notion of curiosity as valuable to both therapists and
required a therapist to adopt a posture of “sci-
clients is also prominent in psychotherapy. Psycho-
entific inquiry” into the family’s situation.
analytic therapists were the first to describe thera-
Within this framework, the therapist operated
peutic curiosity. They viewed it as one of three basic
as dispassionate expert observer and
human drives or instincts, a striving or preoccupa-
interventionist.
tion with discovery, that humans cannot live without
In the late 1980s, an epistemological shift in
(Kunst 2012; Nersessian and Silvan 2007). Psycho-
the Milan Group led to a more vigorous concep-
analysts believed that therapists should be adept at
tualization of curiosity and related concepts of
using curiosity. This means developing a deep inter-
neutrality, hypothesizing, and circularity. Cecchin
est in people’s lives and a push to examine experi-
and Boscolo broke with their colleagues and cri-
ences and activities in the lifespan, to help clients
tiqued their own work on therapeutic curiosity. In
understand themselves, grow, and make peace with
influential publications that are still prominent in
themselves (Nersessian and Silvan 2007).
systemic training and education, Cecchin,
Given the prominence of curiosity in psychoan-
Boscolo, and colleagues recast curiosity as a
alytic thought, it is unsurprising that psychoanalyt-
physiological stance of deep and meaningful col-
ically trained family therapists promoted curiosity as
laboration with clients and within this framework;
both therapeutic philosophy and technique in family
they articulated revised ideas about neutrality,
therapy. To fully understand the place of curiosity in
hypothesizing, and circularity (e.g., Boscolo
systemic thought, one must understand how it
et al. 1987; Cecchin 1987).
became prominent.
Theoretical Framework Description
An emphasis on curiosity as philosophy and Cecchin, Boscolo, and colleagues described the
technique in family therapy originated in the curious therapist as one that co-constructs therapy
1970s and 1980s in the work of family therapy with families or couples while maintaining an
practitioners in Milan, Italy. These clinicians observer position. This stance contrasted with
702 Curiosity in Couple and Family Therapy
the original Milan framework which capacity to hold a plurality of descriptions,

recommended a somewhat aloof posture in ses- including his/her own, and sift through the myr-
sions. They also believed that a therapist’s lack of iad of stories can reveal patterns that incorporate
curiosity may be linked to boredom and psycho- multiple viewpoints. Conducting sessions along
somatic symptoms. When bored, the therapist these lines keeps the therapist and family or
might become superficial, leaving family beliefs couple in a state of “scientific” curiosity, which
and patterns unexamined. In addition to boredom, can generate useful hypotheses (Nersessian and
psychosomatic conditions and stifling contexts Silvan 2007).
can also decrease therapeutic curiosity. Hypothesizing helps the therapist to maintain
A strategy to deal with boredom and psychoso- a stance of curiosity (Boscolo et al. 1987;
matic symptoms is to avoid taking full responsi- Cecchin 1987). In hypothesizing, the therapist
bility for controlling the family’s problem encourages family members to tell stories that
(as earlier ideas on curiosity recommended). reveal underlying family beliefs and patterns.
Rather, therapeutic responsibility begins with a The therapist can then challenge the family to
realistic assessment of one’s position and power abandon unhelpful scripts and adopt ways of
in the system, and curiosity can help the therapist functioning that accommodate phases and tran-
to manage these dynamics (Boscolo et al. 1987; sitions in the family life cycle. Rober (2002)
Cecchin 1987). suggests that constructive hypothesizing
unfolds best in collaborative dialogues among
the therapist and family members, vacillating
Applying Curiosity in Couple and Family between states of knowing and not-knowing.
Therapy The intent is not to confirm or disconfirm any
family member’s views. Rather, the therapist
Cecchin, Boscolo, and colleagues maintained that a shows that embracing multiple viewpoints can
therapist’s posture of neutrality is one in which drive practical action focused on having more
he/she abandons aloofness, noninvolvement, and than one family member adjusting. A therapist
unstated opinions and instead works actively with unable to hypothesize loses curiosity, which
family members to question assumptions (Boscolo leads to therapist and family becoming stuck.
et al. 1987). Cecchin (1987) described neutrality “as Cecchin, Boscolo, and colleagues also sug-
the state of basic curiosity in the mind of a therapist. gest that therapeutic curiosity drives the use of
Curiosity leads to exploration and invention of alter- circular techniques. The curious therapist aban-
native views and moves .. and [such] views breed dons cause-effect or linear questions that stifle
curiosity. In this recursive fashion neutrality and dialogue, emphasize causality, and assign
curiosity contextualize each other in a commitment blame. Instead, he/she showcases circularity
to evolving differences with a concomitant non- by posing questions that amplify the family’s
attachment to any particular position” (p. 405). In understanding of itself. Circular questions
adopting this posture, the therapist stays attuned to imply a lens on action-reaction patterns or
differences among family members without being sequences among family members. For exam-
aligned to any position. ple, “what-if” questions and “future-oriented”
Pedersen et al. (2008) propose a similar (e.g., “If you decided to stop worrying about
understanding of neutrality as a capacity to me, what would you do instead?”). Questions
hold a both-and approach in responding to the that test underlying belief systems can also
complexities of viewpoints and dynamics stimulate fresh viewpoints that help in
within individuals, families, and self. The constructing a systemic view of behavior, rela-
both/and approach is a stance of not-knowing tionships, events, and interpretations as seen
while considering various personal, cultural, through multiple lenses (Boscolo et al. 1987;
and universal issues in play. The therapist’s Cecchin 1987).
Curiosity in Couple and Family Therapy 703
Curiosity has also emerged as an important con- Cross-References

cept in collaborative-dialogic, solution-focused, and
narrative therapies. In collaborative-dialogic ther- ▶ Cecchin, Gianfranco
apy, Anderson (2012) described curiosity as a ther- ▶ Circular Causality in Family Systems Theory
apist stance that allows him/her to be relationally ▶ Selvini-Palazzoli, Mara
responsive to and with the family. Through ▶ Milan Systemic Family Therapy
mutual inquiry, therapist and family create two- C
way curiosity, that is, a reciprocal process of
mutual learning and co-exploration of the famil- References
iar and co-construction of the new (Anderson
2012). In solution-focused therapy, the therapist Anderson, H. (2012). Collaborative relationships and dia-
displays curiosity through open-ended, conver- logic conversation: Ideas for a relationally responsive
sational questions that explore alternative expla- practice. Family Process, 51, 8–24.
Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987).
nations for problem stories (Selekman 1997). In Milan systemic family therapy: Conversations in theory
narrative therapy, curiosity is expressed through and practice. New York: Perseus Book Group.
therapist’s questions that help a client to uncover Cecchin, G. (1987). Hypothesising, circularity and neutral-
and author-preferred narratives buried within ity revisited: An invitation to curiosity. Family Process,
26, 405–413.
problem-saturated storylines (Selekman 1997; Kashdan, T. (2009). Curious? Discover the missing ingre-
White and Epston 1990). dient to a fulfilling life. New York: HarperCollins.
Curiosity is also prominent in positive psy- Kunst, J. (2012). Got Curiosity? The drive that everyone is
chology and wellness promotion. Kashdan talking about. Psychology Today. Retrieved July
20, 2016, from https://www.psychologytoday.com/blog/
(2009) believed that as people live curiously, headshrinkers-guide-the-galaxy/201208/got-curiosity
that is, experiment with new and interesting Nersessian, E., & Silvan, M. (2007). Neutrality and curi-
ideas, they grow personally and expand. osity: Elements of technique. Psychoanalytic Quar-
Kashdan and colleagues examined associations terly, 76, 863–890.
Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclu-
between curiosity and wellness practices (e.g., sive cultural empathy: Making relationships central in
gratitude), and curiosity was associated with counseling and psychotherapy. Washington, DC:
achieving a pleasurable and meaningful life. In American Psychological Association.
examining interpersonal benefits of curiosity, Rober, P. (2002). Constructive hypothesizing, dialogic
understanding and the therapist’s inner conversation:
Kashdan found that curiosity contributes to Some ideas about knowing and not knowing in the
partner attraction and closeness, processes family therapy session. Journal of Marital and Family
linked to relational intimacy (Kashdan 2009). Therapy, 28, 467–478.
In sum, therapeutic curiosity emerged as a fun- Selekman, M. D. (1997). Solution-focused therapy with
children: Harnessing family strengths for systemic
damental concept in psychoanalytic thought and is change. New York: The Guilford Press.
now well-integrated into contemporary family and Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata,
couple therapy practice and training. Other forms of G. (1980). Hypothesizing-circularity-neutrality: Three
psychotherapy and wellness promotion also empha- guidelines for the conductor of the session. Family
Process, 19, 3–12.
size curiosity as “a gateway into creating profound White, M., & Epston, D. (1990). Narrative means to ther-
intimacy, insights and meaning” (Kashdan, p. 5). apeutic ends. New York: Norton.
D
Daneshpour, Manijeh and later transferred to the University of Utah

where she graduated with a bachelor’s degree in
Christi R. McGeorge child and family development. In 1992, still at the
North Dakota State University, Fargo, ND, USA University of Utah, Dr. Daneshpour completed a
master’s degree in family ecology. She then
moved to the University of Minnesota where she
Introduction received her doctorate in family social science,
with an emphasis in MFT. Highlighting her per-
Manijeh Daneshpour, PhD, LMFT, is a professor severance and tenacity, Dr. Daneshpour was a
and system-wide director of the Alliant Interna- single parent for both her master’s and doctoral
tional University Marriage and Family Therapy studies as her husband returned to Iran for a brief
(MFT) programs. With more than 22 years of visit to check on an ailing parent, and the US
academic, research, and clinical experience, government would not allow him to return to the
Dr. Daneshpour is a recognized leader in multi- USA for 9 years despite his repeated attempts to
culturally sensitive therapy, third-wave feminism, get a visa.
and the foremost expert on family therapy with Dr. Daneshpour planned to return to Iran; how-
Muslim families. ever, a series of events surrounding her disserta-
tion research led her to the realization that while
she could have a comfortable life back home in
Career Tehran, she had the opportunity to create signifi-
cant change in the USA by challenging stereo-
Manijeh Daneshpour was born in Tehran, Iran, to types about Middle Eastern individuals and
a philosophy professor father and education relationships. Thus, she began working exten-
minded, stay-at-home mother. She has two sisters sively as an outpatient family therapist serving a
and one brother. Her sisters continue to reside in diverse population. She was then hired as the
Iran pursuing professional careers, while her coordinator of the MFT Program at St. Mary’s
brother lives in Italy. Dr. Daneshpour began her University of Minnesota. After a year of develop-
undergraduate studies in Tehran. In 1984, she ing and teaching courses to postmaster’s students,
made the decision to come to the United States Dr. Daneshpour moved to St. Cloud State Univer-
(USA) to continue her education, intending to sity where she was the MFT program director for
return to Iran to begin her academic career. 13 years. While at St. Cloud State University,
Dr. Daneshpour began her undergraduate stud- she rose through the ranks and became a tenured,
ies in the USA in 1985 at Weber State University full professor and, in 2011, the chair of the
https://doi.org/10.1007/978-3-319-49425-8
706 Daneshpour, Manijeh
Department of Community Psychology, Counsel- deep connection to Islam as a religion. However,

ing, and Family Therapy. During this same time for Dr. Daneshpour wearing the hijab is a repre-
period, Dr. Daneshpour opened the Center for sentation of her sociopolitical agenda, which
Multicultural Systemic Family Therapy through attempts to challenge both the Eastern and West-
which she provided individual, family, and couple ern notion of how an educated, feminist woman
therapy to diverse clients using cognitive, behav- should appear physically.
ioral, strategic, and supportive approaches. Dr. Daneshpour has attempted to be a bridge
In 2015, Dr. Daneshpour moved to Alliant between Eastern and Western cultures and has been
International University in Irvine, California, to willing to challenge the assumptions that each
be a professor in the Department of Couple and group has had about the other. As the majority of
Family Therapy. She was quickly selected for her education has occurred within Western cul-
leadership roles at Alliant. She first became the tures, she is perfectly positioned to be an ambassa-
Irvine site director and currently is the system- dor between two cultures that historically and
wide program director. In her current role, she is currently have little understanding of each other.
responsible for all aspects of the MFT master’s From her important and classic article on Muslim
and doctoral programs on the six Alliant Interna- families and family therapy that was published in
tional University campuses: San Diego, Irvine, the Journal of Marital and Family Therapy
Los Angeles, San Francisco, Sacramento, and (Daneshpour 1998) to her more recent book
the online programs. (Daneshpour 2016), she has been the lone voice
Throughout her career, Dr. Daneshpour has reminding the MFT field that although we may
been very active with her scholarship. Her main have cultural differences, at our hearts, we are all
areas of research are focused on immigration, people who experience similar life events, transi-
multiculturalism, social justice, third-wave femi- tions, challenges, and trauma. Dr. Daneshpour has
nism, premarital and marital relationships, and worked throughout her career to remind family
Muslim family dynamics. She has spent more therapists that Muslim individuals, couples, and
than 20 years training therapists to provide multi- families exist and are deserving of our care and
culturally sensitive therapy and was awarded a services. In her writings, she has provided impor-
5-year grant focused on training therapists to tant insight on working with Muslim couples
work with immigrants and refugees. Further, (Daneshpour 2008) and highlighted how classic
Dr. Daneshpour has worked with and studied and postmodern MFT theories can guide clinical
Muslim families not as a religious group but as a work with Muslim clients (Daneshpour 2011,
distinct group within their own societal context. In 2016). Moreover, Dr. Daneshpour has not been
2016, she published a book titled Family Therapy afraid to address challenging topics within Muslim
with Muslims illustrating how to use classic and families, which is exemplified by an encyclopedia
contemporary MFT theories with this population. entry she wrote in 2004 focused on Muslim
women, gender, and child sexual abuse. Her will-
ingness to continually highlight the similarities
Contributions to Profession between Muslim and Western couples and families
is further illustrative of her desire to be a bridge
The themes that are central to Dr. Daneshpour’s between the two cultures. Her professional career
career have shaped her influence on the MFT and personal life have certainly built this bridge
field. For example, she has emphasized the impor- and significantly enriched the MFT field.
tance of MFTs being their authentic selves, being
true to who they are, and never forgetting the
importance of the person-of-the-therapist Cross-References
(Daneshpour 2009). This commitment to being
her authentic self is illustrated by her decision to ▶ Cultural Competency in Supervision
wear the hijab, which cross-culturally represents a ▶ Cultural Identity in Couples and Families
Davis, Sean 707
▶ Cultural Values in Couples and Families Family Therapy at BYU 2 years later. From there,
▶ Culture in Couple and Family Therapy he received his Doctor of Philosophy (PhD) in
▶ Socioculturally Attuned Family Therapy Human Development with an emphasis in Marriage
and Family Therapy (MFT) at Virginia Tech in
2005. He completed his doctoral internship and
References postdoctoral training as a visiting faculty member
in the University of Kentucky’s MFT program from
Daneshpour, M. (1998). Muslim families and family ther- 2004 to 2006. Dr. Davis’ first core assistant profes-
apy. Journal of Marital and Family Therapy, 24(3),
sor faculty appointment was in the MFT program at D
287–300.
Daneshpour, M (2004). Women, gender and child sexual Alliant International University’s Sacramento cam-
abuse inside and outside family: Iran. Encyclopedia of pus in 2006. He was the Sacramento campus MFT
Women and Islamic Cultures. Brill Academic Pub- program director from 2008 to 2013, during which
lishers, Inc.
time he started their MFT doctoral program. He was
Daneshpour, M. (2008). Couple therapy with Muslims:
Challenges and opportunities. In M. Rastogi & promoted to associate professor in 2008 and profes-
V. Thomas (Eds.), Multicultural couple therapy sor in 2015. He is involved in international MFT
(pp. 103–120). Thousand Oaks: Sage. education in Mexico and Italy. Sean is also a Cali-
Daneshpour, M. (2009). Steadying the tectonic plates: On
fornia licensed marriage and family therapist, an
being Muslim, feminist academic, and family therapist.
In S. A. Lloyd, A. L. Few, & K. R. Allen (Eds.), active clinician specializing in couples therapy, and
Handbook of feminist family studies (pp. 340–350). is the owner of The Davis Group Counseling and
Thousand Oaks: Sage. Wellness Services, a mental health and wellness
Daneshpour, M. (2011). Family systems therapy and post-
agency located in Roseville, California.
modern approaches. In S. Ahmed & M. M. Amer
(Eds.), Counseling Muslims: Handbook of mental
health issues and interventions (pp. 119–135).
New York: Routledge. Contributions to Profession
Daneshpour, M. (2016). Family therapy with Muslims.
New York: Routledge.
Sean is most known for his work in common factors
of marriage and family therapy. His dissertation,
chaired by Dr. Fred Piercy, won both the American
Association for Marriage and Family Therapy
Davis, Sean research and dissertation awards (Davis and Piercy
2007a, b). He expanded his research into the
Fred Piercy book Common factors of couple and family ther-
Virginia Tech University, Blacksburg, VA, USA apy: The overlooked foundation of effective prac-
tice (Sprenkle et al. 2009), the field’s first book on
the topic. He has coauthored several popular articles
Introduction and given several professional presentations related
to common factors, including three of the five most
Sean is a professor of family therapy in the Couple cited articles in the field’s flagship journal, the Jour-
and Family Therapy program, California School nal of Marital and Family Therapy (JMFT)
of Professional Psychology, Alliant International between 2005 and 2008, as well as the 2014 and
University, Sacramento, California. 2015 JMFT articles of the year. Sean has also writ-
ten several other books, including Clinical Supervi-
sion Activities for Increasing Competence and Self-
Career Awareness (Bean et al. 2014), The Family Therapy
Treatment Planner (Dattilio et al. 2010), and Family
Sean earned his Bachelor’s of Science in Family Therapy: Concepts and Methods (Nichols and
Science at Brigham Young University (BYU) in Davis 2016), one of the field’s most widely used
2000, followed by a Master’s in Marriage and textbooks.
708 De Shazer, Steve
In his work on common factors in MFT, Sean Nichols, M. P., & Davis, S. D. (2016). Family therapy:
claims that most theoretical approaches focus on Concepts and methods (11th ed.). Columbus: Pearson.
Sprenkle, D. H., Davis, S. D., & Lebow, J. (2009). Com-
similar processes, but use different language to mon factors in couple and family therapy: The over-
describe these processes. Rigidly sticking to one looked foundation for effective practice. New York:
model can overlook these similarities and lead Guilford Press.
therapists to lack flexibility when working with
clients that may not resonate with the therapist’s
preferred theoretical approach. Being able to see
the common principles underlying different De Shazer, Steve
models may allow therapists to more fluidly
change approaches to adapt to the needs of Cheryl Davies
their clients. Teaching theories this way may Universidad Iberoamericana, Mexico City,
also help streamline training. To these ends, he Mexico
attempts to distill MFT model’s core common
factors down to simple statements of unifying
principles. His best known example of this is the Born into a musical family in Milwaukee, Steve
principle that most couple therapy models focus de Shazer became an accomplished musician and
on three essential things: (1) identifying and a professional jazz saxophonist before developing
slowing down interactional cycles, (2) helping his interest in psychotherapy and social work. He
each person stand meta to their role in the cycle, completed his undergraduate studies in Fine Arts
and (3) helping each person take responsibility at the University of Wisconsin in Madison and
for their role in changing the cycle. Whatever subsequently did a master’s degree in Social Work
the systemic intervention is, it is thought to be at the same university.
doing one of those three things. In 1978 he cofounded the Brief Family Ther-
apy Center in Milwaukee with Insoo Kim Berg,
becoming well-known as the pioneer of solution-
focused brief therapy.
Cross-References
De Shazer’s early work concentrated, funda-
mentally, on defining what makes psychother-
▶ Common Factors in Couple and Family
apy efficient from intellectual and practical
Therapy
standpoints. He borrowed from the work of phi-
losophers and clinicians alike to develop the
essence of brief therapy and how it can be effec-
References tively employed. Influenced predominantly by
the philosophical contributions of Wittgenstein,
Bean, R. A., Davis, S. D., & Davey, M. P. (Eds.) (2014). the sociopsychological position of Milton
Clinical Supervision Activities for Increasing Compe- Erikson, the socio-constructionist epistemology
tence and Self-Awareness, New York: Wiley-Blackwell.
Datillio, F. M., Jongsma, A. E., & Davis, S. D. (2010). The
expounded by Kenneth Gergen, the systemic
Family Therapy Treatment Planner. (2nd ed.). New models of therapy of the MRI and the Milan
York: John Wiley & Sons. School, and the work of Bandler and Grinder
Davis, S. D., & Piercy, F. P. (2007a). What clients of MFT in neurolinguistic programming, a result of
change, part I: Model dependent common factors
these philosophical and academic endeavors
across three models. Journal of Marital and Family was the development of the solution-focused
Therapy, 33, 318–343. approach to psychotherapy in collaboration
Davis, S. D., & Piercy, F. P. (2007b). What clients of MFT with Insoo Kim Berg.
change, part II: Model independent common factors
He borrowed from Wittgenstein his tenets:
and an integrative framework. Journal of Marital and “The limits of my language mean the limits
Family Therapy, 33, 344–363. of my world” and “The meaning of a word is
De Shazer, Steve 709
its use in language.” This interest in the social, the fact that each one of these techniques can be
interactive construction of language and the employed in any clinical situation irrespective of
co-creation of knowledge and meaning forms the presenting problem. Their main objective is to
the basis of de Shazer’s therapeutic work. facilitate the client’s capacity to envisage a life in
When a client says something, the meaning which the problem is not a central, controlling
depends not only upon what is being said but factor. The interventions include the Miracle
also on the context in which it is spoken, i.e., the Question, Scaling Questions, Exception-Finding
context apportions the meaning. This reflects Questions, and Coping Questions.
Gergen’s influence on de Shazer. Gergen explores De Shazer is well-known for his prolific writ- D
how the individual explains and gives meaning to ings, and his books have provided a significant
the world in which he or she lives. Words, gestures, contribution to the evolution of psychothera-
tones of voice, and expressions only “mean some- peutic thought and investigation since the
thing” within discourse which is the product of 1980s. His books include the following: Pat-
collaborative, dynamic interchange. Language terns of Brief Family Therapy (1982), Keys to
and meaning are not objective “realities” but Solution in Brief Therapy (1985), Clues: Inves-
“social artifacts” which are products of social tigating Solutions in Brief Therapy (1988), Put-
interchange – an active and collaborative enterprise ting Difference to Work (1991), Words Were
among people in relationships. The solution- Originally Magic (1994), and More than Mira-
focused perspective focuses on language in this cles: The State of the Art of Solution-Focused
way, concentrating on how a problematic situation Brief Therapy (published posthumously
can be exacerbated by the language used by the in 2007).
client to describe and give meaning to it. De Shazer Steve de Shazer died while on a conference
aids the client in releasing the problem-focused tour in Vienna in 2005. He was survived by his
language and focusing instead on the identification wife, Insoo Kim Berg, who died 16 months later
of solutions and the construction of solution talk. in 2007.
Thus solution-focused therapy is not just a series of
techniques but a way of thinking about and
approaching problematic situations – thus requir- Cross-References
ing a specific posture on the part of the therapist.
De Shazer’s brief, pragmatic, and future- ▶ Assimilation in Integrative Couple and Family
oriented model is based on a number of principles Therapy
which have influenced subsequent therapeutic ▶ Deconstruction in Narrative Couple and Family
advances. They include: Therapy
▶ Postmodernism in Couple and Family Therapy
• If it isn’t broken, don’t try to fix it. ▶ Questions in Couple and Family Therapy
• If something works, “do” more of it.
• If it does not work, do something different.
• Small steps lead to big changes. References
• The solution is not necessarily directly
connected to the problem. De Shazer, S. (1985). Keys to solution in brief therapy.
• Problems do not occur all the time – there are New York: W.W. Norton.
De Shazer, S. (1994). Words were originally magic.
always exceptions. New York: W.W. Norton.
• The future is co-created and negotiable. Gergen, K. J. (2001). Social construction in context.
• Change is constant and inevitable. London: Sage.
Gilligan, S., & Price, R. (1993). Therapeutic conversa-
tions. New York: W.W. Norton.
These principles gave rise to the development Article retrieved from: International Journal of Solution
of therapeutic interventions which de Shazer Focused Practices. (2013). Vol. 1. No. 1. pp. 10–17.
termed collectively “Master Keys.” This refers to www.Ijsfp.com.
710 Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice
These groups install and legitimize the dominant

Decolonizing Couples and societal norms that are more familiar in a given
Family Therapy: Social Justice society. Subjugated knowledge about social values
Praxis in Liberatory Healing and life experiences of marginalized populations is
Community Practice rendered invisible. The demand of coloniality
requires that we live through one mask. The
Rhea Almeida1, Lisa Dressner1 and masks of Latinos, Blacks, Asians, Native Ameri-
Willie Tolliver2 cans, workers, students, athletes, elderly, youth,
1
The Institute for Family Services, Somerset, teachers, social workers, psychologists, and family
NJ, USA therapists are therapeutically processed through the
2
Silberman School of Social Work at Hunter single knowledge system of emotionality.
College, New York, NY, USA The matrix of coloniality is a major site for the
wounding of couples and families. Coloniality is a
phenomenon in the asserted postcolonial era that
“There is no thing as a single-issue struggle because maintains a dominance of world structures by
we do not live single-issue lives.” Audre Lorde
modern-day colonizers in the form of restricted
resources, life opportunities in the lives of disadvan-
Conventional wisdom distilled from Western taged groups (Grosfoguel 2011, 2013; Maldonado-
psychology focuses on the emotional connectivity Torres 2007), and implicit cultural imperialism.
of couples as an indicator of their health. Neverthe- Castro-Goméz (2010) argues that in modern colo-
less perforations from oppressive forces seriously nialism, or coloniality, domination by force is not
impact the development and security of couples the only method of domination. Another method of
lives. These lived experiences lacerate the emotional coloniality is discourse about “the other” embedded
bonding of a couple. Therapeutic attention to the within the everyday lives of both colonizers and
mature and healthy bond of a couple necessitates the colonized. For example, whiteness was the first
process of naming and disrupting oppressive forces cultural and geographical imaginary of the world
that shape the spaces and places in which emotional system from which the ethnic division of labor and
bonding of a couple occurs. the transfer of capital and raw material were legiti-
mized globally (Battalora 2013). This set the staging
Coloniality Matrix of Power for coloniality.
Quijano (2000) describes coloniality as
One of the most powerful weapons of the colonial manifesting in at least three interconnected and
matrix of power is hiding crimes against indigenous interdependent forms:
and enslaved peoples and keeping all of those
harmed by the crimes “linked” to the sickness of a • Systems of hierarchies: racial division and
conquering society. The control of history, knowl- classification as the organizing principle of
edge, health, and justice are features of the colonial White supremacy
matrix of power, or coloniality (Mignolo 2011; • Systems of knowledge: privileging of Western
Quijano 2007). The representation of different or Eurocentric forms of knowledge as univer-
social identity groups in any given society is created sal and objective
and controlled by groups that have greater social, • Societal systems: reinforcing hierarchies
economic, and political power. In general, the cate- through construction of the state and specific
gory of “other” is ascribed to individuals who institutions to regulate, segregate, and diminish
belong to underrepresented, marginalized, or decolonizing systems of healing and lived
oppressed social identity groups. This is done to experiences
differentiate groups from the more valued, more
powerful social groups that set the standard for Examples of these hierarchies and categoriza-
normative lived experiences in a given society. tions are visible in all of the ways our lives are
Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice 711
compartmentalized into silos. The silos of the capital. This knowledge is essential to the forma-
social services and the prison industrial complexes, tion of pathways for emancipation and liberation,
physicians and big pharma, big Agra, and educa- even for couples.
tion are shaped by a principle of corporate profits at
the cost of human lives. The academic disciplines
that produce professionals to populate the silos are Intersectionality
cordoned off from one another’s scholarship, and
professionals in mental health or health are bifur- The concept of intersectionality originated from
cated as advocates or clinicians, academics, or Black and Chicana feminist theory (Anzaldúa D
activists. The list is endless and constitutes a pow- 1987, 1999; Collins 2000, 2004, 2009; Crenshaw
erful capitulation to the hierarchies established by 1994), as well as developing world feminism and
coloniality. These hierarchies are directly contigu- queer theory. It requires the analysis of systemic
ous with the formation of healthy families and power, privilege, oppression, and social location/
healthy functioning couples, with emotional bond- standpoint to be used in understanding multiple
ing being but one factor in the analysis and healing social identities held by human beings (Harding
of healthy couples (Fig.1). 2003; Hankivsky and Cormier 2011).
Gathering knowledge about the lived experi- Intersectionality holds that classifications such
ences of subjugated identities requires a deep as gender, race, class, and other signifiers of identity
understanding of the powerful structures that cre- cannot be examined in isolation from one another.
ate such uneven access to social and cultural They interact and intersect in individual’s lives,
Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice,
Fig. 1 Hierarchy of power, privilege, and oppression (Almeida 2016)
society, and social systems and are mutually consti- Redrawing the Boundaries of Trauma
tutive. It highlights how people with multiple iden-
tities can be excluded from certain initiatives meant Trauma can occur with a single event in one’s life
to “even the playing field,” such as affirmative like an illness, rape or sexual assault, sudden loss
action, because such efforts focus on only one of employment, and death within a normative
oppressed identity, rendering other identities invis- trajectory of the life cycle. Other forms of trauma
ible. Intersectionality decodes the “colonial matrix are experienced when loss accompanies sudden
of power” and creates a foundation for decolonizing death that challenges the lived experiences and
and liberation praxis. normalcy of the life cycle like the death of a
Multiple identities coexist and complicate the child and multiple examples of the brutal separa-
ways in which we typically think of class, race, tion of children from their parents as in foster care
gender, and sexuality as social, political, and eco- or political migration histories. The experience of
nomic problems. It reflects the complexity and targeted identities could be a trauma limited to a
fluidity of lived experiences along multiple trajec- specific time in the life cycle like bullying; loss of
tories of hierarchies and overcomes the challenge a parent; loss of ableness through illness, accident,
of compartmentalizing the pillars of privilege, or political terrorism; and other similar life-
domination, and oppression. threatening events.
All of these traumas however can be situated
within a family or community where there is
Liberation Praxis intergenerational and or historical trauma.
Intergenerational trauma transports these experi-
Liberatory healing practices have distinct founda- ences from one generation to another (DeGruy
tional strategies that draw from knowledge across 2005; Brave Heart et al. 2011; Doucet and Rovers
academic disciplines to disrupt and dismantle the 2010; Jacobs 2011).
residuals of colonial structures. The structures Historical trauma has life-altering conse-
impact clients, practitioners, and students who quences in current generations as witnessed in
engage in teaching and learning contexts in search the development of illnesses such as PTSD,
of healing for themselves and their communities depression, and type 2 diabetes all disproportion-
(Almeida et al. 2015). ately occurring in Native and African American
Relationships are formed and structured communities (Walters and Simoni 2009). For
inside of established systems that dispense power, these communities healing is particularly complex
privilege, and oppression based on social identities. as the injury and lack of sustained dignity con-
Strategies of liberatory healing through tinue on a daily basis.
decolonizing include: When trauma manifests in persons located within
the contours of historical and intergenerational
• Transparency and the naming of structures of trauma, healing occurs within the knowledge space
dominance of these experiences. Trauma that manifests in per-
• Redrawing the boundaries of inclusion sons situated within a legacy of entitlement or
• Disrupting the hierarchical categories of advantages also necessitates the naming of these
coloniality around race, class, gender, sexual legacies that complicate the healing process if left
identity, etc. invisible. This type of trauma is evidenced in the
• Desegregating healing spaces current rage and despair of many White poor com-
• Being free of living the script of coloniality munities struck by opioid tsunamis.
• Affirming and developing knowledge and Addressing trauma through a matrix of perfo-
practices from border spaces across disciplines rations occurring at the colonial wound involves:
and geographic localities
• Sharing social and political capital to create • Addressing intergenerational trauma and its
pathway toward economic capital insidious wear on the body and soul
• Focusing on historical trauma and migration identities to the larger societal context where the
loss norms of socialization around gender, race, class,
• Restructuring parenting hierarchies post- sexual orientation, and other lived experiences are
trauma in families with children incubated.
• Paving the sense of hopelessness with inspira-
tion and dignity
Application of the Approach in Couples
In practice, operationalizing this analysis Therapy: The Power of Language
requires building critical consciousness accompa- D
nied by strategies of empowerment and “They get on the walls. They get in your wallpa-
accountability. per. They get in your rugs, in your upholstery, and
your clothes, and finally in to you.” Maya
Angelou.
Building Critical Consciousness
Samantha and Allen
Although couples will experience varying emo- Not uncommon to most couples, Samantha and
tions based on their own lived experiences and Allen defined their problem as one of communica-
embodiment of the varying social identities tion difficulties. Samantha in her late thirties identi-
constructed by society, building critical conscious- fied herself as Japanese and Chilean who grew up in
ness creates a platform for liberation (Du Bois both places before her family relocated to the United
1903/1994; Freire 1999; Almeida 2003; Almeida States. She speaks both languages fluently.
et al. 2007a, b). Gathering knowledge that struc- Samantha is the youngest of three siblings with
tural forces exist and control all levels of social, two older brothers born to middle-class parents.
economic, and political interaction provides clients She teaches languages at a private high school.
with what Mignolo (2009) refers to as strategies of Allen identified as African American, an only
epistemic disobedience. child also born to middle-class parents, who spent
The method used to raise critical consciousness most of his life in New Jersey. After being laid off
with couples and families is through the use of from a position at a Media Arts Center in NYC, he
popular film vignettes, music, social media, and a decided to open a fitness center. While it did well for
variety of tools (Almeida et al. 2007; Hierarchy of a brief time, the recession and loss of many cus-
Power Privilege and Oppression; Appendix I; tomers made it impossible for Allen to sustain the
Appendix II). The tools are intended to detoxify business. He picked up a few hours a week working
personal issues while simultaneously inviting larger for another fitness center. During their 5-year mar-
context conversations, for example, conversations riage, he worked for the first year and has been
about the trajectory of gender identities. From the unemployed since then. What they defined as com-
outset there is a restructuring of therapeutic conver- munication problems centered mostly around her
sations taking the therapy out of the realm of the wanting to have a child and his reticence to move
personal to the political, from the intrapsychic to the into parenthood, as well as what he described as her
social, and from the interior to the exterior. This “nagging” him to a get a job and help around
process is crucial as it creates a platform from household responsibilities. He claimed his unem-
which healing strategies are created. ployment was the reason for his refusal to consider
Following an initial consultation, couples are having a child at this time. When Samantha
moved into cultural circles for a period of suggested that she could continue to support the
8 weeks. During these 8 weeks, they are offered family if he took on the responsibility of raising
language and analysis to name power, privilege, their child, it was a solution he was uninterested in
and oppression for the dialogue and inquiry that pursuing. They were moved into the separate gender
unfolds. This allows for a linking of internal cou- circles to begin the process of developing critical
ple dynamics and their issues and multiple consciousness.
This is the juncture at which the narrow When exploring Allen’s choices to disengage
boundaried marker of couples as a closed system from the second shift especially since he was not
is challenged. The concept of couples both as an fully employed, he reflected on perhaps sharing
autonomous unit and disconnected from their responsibilities, but would not consider using a
contexts of socialization is a feature of coloniality. mop or cleaning bathrooms, reflecting rigid
In the circles they watched film vignettes like masculinity.
Pretty Woman, Jungle Fever, Straight out of In her circle Samantha saw the graphic pattern
Brooklyn, Hope Springs, Mississippi Masala, of Tony’s nonparticipation in a partnership. She
Love Jones, Crash, Girl Fight, and others. continually offered excuses such as he did not
These films’ depiction of social, political, and understand what was being communicated to
economic markers are used to begin the multiple him by the men and the therapists. She believed
gendered conversations including masculinities that things needed to be broken down for him, as it
and femininities. often needs to be done with the teens in her class.
The clips of movie dialogues reflect the inter- She was challenged to interrogate the ways in
sections of class, race, gender fluidity, and sexual which she infantilized him by having her reflect
orientation, all of which intrude into a couple’s on all of the ways he was competent in some
life. In this case Allen’s unemployment, particu- aspects of his life. She became painfully aware
larly as a Black man, intruded on his masculinity. of the disconnect between them. Not having
Similarly the gendered pressure to have a child knowledge about how power in relationships
with age as a compelling barrier was a great con- operated, she overemphasized the personal
cern to Samantha. In assessing the degree of sex- decontextualized dynamics. Perhaps her efforts,
ual intimacy, they both reported having sex unwittingly to balance the power in their relation-
around once or twice every few months. ship, were to assume a level of literacy that kept
Using the tool called “Money, Sex, and her stuck in this relationship. During this period
Responsibility” (Ault-Riche 1994) that assesses Allen informed her that he would be traveling to
for both of their responsibilities around the second Hong Kong with a male friend to clear his head.
shift, it was apparent that Samantha did the bulk of When asked about his affordability for this trip, he
household responsibilities that included cooking, remained vague. She learned later that his mother
cleaning, grocery shopping, and laundry of com- paid for it.
mon items like sheets and towels. They both did Here is a space where interrogation of
their own personal laundry. Allen took on sched- intergenerational patterns is relevant.
uling car maintenance and caring for his dog, While both of Allen’s parents were frustrated
which he brought into the marriage. Regarding and concerned about his refusal to take up any
financial contributions, he paid for his cell work even if it was not within his projected hopes,
phone, gas, and his car servicing. This tool quan- it became clear that his mother supported him
tifies contributions to the second shift in terms of financially much to the chagrin of his father.
daily, weekly, monthly, and annual tasks (Almeida
et al. 2007). Empowerment: Dismantling Subjugation
Samantha scored considerably higher than did Empowerment first occurred through transpar-
Tony, which offered them an analysis of part of ency and the naming of structures that threaded
their relationship in concrete terms. This informa- gendered norms into this relationship shaping it in
tion is shared by both of them in their respective many ways.
circles. Redrawing the boundaries of inclusion
The focus remains on societal norms that occurred through embracing this couple within a
perhaps informing second-shift decisions, multiracial, multi-gendered healing circle, ending
resisting the default to explore inner contribut- their isolation. Simultaneously hierarchical cate-
ing familial patterns, a potentially pathologiz- gories of coloniality around race, class, gender,
ing course. and sexual identity were disrupted.
Accountability: Dismantling Dominance their marriage was salvageable. After participat-

Following his trip to Hong Kong, Allen decided ing in the dialogue and inquiry of the critical
he would take a break from therapy. Samantha consciousness process and understanding the
was angry and disappointed but still wanted to multiple dimensions of misuse and abuse of
explore healing for them and their future. The power, she was able to start naming the behaviors
therapists (a team of therapists work with the that were eroding their relationship. She was bet-
couple) contacted him, and he indicated he ter able to understand how her experience of being
planned to return soon. Shortly afterward overburdened in her marriage was linked to Jeff’s
Samantha convinced him to join her in a fertility lack of participation in second-shift responsibili- D
consult. Test results from that consultation ties, economic abuse through making unilateral
showed she was positive for herpes. After fierce decisions about family purchases, and emotional
denials he acknowledged having a brief affair abuse as he derailed most of her efforts to speak
during their marriage. This new information con- with him about her concerns. These experiences
firmed for Samantha the fact that they were in fact coupled with the challenges of raising two sons
living single lives in the corridor of couplehood. (one who was beginning to use drugs and alcohol)
led Mary to contemplate divorce.
Jeff engaged in a similar process of developing
Couple Two critical consciousness in his circle of men and
viewed vignettes that focused on the range of
In the next vignette, we introduce Jeff and Mary male norm socialization, White privilege and
and their two sons Jeff Jr. and David. power, and control within heterosexual and
Liberatory strategies, outlined below, were part LGBTQ relationships. This informed his under-
of their healing experience. Raising critical con- standing of how he had absorbed patriarchal mes-
sciousness, promoting empowerment, and sages of masculinity that were threatening both
accountability to different members of this system the health of his marriage and his relationships
was accomplished through the use of: with his sons.
Movie vignettes that included Gridlocked and The cultural circles made it possible to redefine
When a Man Loves a Woman, two movies shown the root of the problem as stemming from influ-
together, juxtaposing a single, poor person of ences of a patriarchal society. Patriarchy empha-
color trying to access substance abuse treatment sizes masculinity as individualistic, stoic, and
with that of a married White upper-class woman. homophobic, therefore making avoiding feminin-
The tools invite clients, families, and communities ity and characteristics/tasks associated with this
to create or draw from their ancestral rituals to socialization of manhood essential. Rather than a
address generational trauma. problem that is unique to this couple, understand-
ing patriarchy gave them hope that there were
Transparency Around Shared Conversations possibilities outside of closed couple model.
and Strategies for Change Within their cultural circle that was multiracial
Jeff and Mary are a White, working class family and socioeconomically diverse, inclusive of sin-
in their early forties with sons Jeff Jr., 14, and gle individuals and LGBTQ couples, Jeff and
David, 11. Both parents were in recovery for Mary began to tease out their self-identification
many years and connected to an AA community. as victims signified by their working class status.
However, like many other couples in AA, sobriety The obfuscation of whiteness has not provided the
brought a new set of challenges, in their case a language or interrogation for such identities
dissatisfied marriage. They both expressed frus- (Pewewardy and Almeida 2013). They were able
tration with their high school education and lim- to claim more of their privilege as White, hetero-
ited careers. Jeff was a carpet layer and Mary sexual individuals who, in spite of financial
worked as an office manager at a pharmaceutical strains due to their limited education, were still
company. Mary was very angry and wondered if able to access treatment keeping their addictions
private from their workplaces. At this juncture they physical brutality. Mary spoke of the trauma she
began to explore and redefine their couple and experienced growing up at the hands of her father
family values, countering much of what they who divorced her mother when she was 9 years
learned in their prior therapy. The prior focus was old. She is certain that he was some sort of gov-
within the interior of their relationship – lending ernment spy, and it was believed that he murdered
support for one another’s professional goals, one of their female family friends but was never
assignments to spend free time with just one charged. He had numerous guns and often threat-
another, and listening assignments to offer reflec- ened her and her siblings. She left home at the age
tive feedback to each other. They questioned the of 16 and started to abuse substances at that time.
commercial definition of relationships, which Mary also talked about the shame she experienced
assumed that all love, caring, and connection because of her small family home. In avoiding
ought to come from two people in an isolated invitations for guests to visit their home, there
context – the couple. It is important to note that was another layer of isolation to their lives.
this limited and harmful delineation of couplehood Through unpacking her complicity with a patriar-
is a construction of coloniality exported globally as chal notion that her husband should be the ulti-
the gold standard. Couple relationships that are mate rescuer and provider, she was able to grasp
supported and embraced within collective family the rage she often directed toward Jeff. Both Jeff
and community circles are not present in much of and Mary succeeded in their journey to increase
this discourse on couples. their education. Jeff became a realtor and Mary a
The transparency of a healing circle, where nurse.
individuals from similar and different and social This linking of societal influences of capital-
locations questioned, explored, tried out, and ism, patriarchy, and White supremacy to genera-
broadened new definitions of couples and family, tional patterns within a family and the passing on
created possibilities that pushed well beyond the of this legacy to future generations are a hallmark
constraints of the initial borders that Jeff and Mary of liberatory healing practices.
defined for themselves.
Accountability: Dismantling Dominance
Empowerment: Dismantling Subjugation In the community circles, Mary began to observe
Jeff and Mary’s transition from identifying pri- that Jeff would lead in challenging other men’s
marily with their locations of oppression had a misuses of power in relationships. She noted how
positive impact not only on their relationship but this witnessing brought her a sense of pride and
with that of their sons as well. The circles opened purpose in their relationship and the legacy they
up spaces for Jeff Jr. and David to develop critical were creating together for their family. As their
consciousness as young White men. As Mary and consciousness developed around their multiple
Jeff created an alternative definition of marital identities, linking sources of oppression and priv-
satisfaction, considering their couplehood in a ilege, and their choices around exercising their
larger community context – where LGBTQ cou- privilege responsibly both within their relation-
ples, single men and women, couples of color, and ship and the outside world, they described an
those more financially burdened than them increased sense of peace and security. One exam-
worked together on all types of life cycle ple of this is when Jeff took his youngest son
challenges – their perspective about their marriage David to a national conference on White privilege
and family shifted. Jeff examined his family of at the suggestion of the therapeutic team and paid
origin and the ideas that were passed along around for by some members of the healing community
men and second-shift responsibilities, and he that were in a position to invest in this activity.
began to assume a more equal role in the tasks in This benefit of social capital in a healing endeavor
his home. He also addressed the trauma he expe- exemplifies the ways in which the healing com-
rienced at the hands of his father from humiliation munity engaged in the process not only to invest
of his masculinity to frequent instances of in Jeff and David but toward the greater good of
the larger community. This experience for David Cross-References

became his gateway as a young White man living
in a White, blue-collar community to excel in his ▶ Fairness in Couples and Families
academics and participate in a summer travel ▶ Gender in Couple and Family Therapy
abroad program. Moving this couple from a ▶ Power in Family Systems Theory
focus on purely the interior of their lives to ▶ Social Constructionism in Couple and Family
broader lived experiences positioned them as Therapy
both contributing to and benefitting from a larger ▶ Socialization Processes in Families
healing community. This was the impetus for their ▶ Social Role Theory in Couple and Family D
transformational shift. Therapy
▶ Torture in Couple and Family Therapy
Conclusion
Appendices
Human beings derive meaning in social con-
texts. Rarely do the human beings who call Appendix 1: Questioning Binary Norms of
those social contexts home construct the social Socialization
contexts in which human beings live. Forces 1. Avoiding historically femininity and behav-
much larger than the individuals living within iors with cisgender women’s role
the structures termed couple, family, commu- (housework, childcare, gender non-
nity, and/or nation shape societies. Societies conforming activities and occupations).
are not innocuous spaces created to ensure the 2. Seeking stereotypically hypermasculine
healthy growth and development of all of its appearance – large upper-body muscular
members. Societies are a mix of all that has build – projecting physical strength and shad-
happened along the trajectories of their exis- ing/avoiding color. Patina of seriousness
tence. In countries whose very existences were around sports and not in fashion or makeup.
achieved through colonization, there are multi- 3. Restrictive emotionality, suppression of range
ple origin narratives; however, the narratives of feelings (except for anger), emotional dis-
that achieve prominence are those of the con- tance, avoidance of affect in self and others.
quering society. The conquering society estab- 4. Seeking social status and self-esteem via
lishes the norms of what constitutes standard achievement, competition primacy of work/
behavior. In the United States, the norms for provider role, earning power.
couples, sexuality, success, and status are all 5. Self-reliance, avoidance of dependency on
based in ideas that have political purposes, yet others even on intimates and friends.
the ways of being are offered as the gold stan- 6. Aggression (sometimes alternating with
dard, and as a result people are legally prose- avoidance/denial) as a means of conflict res-
cuted and/or randomly murdered for failure to olution. Toughness and leadership in the face
comply. of adversity.
The well-being of a couple is inextricably tied 7. Striving for inherited patriarchal dominance
up with the well-being of society. In the absence of in relationships and control over others in the
a society that nurtures the well-being of all people family.
in ways that are equitable, liberatory practices 8. Non-relational attitudes toward sexuality, and
undertaken in healing communities stand as an objectification of others, use of pornography
alternative to a one-size-fits-all focus on individ- rather than erotica as means for arousal.
uals. It is our epistemic right to present this 9. Homophobia and transphobia, fear/anger at
approach to couple therapy to stand alongside the members of the LGBTQ* community/gender
dominant Western psychology that does not cri- nonconforming people and rigid adherence to
tique its White supremacist and patriarchal origins. a gender binary.
10. Seeking stereotyped feminine looks and References

behavior. Thin Barbie dollesque or the sex-
ualized model of a cisgender woman. Almeida, R. (2003). Creating collectives of liberation. In
T. J. Goodrich & L. B. Silverstein (Eds.), Feminist
Choosing historically female roles and
family therapy: Empowerment in social context
over focus on second-shift responsibilities. (pp. 293–305). Washington, DC: American Psycholog-
11. Comfortable with a range of emotions except ical Association.
anger and adopting the caretaker role. Almeida, R. V., Dolan Del Vecchio, K., & Parker,
L. (2007a). Transformative family therapy: Just fami-
12. Seeking social status and self-esteem vicari-
lies in a just society. Thousand Oaks: Sage.
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philosophy of social science. In S. P. Turner & P. A. Narrative therapy draws upon the work of Jacques
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the social sciences (pp. 291–310). Oxford: Blackwell. truth claims about human experience. While Der-
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Maldonado-Torres, N. (2007). On the coloniality of being: granted practices of the self in the historical con-
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Mignolo, W. D. (2009). Epistemic disobedience, indepen- about personhood has more to do with power
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& Society, 26(7–8), 159–181. bedrock, it becomes possible to play with mean-
Mignolo, W. (2011). Geopolitics of sensing and knowing:
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obedience. Postcolonial Studies, 14(3), 273–285. along, waiting in pristine form, unsullied by cul-
Pewewardy, N., & Almeida, R. (2013). Articulating the ture and untarnished by time. This does not make
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25(3), 230–253. right. Rather, they are to be taken as subjectively
Quijano, A. (2000a). Colonialidad del poder y clasifcacion useful or useless depending on the user’s inclina-
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342–386. couples and families to live by. In narrative
720 Deconstruction in Narrative Couple and Family Therapy
therapy a space is reserved for those seeking help regulating our behavior and circumscribing our
to claim their own preferences, even in a field imaginations. Foucault describes “the point where
where voices tinged with a professional tenor power reaches into the very grain of individuals,
aim to impress. It is through the critique of expert touches their bodies and inserts itself into their
knowledge that agency and imagination can actions and attitudes, their discourses, learning pro-
achieve momentum. cesses and everyday lives” (1980, p. 39). We risk
passively receiving our “marching orders” if we
fail to interrogate the ideas that masquerade as
Theoretical Context for Concept truth. Multiple strands of meaning are cropped,
and one shining filament remains. Variety is ratio-
The term deconstruction was coined by the nalized away by the claim to verity.
French philosopher Jacques Derrida to denote Michael White and David Epston drew upon
the inherent contradictions and endless trails of the work of Derrida and Foucault in developing
meaning that are detectable in any word or phrase. their thinking and practice with an interest in
Striving to capture a static definition is an exercise deconstructing discourse – that is, destabilizing
in futility. For starters, the singularity of a concept dominant cultural models that have achieved
is challenged by the unavoidable affiliation to its wide circulation as disembodied truth
opposite through inexorable reference (e.g., the (White 1995). Take, for example, the modes of
notion of “good” is made conceivable only by expression we depend on to convey suffering.
association to “bad”). Attempting to isolate a dis- We scan the cultural lexicon and landscape in its
tinct and self-governing term is further hindered current configuration only to land upon con-
by the interminable “deferral” of meaning cepts that are most conspicuous. As a result,
(Derrida 2016), since a given expression is made we fret along prescribed lines about our addic-
comprehensible, not only in relation to its oppo- tive personalities, poor boundaries, and low
site but by reference to a closely related idea, self-esteem. We fault ourselves for our negative
which in turn is linked to a subsequent neighbor- outlook and tendency to dwell on the past and
ing concept and so on. In an ever-expanding web, for the way we compound our difficulties by
we may pause for only so long before conceiving unnecessarily drifting into imagined worrisome
of a range of possible next moves. We set our futures. We resolve to approach life more posi-
sights, less with a sense of certainty, as if working tively and redouble our efforts to live in the
with compass and datum, and more with an appre- present.
ciation for creativity. One advances through In a neoliberal Western culture that promotes
flights of imagination. The direction chosen in individual advancement through competition, it is
the search for meaning is made plausible, not no surprise that we encounter ourselves as separable
through a process of reductive reasoning but by subjects stirred to undertake one self-improvement
its moral and quixotic resonance for the seeker. project after another. The corporatization of the
Michel Foucault, a contemporary of Derrida’s, state has produced inevitable reverberating effects
sported a similar predilection for contesting final upon its citizenry. With the privatization of public
readings, particularly with respect to human activ- institutions (e.g., education, infrastructure, prisons,
ity. He cautioned that what we come to accept as healthcare, etc.) and the unraveling of the social
truth is anything but stable. He pointed to the fabric, we have become entangled in the rhetoric
indivisibility of power/knowledge in proposing of personal opportunity/blame. What we accom-
how fashion becomes fact. Rather than possessing plish or fail to achieve is seen as the result of
transcendent value, any evaluative concept of the individual effort alone. Critics of neoliberalism
self is made indisputable by its rise to prominence point to how such an emphasis aims to optimize
at a particular time and place in history. Once the efficiency of workers, ultimately serving corpo-
something assumes the form of accepted knowl- rate interests but doing little to advance civic
edge, it functions as a kind of “normalizing power,” welfare.
On the road to becoming the “sciences” they from grief, to get our anger out, and to assert
aspire to be, dominant strains of psychology and ourselves and individuate. We are warned to
psychiatry appear to have fallen in step with heed such advice or risk our own peril. In
privatizing projects as an outgrowth of the politi- questioning self-actualization practices, it was
cal climate of the past 40 years. Encouraged by the never White’s intention to disqualify a given
professional disciplines to better ourselves as indi- idea but rather to bring it down to size so that it
viduals, we consider possible steps toward maxi- could be seen as culture bound – a “timely” rather
mizing our potentials. As social theorist Nicholas than timeless value – as something to take or leave
Rose explains, “This citizenship is to be rather than covet as an emblem of normality or D
manifested not in the receipt of public largesse, moral worth.
but in the energetic pursuit of personal fulfillment In the lives of couples, it is sometimes said “it
and in the incessant calculations that are to enable takes two to tango.” Therapy can organize around
this to be achieved” (Rose and Miller 2010, the premise that each partner has contributed
p. 298). We take the measure of ourselves and equally to the problem. Not only does this perpet-
come up wanting. We give thought to starting uate blame, but it treats the problem as something
therapy, trying antidepressant medication, taking that is wholly personal and overlooks the conse-
a mindfulness class, keeping a journal, reading a quences of power/oppression. As one example,
self-help book, joining a gym, booking a massage, with heterosexually identifying couples, there is
and – if all else fails – mama needing a new pair of the tendency to give considerable focus to a
shoes. Such initiatives are meant to help us func- woman’s part in her partner’s infidelity (e.g., she
tion more productively as willing and (dis)con- is distant, frigid, castrating, etc.) Additionally,
tented members of society, while diverting our women are held to account for the problems that
attention from what has gone missing in the way enter their children’s lives. From the appearance
of structural support. And so, we file out of proof schizophrenia and migraines to stuttering and
fessional offices with 10 min to spare at the end of autism, mothers have taken the brunt of the blame,
the 50-min hour, our heads swimming with infor- often by way of elaborate rationalizations, since
mation about the limitations of our “operating psychology’s inception (Blum 2007). White and
systems” as a result of arrested development, Epston remind us that rather than residing outside
internal conflicts, chemical imbalances, and of culture, as if there is an “outside” from which to
newly minted diagnostic labels. Instead of per- postulate, psychology and psychiatry operate
ceiving our woes within broad fields of power, from within (1990). The impact of patriarchy, for
we are objectified and left to consider the conse- example, can be found at the heart of direct prac-
quences of our own faulty thinking, genetic pre- tice, revealing more about culture than anything in
dispositions, and flawed neural circuitry. And dare the way of human nature or truth.
we think we have tamed our unruly impulses,
there is always the pesky child within to
reason with. Clinical Example
Narrative therapy strives to maintain awareness of

Application of Concept in Couple and the cultural inclination to blame wives and
Family Therapy mothers, in part or in whole, for problems. It
resists patriarchal discourse as an a priori organiz-
In psychotherapy, narrative practitioners have an ing force and instead holds problems at a distance
eye out for “. . .those familiar practices of self and where they might be best observed and critiqued.
relationship that are subjugating of persons’ lives” Viewing problems from a separate perspective
(Epston and White 1992, p. 121). We have come affords those seeking help a vantage point from
to know, beyond question, that we are meant to which to come to their own decisions whether pro-
forgive and to learn to trust, to let go and move on discourse, con, or otherwise.
Don and Louise, a white, middle-class couple Don: That I’m a man. (They laugh.)
in their early 30s, had been married for 5 years Therapist: Have you considered leaving your
family and hitting the natural road with the other
when they decided it was time to see a therapist. guys?
According to Louise, Don never found his way Don: I have but I wouldn’t feel right about it.
into the marriage wholeheartedly. Don admitted Therapist: What wouldn’t feel right?
as much, explaining that the decision to marry was Don: I guess I’d feel guilty if I left.
Therapist: Is it Guilt that’s holding you back?
more the result of Louise’s unplanned pregnancy (Externalizing guilt)
than a settled love. While he guessed he would Don: Not just guilt. I want my family – my wife
have eventually ended up with Louise, the preg- and my family.
nancy obliged him to “do the right thing.” As a Therapist: Why did you say it twice? Why did
you include your wife the second time around? Was
consequence, he felt “cheated” out of other possi- it Guilt reminding you to include her or was it
ble experiences of life. something else?
Don: I love my wife. I may not always show it,
Don: The guys at work don’t make it any easier. but I love my wife (He turns to her.)
Therapist: What do they do? Therapist: (To Louise) What are you reacting
Don: They tell me I turned in my player’s card. to?
When they’re making plans to go out after work, Louise: (Tearing up) It’s nice to hear him say
they tell me, “Time for you to head home to the it. Half the time I feel like I’m keeping him here
Mrs.!” They’re just doing what guys do, but I don’t against his will. . .like he’s just waiting for me to
appreciate it. It makes me feel like I don’t belong, or say, “Okay, you can go.”
like I’m missing out. Therapist: Whether Don stays or leaves, it’s on
Louise: He resents us. you?
Therapist: Is it true, Don? Does resentment Louise: Yes. (She exhales, seeming to feel the
weigh in? weight of it.)
Don: Yeah, I guess, in a way. I know it’s not her Don: It’s not on you. It’s on me. (Stated
fault. She didn’t get pregnant by herself, but yeah, earnestly)
I kind of feel like if she hadn’t had the baby, things Therapist: What are you getting at Don? Is there
would be different. something you’re wanting to take on? (Don may be
Therapist: Different how? finding his own interest in accountability.)
Don: I would have had time to. . .to do more. Don: I’ve got to sort it out. It isn’t fair for her to
I would have been freer. have to deal with all this.
Therapist: Is that what the guys at work are Therapist: When you say she shouldn’t have to
getting at. Is it the idea that men are meant to be deal with “all this,” what is the “this” you’re refer-
free (The question is posed in a way that allows for ring to?
the possibility that the problem is not unique to Don: I have to figure out if I can be happy with
Don.) my choices – having a family and being
Don: I guess so. More or less, yeah. married. . .this is the life I’m living and I have to
Therapist: So what does that make you? Less of decide if I can accept it.
a man? Therapist: Louise, how does that sound to you?
Don: I’m still a man. I’m just not one of How would it be for this to come off your shoulders
the guys. and for Don to carry it for a while?
Therapist: Is there a difference, though? Are Louise: Please, be my guest. (Said with consid-
they real men and are you a “domesticated” man – erable relief)
like it’s a real man’s nature to desire freedom?
(Wondering if Don is connected to a dominant
story about manhood.)
Don: In a way, yeah. So began a dialogue with Don about the resent-
Louise: I have to keep an eye on him. When he ment and ambivalence that had shadowed him
leaves the house I have to remind him what he has at
throughout his marriage. In an unfolding conver-
home and what he’d lose if he makes the wrong
decision. It’s kind of a joke, but kind of not. (Don’s sation, hegemonic masculinity’s image of a foot-
fidelity may be more a reflection of Louise’s resolve loose and natural man was exposed, along with its
than his own, as if she is to be the moral compass emasculation of the sort of man who would seek
that keeps him on the straight and narrow.)
fulfillment at home. The therapist was careful not
Don: Yeah, she reminds me because she
knows me. to guide him toward one preference over another.
Therapist: What does she know? It was more a matter of exposing the discourse and
leaving it to Don to reach his own conclusions. In Therapist: Before getting to know Millie,
the process, Louise was relieved of the responsi- according to any problem, I wonder if you
bility she had previously felt for Don’s behavior would introduce her to me according to her
and, ultimately, the fate of their marriage. wonderfulnesses – those talents and gifts that
Three years had passed by the time Louise show Millie at her best. If you would tell me
called again. She explained that she and Don who she is according to what is wonderful about
were still together and “doing better.” Their cur- her, we can all know what she might have going
rent concern was with their 8-year-old daughter, for her to meet the problem with. (This question is
Millie, who had become “highly anxious.” meant to challenge the image of the precious but D
Louise explained by phone that Millie had trou- useless child. It also relieves the parents of the
ble falling asleep at night, repeatedly calling one unpleasant task of having to introduce their
of them or the other to her bedside. She also daughter at her worst – according to the problem.)
frequently phoned them at work, asking plain-
Louise: Oh, that’s easy. (Looking relieved) Well,
tively when they would be returning home. this is Millie. She is a very special girl. Millie is very
Louise was convinced that if only she had loving. She gives the best hugs. She’s sensitive. She
extended her maternity leave before resuming an amazing artist for her age. She’s very creative.
her career, her daughter would be in far better She’s really smart. . .
Don: She also has a mind of her own. She can be
shape. In her search for answers, she had been very determined. If she is interested in something
reading about “separation anxiety” and was guilt she can stick with it for hours.
ridden over all that she had “gotten wrong.” Both
parents were braced for what their research Louise and Don carried on listing Millie’s virtues
promised would be a long road ahead in trying and, upon request, easily produced stories about her
to help Millie find the confidence she would need to substantiate their claims. Recognizing Millie for
to lead an independent life. particular talents rather than treating her as a gener-
In league with mother-blaming practices is alizable child was bound to pay off when it came
the cultural propensity to portray children as help- time for problem redress. At the halfway point in the
less, prompting parents, under the guidance of meeting, they turned their attention to the problem.
professionals, to carry out any and all corrective Therapist: Okay, now that we know what Millie
measures. This starts with adult ways of concep- might have in hand to meet it with, should we
meet the problem?
tualizing problems from the moment children Louise: (Taking a deep breath) Yes. Alright, let’s
enter therapy offices. Though space is made for see. Millie has always been a little anxious. But over
their feelings, “[c]hildren perhaps more than any the past 6 months or so it’s gotten worse and we’re
other group are prone to having their ‘saying’ not sure why. There have been a few changes. We
moved to a new house, so that could have some-
capabilities overshadowed by what is ‘said’ by thing to do with it, but she says she loves it, and she
others about them. They are the most easily mar- definitely loves her new bedroom. Right honey?
ginalized segment of society” (Wall 2006, p. 537). Millie: Uh huh.
In contrast, narrative therapy aims to treat young Don: And my commute is longer now so I get
home later, but we still manage to have dinner
people as lead agents, turning to them at critical together most nights. Right?
moments and counting on them to act. In doing so, Millie: Yeah.
discourses of mother-blame and adult-centrism Therapist: Millie, I want to get to know if some-
are implicitly defied. thing like Worry is causing problems for you (a first
attempt to externalize a problem), but before I ask
In the following transcript, a space is created you about that, would you mind telling me what you
for Millie to occupy the role of protagonist rather love about your new bedroom?
than passenger through two practices, a wonder- Millie: I have a tent in my room with all of my
fulness interview (Marsten et al. 2016) and the animals and books and other stuff inside, and there
are stars on the ceiling.
externalization of the problem. With all three fam- Therapist: Stars on the ceiling?
ily members in attendance, the first meeting began Don: It’s a sound machine that also projects
as follows: lights that show the constellations.
Therapist: Oh yeah. I’ve seen those. Those are Therapist: What do you think of a problem like
really neat. Worry trying to use a young girl’s talent for imag-
Millie: And my bed is a. . .(looking to her ination against her?
mother) Millie: I won’t let it!
Louise: A trundle. Therapist: But what if Worry decides it wants to
Millie: Yeah, so I can have a friend sleep over. use your imagination as its playground a while
Therapist: Do you have a friend who’s come for longer?
a sleepover? Millie: It belongs to me! (Said with conviction)
Millie: My best friend April. Therapist: (To the parents) Is this the girl you
Therapist: And have you gone for a sleepover at introduced me to with a mind of her own?
April’s house, or has something like Worry tried to Louise and Don: Yes! Yeah! (Overlapping)
get in the way? Therapist: I’m just curious, has Worry tried to
Millie: (She looks down.) sneak into your imaginations too?
Louise: I think she’d like to, but Worry’s gotten Don: It definitely has.
in the way. Therapist: What’s it like to be reminded just
Therapist: Isn’t that just like Worry to play a what kind of girl Millie is?
trick like that on a kid who’s minding her own Louise: It’s wonderful.
business. (Hoping this sort of lively depiction will
bring the problem within a young girl’s range.) Despite every loving attempt on Louise’s and
Therapist: Millie, would it be okay if I asked Don’s part to mitigate Worry and revive Millie’s
you a few more questions about some of the ways spirits, it was only when Millie herself took a
Worry has been messing around in your life?
Millie: Okay. decisive position that events began to turn in her
Therapist: Thanks. Okay, question number 1. Is favor. Young people have the capacity to effect
your mom right? Did you want to go to April’s for a dramatic change. It is a matter of freeing ourselves
sleepover, and did Worry try to take over before you from common conceptions of childhood so that
could imagine how much fun you’d have?
Millie: Yeah. our imaginations, alongside those of children, can
Therapist: How did it do it, Millie? How did take flight.
Worry take a fun idea like a sleepover at your best As people attempt to orient to the problems that
friend’s house and turn it into a bad idea or a scary enter their lives and those of loved ones, ready-
one?
Millie: (She shrugs.) (The question may need made cultural narratives can get out in front and
reshaping to bring it within reach.) shape what is possible to perceive. Narrative prac-
Therapist: Does Worry try to take your fun titioners remain on the lookout for dominant dis-
imagination and turn it into scary imagination? courses (e.g., patriarchal, mother-blaming,
Millie: It makes me think something bad will
happen. diagnostic, etc.) that can capture our attention and
Therapist: And when you had your imagination block out other possible images of life. The aim is,
all to yourself before Worry came along, can you if not to flatten power, to at least account for it. In
think of what you liked to use it for? (Freeman this way people can see it in its operations and find
et al. 1997.
Millie: For Minecraft. opportunities to strike out in preferred directions.
Don: Not just Minecraft. She used her imagina-
tion for all sorts of things. She’s always been very
creative. Remember the story you made up on our
road trip? (Don describes how Millie sat in the
Cross-References
backseat and created a story that “went on for
days” about a whole world with characters and ▶ Deconstructive Listening in Couple and Family
plotlines.) Therapy
Therapist: I’m just thinking, Millie. . .If you had
a small imagination do you think Worry might have ▶ Micropolitics and Poetics in Couple and Family
left you alone? Therapy
Millie: (Thinking) ▶ Narrative Couple Therapy
Therapist: Is it because your imagination is so ▶ Narrative Family Therapy
good that Worry thought you’d be the perfect kid to
pick on?
▶ Poststructuralism in Couple and Family
Millie: Yeah, because my imagination is pretty Therapy
big. (She seems to be getting in the spirit.) ▶ White, Michael
Deconstructive Listening in Couple and Family Therapy 725
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Blum, L. (2007). Mother-blame in the Prozac nation: Rais- potential possibilities (Hibel and Polanco 2010).
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21(2), 202–226.
Derrida, J. (2016). Of grammatology. Baltimore: John of information that information becomes such,
Hopkins University Press. (Original Amreican work making whatever difference (Bateson 1972) in
published in English in 1976). the therapeutic process. Consequently, that
Epston, D., & White, M. (1992). Experience, contradic-
which is not listened to or selected easily gets
tion, narrative and imagination: Selected papers of
lost in the conversation. Solution-oriented thera- D
David Epston and Michael White 189–1991. Adelaide:
Dulwich Centre Publications. pists, for example, would listen to select informa-
Foucault, M. (1980). Power/knowledge: Selected inter- tion that they judge, from their theoretical
views & other writings 1972–1977. New York: Pan-
framework, as exceptions to the presenting prob-
theon Books.
Freeman, J., Epston, D., & Lobovits, D. (1997). Playful lem, constructing them as exceptions in the very
approaches to serious problems: Narrative therapy same act of selecting them as such. This means
with children and their families. New York: W. W. that clients do not bring with them exceptions to
Norton.
their problems per se to put forward. Instead,
Marsten, D., Epston, D., & Markham, L. (2016). Narrative
therapy in wonderland: Connecting with children’s exceptions are constructed in the process of the
imaginative know-how. New York: WW Norton. conversation. Clients bring with them raw mate-
Rose, N., & Miller, P. (2010). Political power beyond the rial of their lives, or a stock of knowledges –
state: Problematics of government. British Journal of
previously constructed in other relationships and
Sociology, 61, 271–303.
Wall, J. (2006). Childhood studies, hermeneutics, and theo- contexts, with different meanings – to put forward
logical ethics. The Journal of Religion, 86(4), 523–548. for therapists and client to construct solutions
White, M. (1995). Re-authoring lives: Interviews and together from the times when the problem was
essays. Adelaide: Dulwich Centre.
not present in the client’s life.
White, M. (2016). Narrative therapy classics. Adelaide:
Dulwich Centre. Therapists who are oriented to listen from a
White, M., & Epston, D. (1990). Narrative means to ther- deconstructive perspective are more likely to
apeutic ends. New York: WW Norton. ascribe to therapies informed by poststructural
philosophies. This is the case of a number of
family therapies. The most prominent post-
structural family therapies are narrative therapy
Deconstructive Listening in
(White and Epston 1990; White 1991) and
solution-focused therapy (de Shazer and Berg
1992). This entry provides an overview of post-
Marcela Polanco
structuralism, deconstruction, and a deconstruc-
Our Lady of the Lake University, San Antonio,
tive listening in couple and family therapy.
TX, USA
Poststructuralism
Therapeutic conversations provide a context for Poststructuralism is a term that came from
change in couple and family therapy and are scholars in the United States to situate French
interconnected with the contexts in which they philosophers’ work during the second half of the
take place, i.e., social, cultural, and historical con- twentieth century. It encompasses a critical polit-
texts. Conversations serve as context and are ical, literary, and aesthetic philosophical turn of
embedded in context. Therapists’ listening orien- the structural model to understand texts and lan-
tation contributes as an important factor in setting guage, not to eradicate it but to introduce another
up a context of response to the concerns that bring order of things. Poststructuralists reevaluated the
clients to therapy. How therapists are oriented to structuralist perspectives of language of
726 Deconstructive Listening in Couple and Family Therapy
Ferdinand de Saussure (1916) and Claude Lévis- meaning from other meanings, culturally, socially,
Strauss (1963), who claimed a universal, stable, and historically negotiated; it is self-contained,
and complete totality of language and realism that articulated on its own, apart, rather than linked
is unchanged by time. The most important repre- to or raised from the identity of the thing named.
sentatives of poststructural philosophy in France The name, or language clients use in therapy to
are Jacques Derrida (1974/1976), Gilles Deleuze describe the problem, is the result of their labor or
(1967/1994), Jean-Francois Lyotard (1984), and construction in their historical contexts. It is an
Michel Foucault (1980) and in the United States, entirely new creation that bears its own weight in
Richard Rorty (1991) and Judith Butler (1999). its expression, undetermined by the thing named
Departing from the study of language as a way and determined instead by the cultural, social, his-
to understand the meaning of the client’s reality as torical contexts in which it is constituted. The name,
well as the reality of the therapeutic conversation or problem, can take on any sense or meaning on its
(in a linguistically forged world, rather than a world own, contextually. Hence, anger, for example, is not
of materiality), among some of the differences a representation of a set of dysfunctional behaviors
between the structuralist and poststructuralist pro- displayed by the person, subsequently diagnosable
posals, one of critical relevance to couple and fam- as an explosive disorder. It is a construct that carries
ily therapists pertains to how they conceive reality social and cultural negotiated meanings of interac-
in the relationship between the name (e.g., angry tion in this particular historical time when it has
person) and the thing named (e.g., the person’s come to be named as “anger.” Language, for post-
behaviors such as yelling, hitting, cursing, etc.). structuralist couple and family therapists, consti-
For structuralists, the relationship is referential. tutes the client’s realities rather than represents a
Behind the name is the thing named, the referent; priori realities. Language creates social and cultural
one corresponds directly to the other, both meanings of anger rather than representing a stable,
encompassing a totality. The name of the problem universal truth about the essence of what an angry
“an angry person” represents a stable and actual person is. Therefore, the clients’ language is consti-
truth, fixed to the essence of the reality of the tutive according to their function in the context in
identity of the person. The behaviors – yelling, which they come to be.
hitting, and cursing – give rise to the name angry For structuralist and poststructuralist couple
person straightforwardly to stand in for them in and family therapists, the world is articulated lin-
their absence. Furthermore, meaning is conferred guistically. For poststructuralists, however, a lin-
to the name (angry person) linked to the thing guistically articulated world is inevitably bound to
named (person’s behaviors), namely, the “sign,” society and culture in their historical moment:
only in contrast with other signs (happy person), There is no longer a tripartite division between a field
e.g., happy/angry, normal/abnormal, presence/ or reality (the world) and a field of representation (the
absence, good/bad, etc. In this binary opposition, book) and a field of subjectivity (the author). Rather,
one has a priority over the other in a hierarchical an assemblage established connections between cer-
tain multiplicities drawn from each of these orders,
order mediated by power. so that a book has no sequel nor the world as its
Derrida (1976/1967), however, considered that object nor one or several authors as its subject.
the referential link between the name and what is (Deleuze and Guattari 1991/1994, p. 22)
named is an illusion. It is an illusion of represen-
tation. He divorces the straightforward link Couple and family therapists informed by a
between the name and the thing named. For Der- poststructuralist perspective are then interested
rida, instead of being a referential relationship, he in clients’ linguistic assemblages of multiple
considered it to be differential. The name is not meanings within the context of their relationships.
like the thing named nor represents it in its Now, Derrida’s divorcing of the unity between the
absence; it is different from it – anger is demar- name and the thing named, dislocating binaries
cated by what is not, excluding or subordinating and locating a historical context in the construc-
other meanings. The name creates its own tion of language instead, results in couple and
Deconstructive Listening in Couple and Family Therapy 727
family therapist’s focus on the deconstruction of lived experience of the person’s relationships
such assemblage. By this Derrida did not mean and out of a binary of normality or abnormality,
destruction but de-sedimentation, disassemblage, other meanings become available in the client’s
decomposition, or undoing of structural truths of own terms (White 2003).
reality and binary oppositions in search for new Derrida clarifies that deconstruction is not a
possibilities of multiple meanings. method nor can it be transformed into one with
the technical or procedural significations that a
method would have; nor does it assume a set of
Deconstruction rules or procedures that could be repeated from D
one context to another. Furthermore, he went on to
A concept constructed by Derrida, deconstruction clarify that deconstruction is not even an act or an
refers to a reading and analysis of texts or lan- operation, since this would imply passivity, on
guage conceived as a systematic chain or inter- one hand, and a person who would take the initia-
connections of previous assemblages or tive and apply it to an object or a text, on the other.
constructions of meanings that can be traced Deconstruction does not depend on its application
within a cultural and historical context. For Der- by a person. Instead, “deconstruction takes
rida, this chain of texts is organized hierarchically. place”; furthermore “it is an event that does not
The text or word has a privileged meaning, while await the deliberation, consciousness, or organi-
the chain of texts embedded in it is subordinated zation of a subject” (Derrida (1976/1967). Much
(White 2003). Deconstruction means the potential like any other word, for Derrida, deconstruction is
dismantling of the hierarchical architecture of the already part of a chain of possible substitutions of
construction of words by undoing and making meanings or potential alternatives in a context; a
visible the chain of meanings that constituted word can be substituted, replaced, and determined
them historically, in the first place. As a result, by other words and supplemented by them.
the predominant text is displaced and loses the Hence, a therapist does not adopt a deconstruction
determination of its words by structures or bina- method to be performed in a conversation.
ries. In a situation highly determined by a struc- A therapist listens to a client’s narrative of the
ture (i.e., a fixed reality of the problem as an problem from a deconstructive orientation to lan-
intrinsic psychopathology of the client), decon- guage to capitalize from its potential alternative
struction serves as an anti-structuralist gesture to meanings to be assembled from the client’s his-
make it underterminate and unsedimented, undo- torical relationships and contexts. A therapeutic
ing the conditions that constructed the meaning of conversation unfolds through the happening of
the problem in the first instance, to construct new the construction and deconstruction of meanings.
words or meanings that will be subject to their The conditions of deconstruction exist within
further deconstruction. the very same systems of that which is to be
Deconstruction results in the dismantling of the deconstructed. Deconstruction is at work in the
assemblage or architecture of the chain of mean- construction of the meaning. That, which can be
ings embedded in the problem the client brings to constructed, can be deconstructed as well when
therapy. It allows for the revision of the surround- situating and calling into question the contexts
ing conditions of the word, or problem, that may within which it was constituted.
have turned into a fact or become naturalized by
the influence of institutional, cultural, social dis-
course of mental health. For example, the term Deconstructive Listening
“depression” is desedimented or undone from
being a taken-for-granted professional discourse A therapist informed by a poststructuralist per-
of a mental disorder related to the psychological spective questions the idea that behind or
structure of the person. When revising the histor- beneath the client’s language is the true essence
ical subordinated chain of meanings from the of who they are, which must be accessed as a
728 Deconstructive Listening in Couple and Family Therapy
target for treatment. Poststructuralist-informed listening takes them to adopt a kind of bilingual
couple and family therapists keep from listening ear that focuses on various languages, i.e., the
to clients’ narratives as if they are a representa- language of the problem and the language of that
tion of a hidden psychological structure that which the problem is infringing on the couple’s
ought to be discovered, whether these are lives. Therefore, therapists select that which is
strengths clients possess or an intrinsic pathol- absent in the couple’s narrative about the prob-
ogy that they are suffering from. A problem in lem, but it is at the same time implicit (White
“communication” that brings a same-sex or 2003) in the chain of associations of meanings
opposite-sex couple is not listened to in search that constructed historically the narrative of the
for a dysfunction in one or both partners. problem as the most prominent one. Within this
A therapist with a poststructuralist orientation, chain of association of meanings, narrative ther-
most prominently a narrative therapist, would apists listen to or select narratives that contradict
assume no essential psychological structures of the privileged account of the problem to assem-
pathology concealed within the couple’s commu- ble, out of underprivileged narratives, aspects
nication. Instead, the therapist would be oriented that more fairly account to what made them a
by a deconstructive listening to disassemble the couple in the first instance.
couple’s linguistic constructions that privilege a A deconstructive listening orientation leads
problem of communication as if it was an essen- couple and family therapists to focus their atten-
tial truth about their lives and relationship, in turn tion to language in context, holding special inter-
neglecting other potential meanings of what the est on the historical assemblage of the meanings
couple judge as important, valuable, and of the presenting problem in their lives and rela-
respectworthy for them and about them. tionships. It is important to note, however, that
Adopting a deconstructive orientation to lis- history is approached in a particular way. It dif-
tening takes couple and family therapists to pay fers from how it is often adopted in other therapy
meticulous attention to the client’s language. perspectives that conceive history from a
They pay close attention to the particular words biopsychosocial assessment perspective in
clients adopt to construct their narratives. They search for the cause or root of the problem for
do so to trace the chain of meanings that are not its resolution. Borrowing from Foucault’s (1980)
explicitly said but which constructed the stated concept of genealogy, rather history is under-
narratives in the first place. This requires for stood as context marker for the constitution of
them to listen in between the lines of what was knowledge, discourse, etc., within which clients
said for what is not said. In a manner of speaking, constitute themselves, as well as the problem
therapists listen bilingually or listen for different across the continuity and discontinuity of time.
languages – the language of what is said by the This means that history serves as an organizing
client, say, a problem, and what is not said, a feature of the client’s meanings about their lives
counter-problem. Michael White (2003) referred and relationships, instead than conceiving life as
to this kind of listening as “double listening” a product of history. From a deconstructive lis-
borrowing from Derrida’s differential perspec- tening orientation, therapists filter information
tive to language (vs. referential as in on how the problem was made up historically.
structuralism). And, once these architectural features are no
Narrative therapists listen doubly to discern longer taken for granted, the building of new
differences in the client’s description of the prob- meanings becomes available. According to Fou-
lem. The problem is a problem because it differs cault (1980), history divides, distributes, orders,
from what it infringes on in relation to what the arranges, establishes patterns, distinguishes
couple gives value to. Implicit in the problem is a between what is relevant and what is not, dis-
chain of meanings about what they have come to covers elements, defines unities, and describes
give worth throughout their relationship and con- relations that make up, in this case, the clients’
texts. The narrative therapists’ deconstructive lives.
Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy 729
Cross-References White, M. (1991). Deconstruction and therapy. Dulwich

Centre Newsletter, 3, 21–40.
White, M. (2003). Narrative practice and community
▶ Absent but Implicit in Narrative Couple and assignments. The International Journal of Narrative
Family Therapy Therapy and Community Work, 2, 17–55.
▶ Communication Theory White, M., & Epston, D. (1990). Narrative means to ther-
▶ Deconstruction in Narrative Couple and Family apeutic ends. New York: W. W. Norton.
Therapy
Therapy D
▶ Externalizing in Narrative Therapy with Cou- Deepening Emotional
ples and Families Experience and Restructuring
▶ Linguistics in Relation to Couple and Family the Bond in Emotionally
Therapy Focused Couple Therapy
▶ Narrative Family Therapy
▶ Problem-Saturated Stories in Narrative Couple Lorrie Brubacher1 and Sue M. Johnson2
1
and Family Therapy University of North Carolina, Greensboro,
▶ Social Constructionism in Couple and Family NC, USA
2
Therapy The International Centre for Excellence in
Emotionally Focused Therapy, The University
of Ottawa, Ottawa, ON, Canada
References
Bateson, G. (1972). Steps to an ecology of mind. Introduction

New York: Ballantine Books.
Butler, J. (1999). Gender trouble. New York: Routledge Emotionally focused therapy (EFT) is based on
Press.
de Saussure, F. (1916/1959). Course in general linguistics
the powerful role which emotion plays in inti-
(R. Harris, Trans.). Chicago: Open Court. mate relationships. The word emotion is based
de Shazer, S., & Berg, I. K. (1992). Doing therapy: A post- on the Latin word emovere, “to move.” In the
structural re-vision. Journal of Marriage and Family Stage 1 change event of EFT– de-escalation –
Therapy, 18(1), 71–81.
Deleuze, G. (1967/1994). Difference and repetition
therapists focus on clarifying how emotion orga-
(P. Patton, Trans.). New York: Columbia University nizes a couple’s typical pattern of interaction (see
Press. ▶ Clarifying the Negative Cycle in Emotionally
Deleuze, G., & Guattari, F. (1994). What is philosophy Focused Therapy, Brubacher and Johnson, this
[H. Tomlinson & G. Burchell, Trans.]. New York:
Columbia University Press Books. (Original work
volume). In Stage 2 of EFT, therapists deepen
published 1991). emotional experience using the power of emo-
Derrida, J. (1976). Of grammatology. (Spivak, G. Ch., tion to fuel the two transformative change events
Trans). Baltimore: John Hopkins. University Press. of withdrawer re-engagement and blamer
(Original work published 1967).
Foucault, M. (1980). Power/knowledge: Selected inter-
softening – thereby reshaping the bond to one
views and other writings. New York: Pantheon of safe connection.
Hibel, J., & Polanco, M. (2010). Tuning the ear: Listening The goal of EFT – reshaping relational dis-
in narrative therapy. Journal of Systemic Therapies, tress and insecure attachment into a secure
29(1), 59–70.
Levis-Strauss, C. (1963). Structural anthropology.
attachment bond – is achieved through deepen-
New York: Basic Books. ing attachment emotion and interacting from
Lyotard, J. F. (1984). The postmodern condition: A report within that deepened emotional experience.
on knowledge (G. Bennington & B. Massumi, Trans.) Support from attachment neuroscience shows
Minneapolis: University of Minnesota Press.
(Originally published on 1979).
that deepening and reprocessing emotion in
Rorty, R. (1991). Objectivity, relativism, and truth. EFT creates secure bonds that not only have a
New York: Cambridge University Press. significant emotion regulation function (Coan
730 Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy
and Maresh 2014), they actually change how expressions of deepened emotion evoke new
the brain responds to threat (Johnson ways of reaching and responding that reshape
et al. 2013). the attachment bond into one of security and
Deepening emotional experience can be defined connection (Johnson and Brubacher 2016).
as heightening and expanding the experience of
attachment emotions that, unacknowledged, drive
partners’ self-protective behaviors in a distressed Rationale for Deepening Emotion
relationship. It includes helping a partner to get an
alive, vivid felt sense of immediately felt primary Emotion is the agent of change as EFT therapists
emotion that is typically quickly obscured by self- help couples to reshape their despair and discon-
protective secondary emotions such as anger or nection into loving, lasting bonds. Emotion is
numbness during attachment threatening moments recognized for priming key responses (Ekman
(Johnson 2004). 2003, 2007) in interactions between partners.
Attachment theory (Mikulincer and Shaver
2016) delineates how partners in insecure attach-
Theoretical Framework ment bonds dismiss or exaggerate emotional cues
in themselves and others, deny and fragment emo-
The practice of deepening attachment emotion tional experience, and send unclear messages in
is based on research regarding the nature of their best attempts to deal with an underlying
couple distress and satisfaction showing that it sense of rejection and abandonment by their
is the quality of emotional engagement and partners.
expression of clear emotional messages that Emotion is also recognized for being a reliable
shift negative interaction patterns and shape source of information about needs (Frijda 1986).
secure bonding interactions (Johnson 2004; Deepening awareness of primary attachment
▶ Circle of Security: “Understanding Attach- emotion gives a partner access to the need
ment in Couples and Families”, Johnson and embedded in that emotion and the capacity to
Wiebe, this volume). Nine process of change send a clear request to the other partner to meet
studies (see www.iceeft.com) validate that the this need, in place of the indirect messages that
two key processes predicting positive outcome have been reinforcing cyclical negative interac-
in EFT are deepening emotional engagement – tion patterns.
especially exploring attachment fears and In the de-escalation change event of EFT
longing – and disclosing and responding to Stage 1, partners typically discover and name
this experience in affiliative (warm, caring, the underlying emotions and attachment fears
self-disclosing, and responsive) interactions driving their negative cycles. The withdrawer
(Greenman and Johnson 2013). newly articulates and touches the aching sense
The initial deepening of attachment emotion that s/he is failing to measure up in his/her
occurs in Stage 1 of EFT when a therapist lover’s eyes. An angry, critical partner formu-
helps each partner to identify and taste the lates and tastes his/her softer underlying fears
primary emotion underlying his/her reactive of abandonment.
moves and secondary emotion in the typical After partners de-escalate (identifying the rela-
negative cycle. It is in Stage 2, however, that tionship problem as the negative pattern fuelled
the fundamental therapeutic focus is on deep- by underlying emotions), they begin Stage 2,
ening and expanding primary attachment fears where the EFT therapist deepens the vulnerable
and longings and accessing and disclosing the attachment emotions that were touched in Stage
needs embedded in that emotion. This forms 1. Deepening engagement with core underlying
the core of the transformative change of EFT, fears and needs increases mutual sharing and
where partners’ disclosure of attachment fears responsivity, restructuring the bond, and creating
and needs pulls for the other partner to respond broaden and build cycles (Mikulincer and Shaver
in new and reassuring ways. Clear, congruent 2016) of security.
Description her primary emotion. Then the other partner is

supported to acknowledge and accept this
Definition “new” spouse. (Disclosures made from newly
“Deepening” means to evoke partners’ present expanded emotions convey a new and different
moment experiencing of primary attachment emo- view of the partner.) Finally, the EFT therapist
tions in a vivid and concrete way. Deepening lingers with the disclosing partner in a felt sense
emotion is a process of present-moment engage- of the fear so as to evoke the attachment needs
ment with the core underlying attachment fears, embedded within that core fear. Choreographing
linking bodily felt awareness, perceptions, affect, reaching and responding between partners to dis- D
and impulses towards action. Deepening emo- close attachment needs and request the other
tional experience makes it possible for a partner partner’s help to meet these needs marks the
to discover and then be guided to disclose the apex of reshaping attachment security.
attachment need embedded within the depth of
core emotion. Clear signals about needs pull for
Interventions
compassionate, empathic, and bonding responses
Primary interventions for deepening emotion
(Johnson 2004).
(illustrated in the case example below) are
empathic reflections, evocative questions that
Core Process for Reshaping the
focus on the cue, the bodily arousal, the attach-
Attachment Bond
ment meanings and the action tendency of the
Reshaping the attachment bond begins with one
emotion, heightening emotional experience and
partner deepening core attachment fears and dis-
empathic conjectures, in an attachment frame, of
closing these fears to the partner, after which the
the client’s emotional experience.
partner is supported to receive this disclosure.
After emotional experience has been deepened
Next, the partner deeply experiencing his/her
and distilled, the therapist will help the partner to
attachment fear is supported to access the attach-
“disclose” this experience to the other partner, as
ment need embedded within that deeply felt emo-
in, “Can you turn and tell your partner, ‘It’s true –
tion. The apex of the change event is when the
I do fire up and get louder (action tendency) when
experiencing partner takes the risk to reach
I see you shrug your shoulders and turn away
towards the other partner to ask for this need to
(cue). I just can’t bear this dreadful loneliness
be met, followed by the other partner’s response to
(primary emotion) and the sense that I am too
that reach. Deepening attachment emotion is the
much for you’ (attachment meaning)?” After
core of EFT’s Stage 2 bonding events: withdrawer
directing the disclosing partner to share this mes-
re-engagement (WRE) and blamer-softening
sage, the therapist checks first what is was like to
(BLS). In WRE, the formerly withdrawn partner
share this, and then asks the listening partner
shares attachment fears and needs and from an
about their in-the-moment experience of receiving
engaged and assertive position, asks for what
the message. Each partner’s emotions that emerge
s/he needs to remain engaged and to have a safe
are then reflected and heightened, to deepen emo-
and secure connection with the other partner. In
tional engagement within and between partners.
BLS, the anxious, pursuing partner explores
attachment fears of the other’s dependability,
fears of one’s own worthiness, and fears of
reaching to the other and while deeply engaging Case Example
with these fears, risks reaching to the now
engaged partner to ask for what s/he needs to Ben and Tiara had a familiar pattern of pursue-
soothe these attachment fears. attack, defend-withdraw. The more she would
This Stage 2 change process is focused first on push him to help around the house, the more he
the more withdrawn partner and then on the more would defend himself and sullenly retreat to his
anxious, pursuing partner. First the exploring part- computer. This rapid-fire cycle began to soften as
ner is helped to deepen, distill, and disclose his or they recognized how they were unwitting
732 Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy
triggering a negative cycle. Both deepened their Therapist: Just this big tense place of, “Oh no,
awareness of the more vulnerable emotional I could lose you!” (Heightening with
music playing in the background. Ben’s deepened proxy voice conjecture/reflecting
engagement with the attachment fears underlying what he has said earlier.) That is a
his defensive, withdrawn position, reveals dread very scary place. I’d like you to
that he is doomed to lose her one day, and a daily imagine telling Tiara how very scary
sensation of his heart dropping into his stomach this is – to be so certain you’ve
with this fear. already lost her – you feel your heart
sink to your stomach and your
Ben: She gets so upset with me – I am stomach becomes rock hard – so
afraid of saying the wrong thing that tense – frozen in fear of losing Tiara.
will fire her up. I hate her being Ben: It makes me really nervous that
upset – my heart sinks to my gut – when we are arguing that you are
and then I fire back at her. going to decide that this is the end of
Therapist: You get scared of her firing at you it and you’re going to decide that
and just before you fire back, your I’m just not good enough for you
heart sinks to your gut sensing she is and that you don’t want to be in this
upset with you. I wonder if we could relationship anymore.
just hear a little more about that
fear – your heart sinking to your gut, (Following this disclosure, the therapist pro-
when this powerful, beautiful person cesses with each one in turn what it was like to
that is obviously so important to you, share and what it was like to hear.)
comes out loud and angry?
Ben: Eeeew! That I’m not good enough Therapist: So, what is it like as you are telling
for her. I’m not meeting her needs. It her this?
makes me feel like I’m screwing up Ben: I feel a bit of relief. I don’t think I’ve
the relationship and I’m doomed to ever told her how get scared I get
lose her. (Note the emergence of when we are arguing or when she is
attachment meanings, negative upset. It’s a relief to let you know
view of self and core fear of losing.) how scared I get– of losing you.
Therapist So, it is really very scary. (Owning his primary emotion).
(Slow, soft (Heightening the fear.) You’re
tone): saying when you hear Tiara angry, When the therapist evokes Tiara’s experience
(reflecting the trigger for the fear) in hearing from Ben, Tiara is clearly moved and
that you get very, very scared. Your expresses her shock and love for Ben.
heart sinks to your stomach. You Deepening the present moment experiencing
think, “Oh no I’m going to lose her, of Ben’s attachment fear, made it possible for
I’m not good enough. Oh, no I can’t him to disclose it clearly to Tiara. The therapist
possibly meet her needs,” and you lingers in Ben’s deepened fear of failing and his
feel you’ve already lost her, yes? exhaustion at trying to get Tiara’s approval,
Ben: I get really tense and anxious (puts until he is able to access his need for assurance
his hand on his abdomen). and acceptance. Ben steps forward, assertively
Therapist: Yeah, right in your gut you feel a stating his longings and needs to Tiara.
tightness. Do you feel any of that
now as you are describing it? Ben: Your complaints and criticism are too
Ben: Totally – it’s rock hard tense. I’m much for me. I need you to back off and
not able to find words to describe show me you still want to give me a
it. Just a real tension I guess. chance. I do want to be close to you.
I don’t want to fire back to shut you down ▶ Circle of Security: “Understanding Attachment
anymore – I just need to know that I’m in Couples and Families”
enough for you. Please give me a chance! ▶ Clarifying the Negative Cycle in Emotionally
Focused Therapy
▶ Emotion in Couple and Family Therapy
Tiara is shocked at Ben’s risk of stepping ▶ Emotionally Focused Couple Therapy and
close to her. She responds with a message of Physical Health in Couples and Families
clearly wanting him and wanting him to know ▶ Emotionally Focused Couple Therapy and
that. Next, the therapist deepens Tiara’s attach- Trauma D
ment fears and shapes enactments where she can ▶ Emotionally Focused Couple Therapy
risk reaching to Ben to ask him to soothe her ▶ Emotionally Focused Family Therapy
fears and meet her attachment needs. ▶ Hold Me Tight Enrichment Program
From within her deepened fears, first that ▶ Hold Me Tight/Let Me Go Enrichment Pro-
Ben might disappear again and secondly shak- gram for Families and Teens
ing in fear and disgust at her own unworthiness, ▶ Johnson, Susan
Tiara accesses her need for Ben to see her vul- ▶ Training Emotionally Focused Couples
nerabilities and uncertainties and to assure her Therapists
he likes what he sees and will not leave. The
therapist supports Tiara to stand on that fearful
ledge, and to risk leaping off the cliff and to ask
Ben to catch her. References
Therapist: (voice quivering) Can, can you Coan, J. A., & Maresh, E. L. (2014). Social baseline theory
and the social regulation of emotion. In J. J. Gross
catch me – want me – when I’m so (Ed.), Handbook of emotion regulation (2nd ed.,
pathetic? pp. 22–236). New York: Guilford.
Ekman, P. (2003/2007). Emotions revealed: Recognizing
faces and feelings to improve communication and emo-
Deeply moved by her vulnerability and her
tional life. New York: St Martin’s Griffin.
need for his response, Ben rises to the Frijda, N. H. (1986). The emotions. Cambridge:
occasion to solidly affirm he loves her more Cambridge University Press.
than ever. Together Ben and Tiara begin to Greenman, P. S., & Johnson, S. M. (2013).
Process research on emotionally focused therapy
create a new positive cycle of reaching and
(EFT) for couples: Linking theory to practice.
responding that pulls them close and reinforces Family Process, 52, 46–61. https://doi.org/10.1111/
their bond. famp.12015.
Deepened emotion, disclosed to the partner Johnson, S. M. (2004). The practice of emotionally focused
creates new contact between them. Clear, sim-
New York: Brunner/Routledge.
ple messages of primary attachment needs Johnson, S. M., & Brubacher, L. L. (2016). Deepening
embedded within deepened primary emotion attachment emotion in emotionally focused
pulls the other partner into offering a positive couple therapy (EFT). In G. Weeks, S. Fife, &
C. Peterson (Eds.), Techniques for the couple thera-
response, initiating new positive bonding cycles
pist: Essential interventions (pp. 155–160).
of reaching and responding. New York: Routledge.
Johnson, S. M., Burgess Moser, M., Beckes, L., Smith, A.,
Dalgleish, T., Halchuk, R., et al. (2013).
Soothing the threatened brain: Leveraging contact
Cross-References comfort with emotionally focused therapy. PLoS One,
8(11), e79314. https://doi.org/10.1371/journal.
pone.0079314.
▶ Attachment Injury Resolution Model in Emo- Mikulincer, M., & Shaver, P. R. (2016). Attachment in
tionally Focused Therapy adulthood: Structure, dynamics, and change
▶ Attachment Theory (2nd ed.). New York: Guilford Press.
734 Delayed Ejaculation in Couple and Family Therapy
capacity but find ejaculating during partnered

Delayed Ejaculation in Couple sex extremely difficult or impossible. Ejaculatory
and Family Therapy difficulty may occur in all situations (generalized)
or be limited to certain experiences (situational).
Michael A. Perelman It may be lifelong (primary) or acquired
Department of Psychiatry, Reproductive (secondary). A man typically is unable to ejac-
Medicine and Urology, Weill Cornell ulate in the presence of a partner (especially
Medicine/New York Presbyterian, New York, during coitus) but is able to orgasm and ejacu-
NY, USA late during solo masturbation. Nomenclature
MAP Education and Research Foundation, confusion arises over ejaculation and orgasm
New York, NY, USA usually occurring simultaneously, despite
being separate physiological phenomena.
Orgasm is typically coincident with ejacula-
Name of Concept tion but is a central sensory event with signif-
icant subjective variation.
Delayed ejaculation in couple and family therapy Men with DE typically report less coital activ-
ity, lower subjective arousal, and often report
feeling “less of a man.” Some partners enjoy
Synonyms extended intercourse, but eventually many expe-
rience some annoyance, pain, and the distressing
Retarded ejaculation; Inhibited ejaculation; question: “Does he really find me attractive?”
Inhibited male orgasm Initially blaming themselves, partners frequently
become angry at the perceived rejection. Men
with DE may fake orgasm to avoid negative part-
Introduction ner reaction. Finally, distress is extreme when
conception “fails,” while fear of pregnancy leads
Delayed ejaculation (DE) is a type of diminished other men to avoid sex (Perelman 2016).
ejaculation disorder (DED), which includes all
subtypes manifesting ejaculatory delay/absence
(Perelman et al. 2004). Many clinicians may find Theoretical Context for Concept
DE difficult to treat and may not grasp the
psychosocial distress it causes. Assessment The Diagnostic and Statistical Manual of Mental
requires a thorough sexual history including Disorders defines DE as marked delay in ejacula-
inquiry into masturbatory methods to ascertain tion and/or marked infrequency or absence of
the information needed for proper diagnosis ejaculation. Five additional factors must be con-
and treatment. This entry describes a transdis- sidered during assessment: (1) partner issues,
ciplinary approach to the etiology, diagnosis, (2) relationship quality, (3) individual vulnerabil-
and treatment of men with DE based on ity, (4) cultural/religious influences, and (5) medi-
the Sexual Tipping Point ® model (Perelman cal diagnoses relevant to prognosis (American
2009, 2016). Psychiatric Association 2013). “Worldwide” nor-
DE remains an uncommon disorder, with prev- mative studies indicate that heterosexual males
alence rates in 1–4% of males (Rowland and in stable relationships have a median coital dura-
Perelman 2006). Rates are increasing due to tion of approximately 5–6 min (Waldinger 2009,
greater use of pharmacotherapy [5-alpha reduc- p. 2888; Patrick et al. 2005). Influenced by those
tase inhibitors (5aRIs), serotonin reuptake inhib- studies, the International Society of Sexual Med-
itors (SRIs), etc.] and an aging population’s icine’s ejaculation disorder definitions invoke a
declining ejaculatory capacity (Perelman 2016). concept of percentage (0.5% and 2.5%), often
A man with DE usually has intact erectile used in medicine. The 3rd International
Delayed Ejaculation in Couple and Family Therapy 735
Consultation On Sexual Medicine defines DE as a reality (Perelman 2005). Although correlated

threshold beyond 20–25 minutes of coital activity, with high frequency masturbation, the primary
as well as negative personal consequences such as causative factor for many men was an “idiosyn-
distress (McCabe et al. 2016). Perelman has cratic masturbatory style,” as first identified by
recommended that any bilateral deviation from Perelman was defined as not easily duplicated
the majority of men’s 4–10 min coital range with the partner’s body, i.e., hand, mouth, or
would meet the temporal criterion. However, a vagina. These men engaged in patterns of self-
licensed healthcare clinician must also assess for stimulation notable for one or more of the follow-
“lack of control” and “distress,” which are the ing idiosyncrasies: speed, pressure, duration, D
most important determinants when diagnosing body posture/position, and specificity of focus
either premature or delayed ejaculation (Rowland on a particular “spot” in order to produce
and Perelman 2006, Perelman 2016a, b). He also orgasm/ejaculation. Disparity between the reality
recommended qualifying lifelong (primary) or of sex with their partner and their preferred
acquired (secondary), global or situational, and sexual fantasy used during masturbation is
then specifying: mild, moderate, or severe. another cause. That disparity takes many forms,
A man’s inability to ejaculate in response to such as partner attractiveness, body type, sexual
coital stimulation may be due to biological and/or orientation, and the sex activity performed
a range of psychosocial and cultural factors. Typ- (Perelman 2016).
ically, medical examination, laboratory testing, A focused sexual history or sex status is critical
and sexual history are all used to rule out anatom- (Perelman 2003, Perelman 2018a, b). A sex status
ical, hormonal, and neurological abnormalities as begins by differentiating DE from other sexual
well as pharmaceutical causes. However, clini- problems and reviewing the conditions under
cians should also be alert to the numerous poten- which the man can ejaculate. Perceived partner
tial psychological and behavioral causes of attractiveness, the use of fantasy during sex,
DE. These can include ineffective sexual commu- anxiety-surrounding coitus, and masturbatory pat-
nication, cultural and religious prohibitions, terns all require meticulous exploration. Identify
mood disorders, anxiety, fatigue, trauma, and important causes of DE by juxtaposing the
psychodynamic issues such as abandonment/ patient’s cognitions and the sexual stimulation
rejection concerns, emotional intimacy conflicts, he experiences during masturbation versus a
and unwanted pregnancy. Additionally, hostility partnered experience.
toward the partner and paraphilic inclinations/
interests also may play an etiological role
(Masters and Johnson 1970; Rowland and Application of Concept in Couple and
Perelman 2006). Family Therapy
Regardless of the degree of organic etiology,
DE is exacerbated by insufficient stimulation: an Consider asking clients: “In what way does the
inadequate combination of “friction and fantasy” stimulation you provide yourself differ from your
(Perelman 2016). Fantasy refers to any erotic partner’s stimulation style, in terms of speed, pres-
thought associated with a given sexual experi- sure, etc.?” “Have you communicated your pref-
ence. High frequency negative thoughts may neu- erence to your partner and if so, what was their
tralize/override erotic cognitions (fantasy) and response?” Some patients might balk at these
subsequently delay, ameliorate, or completely personal questions, but once assured that research
inhibit ejaculation, while inadequate partner phys- has shown such information is critical to success-
ical stimulation (friction) may lessen response. ful outcome, refusal to answer is rare.
Perelman identified three masturbatory factors Assess for the degree of immersion and focus
associated with DE: frequency of masturbation, on “arousing” thoughts and sensations during
idiosyncratic masturbatory style, and unsettling masturbation versus partnered sex including: fan-
disparity between masturbatory fantasy and tasy, watching/reading pornography, sexy versus
736 Delayed Ejaculation in Couple and Family Therapy
antierotic intrusive thoughts, e.g., “It’s taking too from the patient to temporarily refrain from ejac-
long!” How do his thoughts/feelings during sex ulating alone. If he will not stop, negotiate a
with a partner differ from those during solo mas- reduction in his masturbatory frequency with a
turbation? Additional questions will identify other minimum commitment of no ejaculation within
etiological factors that improve or worsen perfor- 72 hours (experience based) of his next partnered
mance. Obtain the disorder’s development history experience. The clinician must provide support to
and if orgasm was ever previously possible. ensure adherence to this suspension. The patient
Review life events/circumstances temporally who continues to masturbate alone must do so in a
related to orgasmic cessation. Investigate previous manner different from his normal routine. Limit
treatment approaches, including the use of herbal his orgasmic outlet from his easiest current capac-
therapies, home remedies, etc., and if there was ity (usually a specific style) and progressively
benefit. Information regarding the partners’ per- “shaping” it closer to his likely partnered experi-
ception of the problem and their satisfaction with ence. This can vary from changing hands or the
the relationship may assist treatment planning. position he uses during self-stimulation to mastur-
There are no pharmaceuticals proven to treat DE, bating in his partner’s presence. Transitioning
but numerous techniques can be combined to treat from manual to oral and to coital stimulation is
DE including and not limited to sex education, typical, each providing progressively less friction.
cognitive-behavioral therapy, mindfulness, psycho- The patient’s coital bodily movements and fanta-
dynamic exploration of underlying conflicts, and/or sies should approximate the thoughts and sensa-
couples’ therapy. Patient and partner (when present) tions experienced in masturbation. Single men
education should be integrated into the history tak- should use condoms during masturbation to
ing process to the extent it does not interfere with rehearse “safe sex” (Perelman 2016).
rapport building or obtaining needed information. Success rates for treatment by a skilled sex
Before the evaluation concludes, offer the patient a therapist are greater than 75% (Perelman 2016).
formulation that highlights the immediate cause of Yet, not all cases resolve themselves easily. Natu-
his problem and how it can be alleviated. The Sexual rally, more complex cases require more time for
Tipping Point® model can provide a useful frame treatment. The longest latency a DE patient in
for helping the patient (and partner) understand this author’s practice who limited masturbation
etiology and treatment planning. Explain how the but eventually reached coital orgasm was
mental and physical erotic stimulation he is receiv- 8 months. That couple required management of
ing is insufficient for him to ejaculate in the manner numerous relational problems before he was will-
he desires. Successful treatment will depend on the ing to stop masturbating and be truly motivated to
patient’s willingness to follow therapeutic experience a coital orgasm with his wife. Often
recommendations, which will be influenced by the coital orgasms are obtained but no longer
extent of organicity, relational issues, and potentially remain the preferred choice. Despite being the
deeper patient/partner psychodynamic problems. patient/partner’s initial preference, coital orgasms
Behavioral masturbatory retraining within a may be less pleasurable and intense than mastur-
nuanced sex therapy serves as a frequent primary batory orgasms. Nonetheless, for many men and
or adjunctive treatment (Apfelbaum 2000; Perelman their partners, it is often subjectively the most
2003, 2016). Masturbation can serve as rehearsal for satisfying for a variety of psychosocial-cultural
partnered sex. By informing the patient how mas- reasons. This potential conundrum is best
turbation conditioned his response, stigma is mini- resolved when the clinician allows the choice of
mized and partner cooperation is evoked. posttreatment orgasmic preference to remain the
Masturbation retraining is only a means to an end; decision of the man/couple. Sometimes these men
the goal of therapy is higher levels of arousal within will need clinician support to express their prefer-
mutually satisfying experiences. ence for noncoital orgasms, especially when their
For both primary and secondary DE (when coital orgasms were less satisfactory and only
therapeutically possible), obtain an agreement obtained by painstaking effort. However,
Delayed Ejaculation in Couple and Family Therapy 737
clinicians who readily negotiate compromise with Alternatively, both partners may be disconnected
a couple whose female partner prefers noncoital from each other but otherwise in a valued stable
stimulation should recognize the parallel with relationship. Support the patient’s goals, but do
men suffering from coital DE. Finally, for some not push the man (couple) toward the clinician’s
men with DE, failure is predetermined secondary own preordained concept of a relationship.
to partner psychopathology, values regarding por- Instead, embrace McCarthy’s “good enough” sex
nography and their relationship issues, etc. model (Metz and McCarthy 2007). The more
Couples’ therapists will readily notice that relationship strife, the less likely treatment will
many partner issues may affect males’ ejaculatory succeed. Clinicians should practice to their level D
interest and capacity, but two require special of comfort but should not hesitate to refer as
attention: fertility and resentment. The pressure needed to an expert sex therapist (Perelman 2016).
of a woman’s “biological clock” is often an initial
treatment driver. The women – and often the
man – usually resist anything delaying their plan Clinical Example
to conceive. However, the clinician suspecting
the patient’s DE is related to conception fears David (34) worked as a lawyer and was recently
should note any disparity during sex with contra- living together with his girlfriend Judy (28), who
ception versus “unprotected” sex. If the DE only he has dated for 18 months. They shared values
occurs during “unprotected” sex, the clinician can and enjoyed each other’s company. He planned to
assume that impregnation reluctance is a primary propose marriage, but she recently indicated
variable. Resolution typically requires individual her reluctance to commit in light of their sexual
work with the man and occasionally with the difficulties. They were extremely distressed by his
partner. coital anorgasmia, causing a crisis as they
Fertility related or not, patient/partner anger questioned his attraction toward her despite his
is an important causational factor and must assurances of her desirability. Subsequently, he
be ameliorated through individual and/or con- consulted his urologist, who referred to this
joint consultation. Anger acts as a powerful author.
anti-aphrodisiac. While some men avoid sexual The decision to meet alone with David or
contact entirely when angry, others attempt to meet with them conjointly was left to David when
perform, only to find themselves modestly he first called. Be sensitive to patient preference
aroused and unable to function. The man’s asser- regarding partner participation, as patient and part-
tiveness should be encouraged, but the clinician ner cooperation is more critical to successful treat-
should also remain sensitive and responsive to ment than partner attendance at all office visits
the impact of change on the partner, as well (Perelman 2003). A focused sex history was
as alterations in the couple’s equilibrium obtained from David during the first session. He
(Perelman 2016). reported that she usually initiated sex, had high
As treatment progresses, interventions may be desire, and was easily aroused and was orgasmic
experienced as mechanistic and insensitive to with manual, oral, and coital stimulation. The crit-
the partner’s needs and goals. Understandably, ical issue was his ability to orgasm on masturba-
partners’ respond negatively to the impression he tion, but not during partnered sex. That was
is essentially masturbating with her body, as lifelong. He described an idiosyncratic masturba-
opposed to engaging in connected lovemaking. tion technique, and his masturbation frequency was
Indeed, some men are disconnected emotionally high. He reported first masturbating using his right
from their partners. The clinician must empathic- hand, but when he broke it at athletic camp at age
ally help the partner become comfortable with the 15, he switched to lying on his belly and pressing
idea of temporarily postponing desired intimacy. his penis into the bed until he ejaculated. He con-
Once the patient is functional, the clinician can tinued doing so until the present more than four
encourage a man/couple toward greater intimacy. times per week, plus having sex (non-orgasmic)
738 Dell, Paul
with Judy. His current sexual fantasy was, “making ejaculation: An observational study of men and their
love to Judy,” which was not contributing to his partners. The Journal of Sexual Medicine, 2(3),
358–367. http://doi.org/10.1111/j.1743-6109.2005.
delayed ejaculation. 20353.x
Other dynamic issues may have caught a coun- Perelman, M. A. (2003). Sex coaching for physicians:
selor’s attention. For instance, his shyness and Combination treatment for patient and partner.
passivity contributed to his not communicating International Journal of Impotence Research, 15
(Suppl 5), S67–S74.
to Judy about his sexual preferences or how he Perelman, M. A. (2005). Idiosyncratic masturbation pat-
pleasured himself. Although that type of character terns: A key unexplored variable in the treatment of
issue could be addressed, a direct symptomatic retarded ejaculation by the practicing urologist. Journal
focus is preferred unless individual or relational of Urology, 173(4), 340–Abstract 1254.
Perelman, M. A. (2009). The sexual tipping point:
dynamics require doing otherwise. David was A mind/body model for sexual medicine. Journal of
instructed to stop masturbating and to limit his Sexual Medicine, 6(3), 227–632. http://doi.org/10.
attempts to reach orgasm during coitus only to 1111/j.1743-6109.2008.01177.x
those times when he was initiating sex because Perelman, M. A. (2016a). Psychosexual therapy for
delayed ejaculation based on the Sexual Tipping Point
he wanted it, independent of who initiated. That model. Translational Andrology and Urology, 5(4),
suggestion which he followed religiously until 563–575. http://doi.org/10.21037/tau.2016.07.05.
follow-up 2 weeks later was sufficient for David Perelman, M. A. (2016b). Reexamining the Definitions of
to experience his first coital orgasm. Both Judy PE and DE, Journal of Sex and Marital Therapy. Taylor
& Francis Group, (pp 1–12). http://doi.org/10.1080/
and David were exuberant. Judy and David mar- 0092623X.2016.1230161
ried and 2 years later had their first child. Their Perelman, M. A. (2018a). Why The Sexual Tipping Point is
case is not offered to suggest that DE can always a Variable Switch Model. Current Sexual Health
be treated so easily and rapidly but to emphasize Reports, 10: 38. Springer Publications.
Perelman, M. A. (2018b). Sex Coaching for Non-Sexo-
the importance of a counselor obtaining specific logist Physicians - How to Use Sexual Tipping Point
sexual experience data as part of the history taking Model. The Journal of Sexual Medicine, 15(12).
because of its profound ability to influence both Perelman, M. A., McMahon, C., & Barada, J. (2004).
treatment and outcome. Evaluation and treatment of the ejaculatory
disorders. In T. Lue (Ed.), Atlas of male sexual dysfunc-
tion (pp. 127–157). Philadelphia: Current Medicine,
Inc..
Rowland, D. L., & Perelman, M. A. (2006). Retarded
References ejaculation. World Journal of Urology, 24(6), 645–652.
Waldinger, M. D., McIntosh, J., & Schweitzer, D. H.
American Psychiatric Association. (2013). Diagnostic and (2009). A five-nation survey to assess the distribution
statistical manual of mental disorders (5th ed.). Amer- of the intravaginal ejaculatory latency time among
ican Psychiatric Association. http://doi.org/10.1176/ the general male population. Journal of Sexual Med-
appi.books.9780890425596 icine, 6(10), 2888–2895. http://doi.org/10.1111/j.
Apfelbaum, B. (2000). Retarded ejaculation: A much- 1743-6109.2009.01392.x
misunderstood syndrome. In S. Leiblum & R. Rosen
(Eds.), Principles and practice of sex therapy (3rd ed.).
Guilford Press NY, USA
Masters, W. H., & Johnson, V. E. (1970). Human sexual
inadequacy. Boston: Little, Brown & Co..
McCabe, M., Sharlip, I., Atalla, E., Balon, R., Fisher, A., Dell, Paul
Laumann, E., et al. (2016). Definitions of Sexual Dys-
functions in Women and Men: A Consensus Statement Diana J. Semmelhack, Natalie Berry and
From the Fourth International Consultation on Sexual
Dominique Lawson
Medicine 2015. Journal of Sexual Medicine, 13(2),
135–143. http://doi.org/10.1016/j.jsxm.2015.12.019 Midwestern University, Downers Grove, IL, USA
Metz, M. E., & McCarthy, B. W. (2007). The “Good-
Enough Sex” model for couple sexual satisfaction.
Sexual & Relationship Therapy, 22(3), 351–362.
http://doi.org/10.1080/14681990601013492
Name
Patrick, D. L., Althof, S. E., Pryor, J. L., Rosen, R.,
Rowland, D. L., Ho, K. F., et al. (2005). Premature Paul F. Dell
Dell, Paul 739
Introduction widely accepted view that family pathology was

maintained by a homeostatic mechanism that pre-
Paul F. Dell, Ph.D., ABPP is an American clinical vented change from occurring. He not only
psychologist currently specializing in trauma and questioned the theoretical underpinnings of this
dissociation. Dr. Dell pursued a Bachelor of Sci- theory but also called into question why a field
ence degree from Penn State University and grad- such as family therapy dedicated to change would
uated in 1970. From there, Dr. Dell furthered his be grounded in a theory of stability. His work
education in Clinical Psychology. He graduated spawned a series of theoretical papers that
from the clinical psychology department of the together constituted the “Epistemology Debates” D
University of Texas at Austin with his Doctor of of the 1980s. These debates are credited with
Philosophy Degree in 1977. Dr. Dell played an clarifying and shifting the theoretical underpin-
important role in the development of family ther- nings of family therapy.
apy, particularly with regard to a period of time in Dr. Dell later shifted the focus of his work to
the 1980s when the field began to question its dissociation and trauma, working both as an
theoretical underpinnings. His seminal article, empirical clinician and researcher, with focus on
“Beyond Homeostasis,” published in Family Pro- diagnosis and theory. In his 25+ years of working
cess, created debates about epistemology that within the field of dissociation and trauma,
would last for a decade. This paper states that Dr. Dell developed a diagnostic instrument for
the idea of homeostasis is fundamentally incon- dissociation, the Multidimensional Inventory of
sistent with systemic epistemology and should be Dissociation (MID). He also made contributions
substituted with the more appropriate concept of conceptually and theoretically. Dr. Dell spent
coherence (Dell 1982). 23 years running a training program for individ-
uals suffering from dissociative identity disorder
(DID) and other major posttraumatic stress disor-
Career ders (PTSD). While serving as Director of the
Trauma Recovery Center of Norfolk, he simulta-
Dr. Dell began his career in academia, climbing neously maintained a role as a clinical psycholo-
the professional ladder as a professor of Psychia- gist at Psychotherapy Resources of Norfolk
try and Behavioral Sciences at Eastern Virginia (PRN). While at PRN, a trauma-oriented psycho-
Medical School. In his years in academia, Dr. Dell therapy practice, he worked to provide services to
transitioned from being a family therapy specialist patients suffering from DID.
to specializing in posttraumatic and dissociative Since 2010, Dr. Dell has further developed
disorders. Dr. Dell achieved the Ernst R. & his professional standing. He served as the Pres-
Josephine R. Hilgard Award for Best Theoretical ident of the International Society for the Study
Paper on Hypnosis in October of 2017 and the of Trauma and Dissociation (ISSTD) from 2010
Lifetime Achievement Award from the Interna- to 2011. He also recognized the importance of
tional Society for the Study of Trauma and Disso- utilizing technology to spread knowledge about
ciation in November of 2011. Currently, Dr. Dell trauma and dissociation. Dr. Dell developed
works as a psychotherapist at Churchland Psycho- Understanding Dissociation.com as a website
logical Center in the Norfolk, VA area. where individuals are invited to participate in
discussion surrounding dissociative experi-
ences and dissociative disorders. Since its
Contributions to Profession inception, the cite has grown to include partici-
pation from clinicians, graduate students, spe-
As a family therapist, Dr. Dell’s contributions to cialists, and other interested parties who desire
the field were primarily theoretical. In his seminal better understanding of how to treat and work
article, “Beyond Homeostasis” published in Fam- with people suffering from dissociative and
ily Process in 1982, he called into question the trauma-related disorders.
740 Depression in Couple and Family Therapy
Cross-References Theoretical Context for Concept
▶ Family Therapy There are many models that have been advanced
▶ Personality in Couple and Family Therapy to understand the onset and course of depres-
▶ Systems Theory sion, including genetic and neurobiological vul-
nerabilities, cognitive characteristics, and
environmental risk factors (e.g., early adversity,
References stress). Because depression is associated with
difficulties in a variety of areas, including inter-
Dell, P. F. (1982). Beyond homeostasis: toward a concept personal functioning, there has also been a long-
of coherence. Family Process, 21, 21–41.
standing interest in understanding how couple
Dell, P. F. [Paul]. (n.d.). Posts [LinkedIn page]. Retrieved
29 June 2018 from https://www.linkedin.com/in/paul- and family relationships may impact and be
f-dell-66045223/. impacted by depression. On the one hand,
Dell, P. F. (2018). About [Blog Post]. Retrieved from: symptoms of depression may increase the like-
https://understandingdissociation.com/about/.
lihood of couple or family problems. For exam-
ple, a depressed individual may withdraw and
be uninterested in engaging in family and
Depression in Couple and household activities, which may increase con-
Family Therapy flict with other family members. On the other
hand, the stress of couple or family problems,
Briana L. Robustelli and Mark A. Whisman such as poor communication, a decline in social
Department of Psychology and Neuroscience, support, or an increase in criticism and blame,
University of Colorado Boulder, Boulder, may increase the likelihood of a person becom-
CO, USA ing depressed.
Although people may become depressed for
a variety of reasons, once present, depression is
likely to impact couple and family relationship
Depression is characterized by a range of symp- functioning, which may in turn increase the
toms, including depressed mood, loss of interest persistence or severity of depression over
or pleasure in activities, change in appetite or time. In other words, depression may contribute
weight, sleep dysregulation, psychomotor agita- to couple and family problems, which may
tion or retardation, fatigue or loss of energy, feel- increase perceived stress and loss of support,
ings of worthlessness or guilt, difficulty thereby maintaining or exacerbating depressive
concentrating or indecisiveness, and thoughts of symptoms (Beach and Whisman 2012).
death or suicide. In the United States, it is esti- Consequently, couple and family problems are
mated that nearly 1 out of every 6 adults (16.6% of likely to be common among depressed individ-
the population) will meet criteria for a major uals, and, therefore, they are likely to become a
depressive disorder sometime in their lifetime focus of clinical attention in a variety of treat-
(Kessler et al. 2005), whereas general population ment settings. Furthermore, problems in the
surveys in 18 countries estimated lifetime preva- couple or parenting domain predict poorer
lence of major depressive disorder to be 14.6% in response to individual and pharmacological
high-income countries and 11.1% in low- to interventions for depression, perhaps because
middle-income countries (Bromet et al. 2011). these interventions do not adequately resolve
Therefore, many people are likely to have had marital, family, or other interpersonal issues,
personal experience with depression, having suggesting that such treatments are often
been depressed themselves or through having a incomplete without some attention to
relationship partner or family member with couple or family issues (Beach and Whisman
depression. 2012).
Depression in Couple and Family Therapy 741
Description and Robustelli 2016). Expressed emotion refers to

the extent to which family members express crit-
There is a large literature linking couple and fam- icism, hostility, and emotional overinvolvement
ily functioning with depression (Beach and about a specific family member, whereas per-
Whisman 2012; Whisman and Baucom 2012). ceived criticism refers to the degree to which
Results from these studies suggest that poorer people view their partner or family members as
relationship adjustment is associated with higher being critical or judgmental, irrespective of their
levels of depressive symptoms in cross-sectional actual behavior.
studies and increases in depressive symptoms D
over time in longitudinal studies. Poorer relation-
ship adjustment is also associated with depressive Application of Concept in Couple and
disorders in both cross-sectional and longitudinal Family Therapy
studies. Compared to couples in which neither
partner is depressed, couples with a depressed There are several couple-based approaches that
partner tend to engage in more frequent negative have been developed and evaluated as treat-
communication behaviors (such as withdrawing, ments for depression. The approach that has
blaming, or being verbally aggressive) and fewer been most widely studied is based on the cogni-
positive communication behaviors (such as smil- tive behavior framework (Whisman and Beach
ing, making eye contact, and self-disclosing) 2015). Cognitive behavioral couple therapy for
(Rehman et al. 2008). depression generally follows three stages. The
Poorer family functioning is correlated with first stage involves eliminating major stressors
depressive symptoms and depressive disorders and reestablishing positive activities in the rela-
and predicts a poorer course and a higher rate of tionship. Therapists first address severe nega-
remission of depressive disorders over time tive behaviors in the relationship, including
(Beach and Whisman 2012). Furthermore, verbal or physical abuse, threats to leave the
depression has been shown to result in problems relationship, and extramarital affairs; depending
with parenting. For example, compared to non- on the severity and scope of these issues, thera-
depressed parents, depressed parents display more pists may refer one or both partners to additional
negative or coercive parenting behavior (e.g., irri- or alternative treatments to address these issues.
tability, hostility), are more disengaged from their Increasing the frequency of caring behaviors,
children, and engage in less positive parenting companionship activities, and self-esteem sup-
behavior (e.g., play, affection) (Lovejoy et al. port also occurs during this stage. The second
2000; Wilson and Durbin 2010). In addition, stage of therapy focuses on teaching couples
poor parenting has been associated with child- skills to improve communication and their abil-
hood depression, with larger effects observed for ity to solve problems in their relationship.
measures of parental rejection relative to mea- Through instruction, modeling, practice, and
sures of parental control (McLeod et al. 2007). feedback, both in and out of therapy sessions,
Adverse family processes are also associated couples learn effective receptive and expressive
with adolescent depression. Specifically, depres- communication skills (e.g., use of “I” state-
sion in adolescents is negatively associated with ments, sharing thoughts and feelings, nonverbal
the level of support, attachment, and approval and active listening skills) and problem-solving
provided by the family environment, and posi- skills (e.g., defining problems, brainstorming
tively associated with the level of family conflict and evaluating pros and cons of solutions,
(Sheeber et al. 2001). implementing solutions). The final stage of ther-
For both couples and families, high levels of apy focuses on helping couples solidify the
expressed emotion (EE) and perceived criticism gains made in earlier stages of therapy and
have been associated with greater depressive learn strategies to prevent relapse of depression
symptoms and higher rates of relapse (Whisman and relationship problems (e.g., identify high-
742 Depression in Couple and Family Therapy
risk situations, recognize warning signs of In addition to these efficacy studies of couple-
depression recurrence). based treatments for depression evaluated under
Whereas the cognitive behavioral approach is ideal and highly controlled circumstances,
the most frequently studied couple therapy for researchers have also examined the impact of couple
depression, other couple-based approaches have therapy on depression in community clinics. There
also been used to treat depression (Whisman et al. are promising findings from such effectiveness stud-
2012; Whisman and Robustelli 2016). For exam- ies that couple therapy results in a reduction in
ple, researchers have evaluated emotionally depressive symptoms (Whisman et al. 2012).
focused couple therapy (which integrates attach- Research has also provided support for the
ment theory with techniques from experiential potential efficacy of parent training as a treat-
and family systems approaches) and systemic ment for depression. Parent training programs
therapy (which combines strategic and structural seek to improve parenting behavior and the
concepts and techniques with feminist, narrative, quality of the parent-child relationship. Results
and social constructionist approaches) as treat- from several studies have shown that parenting
ments of depression. Studies have also evaluated approaches show promising results for alleviat-
the impact of including the partner or spouse in ing parental depressive symptoms as well as
individual-based treatments, such as including the enhancing child outcomes (Beach and Whisman
partner in cognitive behavior therapy or interper- 2012).
sonal psychotherapy. Family therapy has also been shown to be effi-
A meta-analysis of studies evaluating the efficacy cacious for treating adolescents with depression.
of couple-based treatments for depression reported One promising treatment is attachment-based family
that there was no difference between couple therapy therapy (ABFT), which seeks to increase emotional
and individual psychotherapy (most commonly cog- closeness between parents and adolescents, improve
nitive behavior therapy) in the treatment of depres- the quality of parent-child relationships, facilitate
sion; there was insufficient data to examine the increased communication, and increase adolescents’
comparison between couple therapy and medication autonomy while still receiving support from their
(Barbato and D’Avanzo 2008). However, couple- parents (Diamond et al. 2016).
based interventions were significantly more effective
than individual psychotherapy in improving rela-
tionship discord when discord was present. Clinical Example
Whereas most couple-based treatments for
depression have focused on couples with Diane presented with a recurrent major depressive
co-occurring depression and relationship dis- disorder, and the current episode was of moderate
cord, there is promising preliminary support severity. She and Peter had been living together
for the efficacy of couple-based interventions for 5 years and had a 2-year-old daughter. Both
for depressed individuals who are not necessar- partners were focused on their careers, and what
ily experiencing relationship discord (Beach little free time they had was spent with their
and Whisman 2012; Whisman et al. 2012). daughter. The early stage of therapy focused on
Coping-oriented couple therapy includes ele- increasing the frequency of the partners’ caring
ments of cognitive behavioral couple therapy behaviors, such as texting each other throughout
but focuses primarily on enhancing understand- the day, buying small gifts for one another, and
ing of stressful experiences and promoting devoting more time to taking care of household
emotion-focused and problem-focused support. responsibilities that had piled up and were causing
Brief couple therapy for depression provides considerable stress for both partners. They also
psychoeducation and uses cognitive and behav- increased the amount of time spent with one
ioral techniques to improve distress and symp- another by more frequently going for hikes, eating
toms in the depressed person and his or her dinners together, and taking their daughter to the
partner. park. They also worked on increasing self-esteem
Depression in Couple and Family Therapy 743
support by noticing and complimenting one 201–219. https://doi.org/10.1111/j.1752-0606.2011.

another for things they typically took for granted. 00243.x.
Bromet, E., Andrade, L. H., Hwang, I., Sampson, N. A.,
In the second stage of therapy, the therapist Alonso, J., de Girolamo, G., . . ., Kessler, R. C. (2011).
worked with Diane and Peter on improving their Cross-national epidemiology of DSM-IV major
communication and problem solving. In the initial depressive episode. BMC Medicine, 9, 90. https://doi.
assessment, both partners complained that org/10.1186/1741-7015-9-90.
Diamond, G., Russon, J., & Levy, S. (2016). Attachment-
because of their busy schedules, they did not based family therapy: A review of the empirical sup-
spend much time talking and what time they did port. Family Process, 55, 595–610. https://doi.org/
spend was devoted to brief updates. The therapist 10.1111/famp.12241. D
worked with the couple on sharing thoughts and Kessler, R. C., Berglund, P., Demler, O., Jin, R.,
Merikangas, K. R., & Walters, E. E. (2005). Lifetime
feelings about their experiences, rather than just prevalence and age-of-onset distributions of DSM-
talking about “the facts.” Diane found this to be IV disorders in the National Comorbidity Survey
particularly helpful, as she reported feeling distant Replication. Archives of General Psychiatry, 62,
from Peter much of the time, which contributed to 593–602. https://doi.org/10.1001/
archpsyc.62.6.593.
her general sense of isolation and loneliness. The Lovejoy, M. C., Graczyk, P. A., O'Hare, E., & Neuman,
couple also learned and practiced problem- G. (2000). Maternal depression and parenting behavior:
solving skills and worked through a variety of A meta-analytic review. Clinical Psychology Review,
issues related to time management, lifestyle bal- 20, 561–592. https://doi.org/10.1016/S0272-7358(98)
00100-7.
ance, and child care. In the final stage of therapy, McLeod, B. D., Weisz, J. R., & Wood, J. J. (2007). Exam-
the therapist reviewed with the couple the skills ining the association between parenting and childhood
they had learned in therapy, as well as discussed depression: A meta-analysis. Clinical Psychology
the importance of planning for ongoing and Review, 27, 986–1003. https://doi.org/10.1016/j.
cpr.2007.03.001.
upcoming potential stressors in their lives, includ- Rehman, U. S., Gollan, J., & Mortimer, A. R. (2008). The
ing chronic health problems in a close family marital context of depression: Research, limitations,
member and a potential promotion for Diane at and new directions. Clinical Psychology Review, 28,
work. At the end of treatment, Diane no longer 179–198. https://doi.org/10.1016/j.cpr.2007.04.007.
Sheeber, L., Hops, H., & Davis, B. (2001). Family pro-
met criteria for major depressive disorder, and cesses in adolescent depression. Clinical Child and
both partners’ relationship satisfaction had mark- Family Psychology Review, 4, 19–35. https://doi.org/
edly improved. 10.1023/A:1009524626436.
Whisman, M. A., & Baucom, D. H. (2012). Intimate rela-
tionships and psychopathology. Clinical Child and
Family Psychology Review, 15, 4–13. https://doi.org/
Cross-References 10.1007/s10567-011-0107-2.
Whisman, M. A., & Beach, S. R. H. (2015). Couple
therapy and depression. In A. S. Gurman, J. L.
▶ Cognitive Behavioral Couple Therapy Lebow, & D. K. Snyder (Eds.), Clinical handbook
▶ Communication Training in Couple and Family of couple therapy (5th ed., pp. 585–605). New York:
Therapy Guilford Press.
▶ Expressed Emotion in Families Whisman, M. A., & Robustelli, B. L. (2016). Intimate
relationship functioning and psychopathology. In
▶ Problem-Solving Skills Training in Couple and K. T. Sullivan & E. Lawrence (Eds.), The Oxford
Family Therapy handbook of relationship science and couple inter-
ventions (pp. 69–82). Oxford: Oxford University
Press.
Whisman, M. A., Johnson, D. P., BE, D., & Li, A. (2012).
References Couple-based interventions for depression. Couple and
Family Psychology: Research and Practice, 1,
Barbato, A., & D’Avanzo, B. (2008). Efficacy of couple 185–198. https://doi.org/10.1037/a0029960.
therapy as a treatment for depression: A meta-analysis. Wilson, S., & Durbin, C. E. (2010). Effects of paternal
Psychiatric Quarterly, 79, 121–132. https://doi.org/ depression on fathers’ parenting behaviors: A
10.1007/s11126-008-9068-0. meta-analytic review. Clinical Psychology
Beach, S. R. H., & Whisman, M. A. (2012). Affective Review, 30, 167–180. https://doi.org/10.1016/j.
disorders. Journal of Marital and Family Therapy, 38, cpr.2009.10.007.
744 Derrida, Jacques
Derrida, Jacques
Derrida ultimately challenged the idea of ratio-
Megan J. Murphy and Kaylyn E. Gyden nality and the reliance on reason. “Derrida first
Purdue University Northwest, Hammond, views language as a system of differences, a
IN, USA system in which each word is distinct from all
others” (Gergen 2015, p. 19). We understand
words in terms of binaries – a word is the pres-
Introduction ence of something, contrasted with the absence
of something else. The signifier of a word that is
Jacques Derrida is associated with poststructuralist, present is necessarily given foreground in rela-
postmodern thought. Derrida was a French philoso- tion to the absence inherent in the word.
pher whose ideas shook the philosophical world in The most frequently cited of Derrida’s writ-
the 1970s and 1980s. His influence extended much ings by family therapists involves the concept of
beyond philosophy into the fields of literature, com- deconstruction. Derrida himself may object to
munication, linguistics, and therapy. He himself was providing a definition of deconstruction; in
influenced by – and critical of – other philosophers addition, his work can be difficult to understand.
including Michel Foucault, who he studied under Put simply, deconstruction refers to understand-
early in his career. In the field of family therapy, ing a word or words in the context that sur-
several contemporary, poststructuralist therapists rounds those words. In so doing, the context is
have cited his work, including Harlene Anderson, inherently important – in terms of structure of
Steve de Shazer, and Michael White. Specifically, the actual word itself, the evocations that the
therapists were drawn to his ideas involving decon- word brings about in terms of meaning (and
struction, which was intriguing to therapists anti-meaning), and an awareness of what gives
attracted to postmodern thought. The therapists the word meaning. Depending on your position
above drew on Derrida’s ideas and applied them in as reader, this “definition” means something
various ways to the field of family therapy. different for you than it does for someone else.
Moreover, the word deconstruction exists
within its own context; it evokes notions of
Career construction, if nothing else. Deconstruction
can be viewed as “taking apart,” critically
Jacques Derrida was born in 1930 in French colo- questioning, and drawing forth contrasts and
nial Algeria to a well-to-do Jewish family differences between a word and other words.
(Stocker 2006). He attended the highly regarded Several authors have cited Derrida’s philosophi-
École Normale Supérieure (ENS), writing his cal work as influential on the development of their
Master’s thesis on Husserl. From 1960 to 1964, ideas (Harlene Anderson, Steve de Shazer, and
he taught at the Sorbonne, after which he was a Michael White). For example, de Shazer heavily
lecturer at ENS until 1984. In 1983, he became the cited Derrida in his 1994 text Words Were Originally
founding director the Collège International de Magic. He cites Derrida’s critique of the then-
Philosophie (Stocker 2006). He was a well- prevailing view of structuralism, and the structural
known philosopher in France, whose influence view of language. In a sense, de Shazer was citing
reached into several fields, including literature, Derrida’s indeterminacy of language in arguing that
cultural studies, and the humanities. He studied there can be no confirmed difference between a
under Foucault. Among his most frequently cited signifier and the signified. From this, and informed
works are Of Grammatology (Derrida 1976); by Derrida’s idea of deconstruction, de Shazer pur-
Writing and Difference (Derrida 1978); Positions ported a “text-focused reading” rather than “reader-
(Derrida 1981); and Margins of Philosophy focused reading.” Text-focused reading involves
(Derrida 1982). consideration of the author and reader’s point of
Detriangulation in Couple and Family Therapy 745
view, which is a reading of text (or therapeutic con- ▶ Foucault, Michel

versation) focused from inside the text as opposed to ▶ Poststructuralism in Couple and Family
outside the text. Words give meaning to the text that Therapy
cannot be considered from outside the structure of ▶ Social Construction and Therapeutic Practices
language. ▶ Social Constructionism in Couple and Family
de Shazer’s application of Derrida’s concepts Therapy
is consistent with solution-focused therapy, in ▶ Training Narrative Family Therapists
which therapists attend closely to clients’ con- ▶ White, Michael
cerns, and refrain from imposing their own con- D
cerns onto the client. de Shazer privileges a
close reading of the client’s text. His application References
of Derrida’s concept of deconstruction differs
from Michael White’s, in that White focused Anderson, A. (1997). Conversation, language, and possi-
on contrasting experiences clients have from
Basic Books.
other surrounding experiences (White 2007). de Shazer, S. (1994). Words were originally magic.
In narrative therapy, White would intervene in New York: Norton.
helping clients distinguish one narrative from Derrida, J. (1976). Of grammatology. Baltimore: Johns
Hopkins University Press.
another, with an eye toward the client’s pre-
Derrida, J. (1978). Writing and difference. Chicago: The
ferred narrative. White emphasized the larger University of Chicago Press.
context in terms of clients’ experiences, Derrida, J. (1981). Positions. Chicago: The University of
whereas de Shazer focused on clients’ textual Chicago Press.
Derrida, J. (1982). Margins of philosophy. Chicago: The
meanings in a more immediate sense.
University of Chicago Press.
Harlene Anderson (1997) describes being Gergen, K. J. (2015). An invitation to social construction
generally influenced by postmodern thought (3rd ed.). Los Angeles: Sage.
as developed, in part, by Derrida, and is inspired Stocker, B. (2006). Derrida on deconstruction. New York:
Routledge.
by postmodern ideas of “uncertainty,
White, M. (2007). Maps of narrative practice. New York:
unpredictability, and the unknown” (Anderson Norton.
1997, p. 36). She cited Derrida when talking about
the “not-knowing” position associated with Collab-
orative Language Systems. Quoting Derrida, she
says that “not-knowing” does not mean that one Detriangulation in Couple and
does not know anything, rather the value comes in Family Therapy
a collaborative relationship therapists develop with
clients, in which therapists do not work to retain Kaylyn E. Gyden and Megan J. Murphy
their own knowledge; therapists actively work with Purdue University Northwest, Hammond,
clients to seek understanding. IN, USA
Cross-References Name of Concept
▶ Anderson, Harlene Detriangulation

▶ de Shazer, Steve
▶ Deconstruction in Narrative Couple and Family
Therapy Introduction
Therapy The process of detriangulating is arguably the
▶ Externalizing in Narrative Therapy with Cou- most important technique in family systems ther-
ples and Families apy (Kerr and Bowen 1988). However, it is
746 Detriangulation in Couple and Family Therapy
important to briefly discuss Murray Bowen’s con- completing the process of detriangulation. Kerr
cept of triangles and triangulating before discussing and Bowen (1988) suggest that the most effective
detriangulation further. Triangle is a term used to way to communicate a neutral position in a trian-
describe a three-person system that is formed when gle is to do so by responding to one’s efforts to
an unstable two-person systems begins to experi- triangulate by saying and/or doing things that
ence stress (Landers et al. 2016). The process of push that person closer to the person they are
triangulating occurs when the two-person system having a problem with.
introduces a third party to the system in hopes of
stabilizing the relationship and reducing the amount
of anxiety being experienced (Kerr and Bowen Application of Concept in Couple and
1988). Thus, detriangulation is the process in Family Therapy
which the third party begins to remove themselves
from the unstable two-person system. There are several ways in which detriangulation
can take place in therapy. More specifically,
there are two concrete ways that emotional neu-
Theoretical Context for Concept trality is incredibly relevant to triangles: first,
through the ability to see both sides of a relation-
Detriangulation as a concept was developed by ship process, and second, the ability to refrain
Bowen, the founder of Bowen family systems from having one’s own thoughts about the process
therapy, an intergenerational approach to family be shaped with opinions of what “should be”
therapy. (Kerr and Bowen 1988, p. 150). When one is
able to meet the aforementioned criteria, the abil-
ity to differentiate and detriangulate is increased.
Description Detriangulation can also be applied to therapists
working with client systems. When working
Developed by Murray Bowen, detriangulation with couples and families in a therapeutic setting,
is the clinical technique in which an individual it is important for the therapist to remain de-
refrains from joining the emotional field of triangulated from the system under stress. It is
another dysfunctional dyad or system by gradu- equally important for the therapist to address tri-
ally separating from one or more members in angulated individuals throughout the system and
that system. Although detriangulation is viewed begin working toward detriangulating them. As
as a technique, Kerr and Bowen (1988) argue that mentioned earlier, the most effective way for a
detriangulation is “a way of thinking” (p. 150). To therapist to detriangulate triangulated individuals
expand upon this, it is believed that de- is by continuously pushing the two individuals
triangulation as a way of thinking allows one to under stress closer together. Once the level of
be mindful of the emotional process that con- stress decreases and the two individuals can com-
nects people instead of focusing on the cause of municate with one another, the triangulated indi-
the problem, which in turn makes the act of vidual is removed from the triangle and the dyad
detriangulating more effective. Keeping this reappears.
thought, detriangulation then becomes the process
in which an individual refrains from joining the
emotional field of another system by practicing Clinical Example
emotional neutrality. Emotional neutrality is
defined as the ability to define self without being Marcus and Keisha, both in their mid-30s, came to
emotionally tied to one’s own viewpoint or in therapy concerned about difficulty communicat-
changing the viewpoints of others. After one is ing with each other. Marcus is a partner at a law
able to remain emotionally neutral, one must be firm, and Keisha is studying for her Ph.D. in
able to properly communicate this attitude, thus biology at the local university. They have been
Development in Couples and Families 747
married for 10 years, and have no children. In their

first session, the therapist asks the couple about Development in Couples
their communication concerns. Keisha describes and Families
being very frustrated that Marcus does not listen
to her when she talks, that he does not help out Katharine Ann Buck1 and Marte Ostvik-de
much around the house, and that he spends his Wilde2
1
weekends out with his colleagues either hunting Department of Human Development and Family
or golfing. Marcus counters that he works long Studies, University of Saint Joseph, West
hours at the law firm and so he deserves time with Hartford, CT, USA D
2
his friends on the weekend. He seems puzzled by Counseling and Applied Behavioral Studies,
Keisha’s statement that he does not listen to her. University of Saint Joseph, West Hartford,
He expressed understanding that Keisha was CT, USA
experiencing a great deal of stress from her doc-
toral work, and that he helps out as much as he can
around the house when he is home. Marcus says Introduction
that Keisha spends a lot of her time with her sister,
Tonya. Keisha says that Tonya has been her major Theories of human development offer explanations
support in listening to Keisha’s concerns about her for how couples and families grow, remain stable,
marriage. Keisha says that Tonya agrees with and change across time. Growth and change may be
her – that Marcus spends too much time away gradual, quantitative, and continuous or abrupt,
from the home and should be spending more qualitative, and discontinuous. Stage theories such
time with Keisha. as Piaget’s cognitive developmental theory and
A Bowenian therapist would immediately see the Erikson’s psychosocial theory emphasize the dis-
triangle that has developed between Marcus, continuous nature of development. For example,
Keisha, and Tonya, in that there is tension or anxiety couples in young adulthood who struggle to resolve
in Keisha and Marcus’s relationship. In an effort to the developmental crisis of intimacy versus isolation
reduce that tension, Keisha brought Tonya into the are in a qualitatively different period of development
relationship (i.e., triangled her in) to help reduce her than adolescents who are challenged with resolving
own anxiety. The therapist would see the need for the crisis of identity versus identity confusion.
detriangulation, and would encourage Keisha to Behavioral theories of learning (e.g., Bandura’s
talk directly with Marcus about her concerns instead social learning theory, Skinner’s operant condition-
of talking with Tonya. Although initially this may ing theory), on the other hand, characterize devel-
increase anxiety in the couple’s relationship, in the opment as a gradual, continuous process that is
long term, their relationship would be healthier driven by experiences within our social environ-
when they develop the ability to talk with each ment. In his social learning theory, for example,
other about their concerns instead of talking with a Bandura asserts that individuals learn and develop
third person. A Bowenian therapist would also be gradually through continual observation of models’
aware of the possibility of being triangled into the behavior.
couple’s relationship, and would take steps to To understand development in couples and
detriangulate themselves if needed. families, it is critical to consider multiple domains
of development, including physical, cognitive,
emotional, and social. Although specific develop-
References mental theories focus primarily on one or two
domains (e.g., Piaget’s cognitive developmental
Kerr, M. E., & Bowen, M. (1988). Family evaluation. theory focuses on cognitive development,
New York: Norton.
Erikson’s psychosocial theory emphasizes social
Landers, A. L., Patton, R., & Reynolds, M. (2016). Family
therapy glossary. Alexandria: American Association and emotional development), most contemporary
for Marriage and Family Therapy. theorists recognize the interdependent nature of
748 Development in Couples and Families
these domains. Moreover, current developmental within the family (Broderick 1993). In other
theorists acknowledge the complex interplay of words, the family is viewed as one whole unit,
genes and environment in their influence on which is greater than the sum of the individual
human development. Family and couple function- parts within the family. The family is comprised of
ing across these domains is also shaped by broad subsystems (e.g., spousal, sibling) that operate
cultural, historical, and social contexts. Systems with rules, roles, routines, rituals, and interaction
theories (e.g., Bronfenbrenner’s ecological sys- patterns, which may evolve across the course of
tems theory) emphasize these contextual influ- development. Routines around childrearing and
ences on development. rules set for children are adjusted when children
Developmentalists consider the impact of early reach adolescence, for example.
experiences on subsequent development across the The family system is maintained by bound-
life span. Attachment theorists highlight the impor- aries, which are reflected in rules for membership
tance of early experiences within the parent-child within systems, information transmission, and
relationship. A secure attachment formed in the first appropriate conduct. Boundaries range on a con-
few years of life can increase the probability of tinuum from diffuse (i.e., open to outside influ-
subsequent adaptive socio-emotional functioning ence) to rigid (i.e., closed to outside influence).
and relationship success during adolescence and Relatedly, family functioning can be measured by
adulthood. Relatedly, the timing of life events is a its level of cohesion (i.e., emotional bonding) and
key consideration for the field of human develop- flexibility. Enmeshment (i.e., overly involved, lit-
ment. Sensitive periods in development reflect times tle individuation) and disengagement (i.e., under-
during which couples and families may be particu- involved, distant) represent the extreme poles of
larly susceptible to the effects of certain events. cohesion, which are maladaptive for family func-
A couple’s divorce, for example, can lead to a tioning. Because of the push toward greater auton-
range of salient outcomes in children depending on omy and individuation during adolescence,
when it occurs. Finally, developmentalists study development may be hindered for teens in fami-
growth and change in couples and families through- lies characterized by enmeshment or rigidity.
out the life course. Although historically some the- Families manage their separateness and connect-
ories focused primarily on one period of edness by balancing centrifugal forces that divide
development (e.g., childhood is the focus of Freud’s members and centripetal forces that unite mem-
psychoanalytic theory), essentially all contempo- bers. Flexibility, or the amount of change allowed
rary developmentalists acknowledge that couples in leadership roles and relational rules, ranges
and families are not static, but rather evolve in from chaotic (i.e., excessive change) to rigid
their functioning until death. (i.e., little change permitted). Feedback loops reg-
ulate the family interactional patterns that reflect
cohesion, flexibility, and boundaries. Balance in
Prominent Associated Figures cohesion, flexibility, and boundaries is related to
adaptive family functioning across development.
Albert Bandura, John Bowlby, Urie Ecological Systems Theory. In his ecological
Bronfenbrenner, Erik Erikson, Sigmund Freud, systems theory, Bronfenbrenner proposed that
Jean Piaget, B.F. Skinner, Lev Vygotsky, John individuals and families can be understood only
B. Watson by examining the nested systems in which they
exist. Moving from proximal to distal systems of
influence are the microsystem, mesosystem, exo-
Description system, and macrosystem (Bronfenbrenner 1979).
The microsystem consists of individuals with
Systems Theories whom the individual and family come into direct
Family Systems Theory. Family systems theorists contact. Spouses, children, siblings, and peers are
underscore the interdependence of individuals key figures in the microsystem. The mesosystem
reflects the interactions that occur between the developmental task for families with adolescents.
microsystem elements. A supportive relationship Key developmental tasks for couples in middle
between a child’s school teacher and his or her adulthood include a renewed focus on the mar-
parents represents a powerful mesosystem influ- riage and maintaining ties with adult children.
ence on the child’s development. The exosystem Failure to complete developmental tasks does
includes factors that indirectly influence the indi- not guarantee future maladaptation, but may indi-
vidual’s and family’s development. A stress- cate that families are susceptible to societal disap-
intensive workplace environment that induces proval or challenges in subsequent tasks.
parental negative reactivity represents an exo- Social Role Theory. Social role theory stresses D
system influence on children’s and couple’s func- the roles that individuals, couples, and families
tioning. Finally, the macrosystem consists of fulfill throughout the life span. Roles refer to a set
cultural beliefs, values, and social norms. Chil- of behaviors that are carried out through role
dren raised in western parts of the world may be enactment. Across development, humans are
exposed to individualistic ideals, whereas those in socialized into an increasingly complex and
eastern areas may be raised to value collectivistic diverse set of roles, and these roles are thought
ideals. These values may affect couple and family to shape personality (Brim 1966; Parsons and
development as life expectancy increases and Bales 1955). Each role is associated with cultur-
families are faced with decisions on how to care ally driven expectations for appropriate conduct.
for their aging parents. Finally, each of these sys- A large number of roles or an intense level of
tems is affected by the chronosystem, which sig- role involvement can lead to role overload. Par-
nifies the element of time and related ents with four children may experience role over-
sociohistorical conditions. load, for example, from the demands of getting
Family Developmental Theory. Family devel- children ready for school, attending the children’s
opmental theorists propose a series of stages that extracurricular activities, and supporting children
families move through across the family life emotionally. Role conflict also impacts families
cycle. Within each stage, family interaction pat- when the demands or expectations of one role are
terns are guided by roles reflecting kinship posi- at odds with another. When a mother is asked to
tion and norms regarding cultural expectations for stay late at work and miss her daughter’s birthday,
appropriate behavior (Duvall and Miller 1984; role conflict has occurred. Role spillover threatens
Gerson 1995). Common roles within families are families when the demands of one role interfere
caring for children and supporting the family with the ability to successfully complete tasks
financially. The eight stages guiding family roles required of a separate role. Role spillover may
and norms are: married without children, child- occur when exhaustion from caring for an ill,
bearing families, families with preschool children, elderly parent reduces one’s productivity at
families with school-age children, families with work. Spousal support for partner’s involvement
adolescents, families launching children (first in work, however, can buffer the negative effects
child gone, last child still in home), middle years of these role strains and contribute to marital
(“empty nest” to retirement), and aging families satisfaction (Dreman 1997). Relatedly, couples
(retirement to death). These stages can be further who share in each other’s personal and economic
condensed into expansion (i.e., family growth due well-being experience less role overload and
to children) and contraction (i.e., family shrinkage higher marital satisfaction (Helms et al. 2010).
when children leave the home). Family Stress Theory. Family stress theorists
Developmental tasks accompany each stage of emphasize the role that stress plays in family
family development. Successful task completion functioning and adaptation. Stress is understood
during the family’s current stage bodes well for as a source of tension that can deplete family’s
successful task completion in the following stage. resources and result in family crisis. The ABC-X
Working with adolescents as they strive for model of family stress and crisis is used to con-
increased autonomy represents a salient ceptualize the effects of stress on the family (Boss
2002; Weber 2011). The model’s “A” represents and family functioning. Excessive use, however,
the stressor, which can be a normative, expected is thought to promote and reflect pathology.
life event or nonnormative, unforeseen event. Psychosocial Theory. In his psychosocial the-
Normative stressors include events such as con- ory of development, Erikson argued that develop-
flicts over family roles or adjustment to an ado- ment occurs across the life span in a series of eight
lescent’s push for autonomy, whereas psychosocial crises (Erikson 1963). Within each
nonnormative stressors include the death of a developmental period exists a psychosocial crisis,
child or a sudden, traumatic disabling accident. where the, timing is determined by nature and
Stressors may be internal or external to the family, difficulty determined by societal pressures and
brief or prolonged, ambiguous or clear. The prior crisis resolution. The crises are the follow-
family’s individual and collective ability to cope ing: infancy – trust vs. mistrust; toddlerhood –
with the stressor is represented by the model’s autonomy vs. shame and doubt; early childhood
“B.” Coping resources may include economic – initiative vs. guilt; middle childhood – industry
means, material goods, relational skills, or psy- vs. inferiority; adolescence – identity vs. identity
chological attributes. The model’s “C” represents confusion; young adulthood – intimacy vs. isola-
the family’s shared understanding or constructed tion; middle adulthood – generativity vs. stagna-
meaning assigned to the stressor. Taken together, tion; and late adulthood – integrity vs. despair.
the stressor, the family’s perception of the stress- Across childhood, families and teachers are criti-
ful event, and their use of resources to manage the cal for successful crisis resolution. By providing
stressor determine the family’s response and level responsive, consistent care, for example, parents
of crisis, which is signified by the model’s X. support infants in developing a sense of trust.
Stressors are not inherently problematic for family Couples in young adulthood are tasked with
functioning, but can threaten family functioning if achieving commitment and intimacy in order to
accumulation leads to family resource depletion. resolve the crisis of intimacy versus isolation. The
resolution of each crisis results in a related virtue
Psychodynamic Theories (e.g., hope results from resolving trust
Psychoanalytic Theory. Freud’s psychoanalytic or vs. mistrust) and affects subsequent attempts to
psychosexual theory of development stresses that resolve future crises across development.
unconscious processes and innate biological Attachment Theory. Attachments represent an
drives are primarily responsible for human behav- enduring emotional tie that persist across time and
ior and the development of personality (Freud space and influence subsequent relationships
1920). Personalities are comprised of three major (Bowlby 1969). During the first year of life,
components: the id (i.e., the unconscious, pleasure infants develop an attachment style, which reflects
principle), the ego (i.e., conscious, reality princi- the pattern of caregiving received. Consistent,
ple), and the superego (i.e., the conscience, per- responsive, and sensitive parenting promote a
fection principle). Freud proposed that humans secure attachment style (Ainsworth et al. 1978).
derive pleasure or gratification as they progress A secure attachment is reflected in positive affec-
through a series of four stages across childhood tive sharing with the caregiver, using the caregiver
and adolescence: infancy – oral, toddlerhood – as a secure base from which to explore, and draw-
anal, childhood – latency, and adolescence – ing on the caregiver as a source of comfort during
phallic. When these pleasures are not fulfilled, times of distress. Unresponsive or rejecting care-
psychological problems may ensue. Threats to giving predicts insecure-avoidant attachment
one’s personality are dealt with by what Freud styles, which are characterized by little affective
termed defense mechanisms. These include sharing and avoidance of the caregiver when dis-
repression, displacement, sublimation, denial, tressed. Inconsistent or interfering parenting leads
regression, projection, reaction formation, and to insecure-resistant or ambivalent attachments,
rationalization. Minimal or moderate reliance on characterized by little exploration of the environ-
defense mechanisms can promote adaptive couple ment, and both clingy and resistant behavior with
caregiver when distressed. Dissociative, frighten- of a stimulus and negative refers to the removal of
ing, or frightened parenting behaviors lead to a a stimulus. Negative reinforcement, then, indi-
disorganized-disoriented attachment style. This cates the removal of an aversive stimulus, which
attachment is characterized by a breakdown in then increases the likelihood of a behavior to
strategy for seeking support when distressed. recur. Daily, children learn from parents through
The attachment relationship becomes the foun- rewards and punishments. Praise and positive
dation for the individual’s internal working model attention serve as effective positive reinforce-
or mental representation of the world, others, self, ments, while removal of attention and time-out
and relationships that guides one’s expectations serve as negative punishments. This learning is D
and behavior during social interactions. Internal also evident in couple functioning when bids for
working models of securely attached children are attention are met with positive responses, which
characterized by feelings of trust that their needs reinforces contact between partners.
will be met and that they are worthy of love. Social Cognitive Learning Theory. According
Children who are insecurely attached view them- to social cognitive learning theorists, develop-
selves as unworthy of love and believe that others ment is driven not only by reinforcements and
are unreliable and cannot be trusted (Ainsworth punishments, but also by observational learning
et al. 1978). These internal working models are (Bandura 1977). For learning to occur, the
manifested in adulthood within couples’ attach- observer must attend to the model’s behavior,
ment representations, which may be secure, store the behavior in memory, and have the phys-
dismissing, preoccupied, or unresolved (e.g., ical or mental capacity to imitate the behavior.
Hesse and Main 2006; Jacobvitz et al. 2006). Behaviors that are rewarded are particularly likely
to be imitated by the observer. Moreover, the
Learning and Cognitive Theories probability of imitating behaviors increases
Classical Conditioning. Classical conditioning when the observer identifies with the model.
refers to learning that occurs when associations This type of learning is evident in families as
are formed between a neutral, or unconditioned, children frequently imitate parents’ words and
stimulus and an conditioned stimulus. Over time, actions. Exposure to family violence, for example,
humans react to the neutral, unconditioned stimu- consistently predicts childhood aggression (e.g.,
lus with a conditioned, or learned, response Farver and Frosch 1996).
(Watson 1925). This type of learning was first Cognitive Developmental Theory. One of the
demonstrated in the case of “Little Albert,” a most influential theories of cognitive develop-
male child who eventually developed a fear of ment comes from Jean Piaget. Piaget proposed
white rats due to repeated, simultaneous presenta- that cognitive development occurs as children
tion of a white rat and a loud noise. Classical move through four stages: sensorimotor, pre-
conditioning is relevant for couple and family operational, concrete operational, and formal
development in a few respects. Such learning is operational (Piaget 1952; Piaget and Inhelder
useful in explaining the development of some 1958). During each stage, individuals make
phobias. Classical conditioning can also be seen sense of their world by interacting with the envi-
through the conditioning of infants that bond with ronment. In the sensorimotor stage, infants use
specific caregivers once the caregiver is consis- their developing senses of sight, touch, and hear-
tently associated with feelings of positivity. ing in concert with emerging muscular control to
Operant Conditioning. Operant conditioning interact with objects and learn about their social
refers to learning that occurs as a result of rein- world. The preoperational period of early child-
forcements and punishments. Reinforcements are hood can be characterized by the use of symbolic
events or rewards that increase the likelihood of a thought or mental representation (e.g., an under-
behavior recurring, whereas punishments are standing that words can be used to represent
aversive experiences that decrease that likelihood objects and ideas), egocentrism (i.e., failure to
(Skinner 1975). Positive refers to the presentation recognize other’s thoughts as separate from
one’s own), and illogical mental processes (e.g., mentioned theories in the section above can be
centration or focus on only one aspect of an object used on an individual basis to best serve the needs
or situation). During the concrete operational of each person – child, adolescent, adult, elder – as
stage, children ages 7–12 use logical mental oper- well as provide context to best conceptualize sys-
ations to solve concrete problems. Finally, in the temic issues within the family and community.
formal operational stage and beyond, adolescents’ According to Erikson’s psychosocial theory, for
cognitive understanding of their world is reflected example, a couple may be jointly facing a psycho-
in abstract thought and reasoning. In each stage of social crisis of generativity versus stagnation during
cognitive development, children’s understanding the middle adulthood stage. While one partner may
of the world is organized mentally into schemes. feel successful balancing productivity at work and
Equilibrium is achieved when children are able to giving back to society through raising children, the
effectively engage their environment with other partner may struggle and feel stagnant. This
existing mental schemes through the use of assim- conflict between partners who are in the same psy-
ilation. Accommodation occurs when changes in chosocial crisis, but tackling it differently, will
the environment require modifications to existing impact both the relationship and family unit. Fur-
schemes. thermore, an early adolescent child in this same
Sociocultural Theory. In his sociocultural the- family will face a threat of dissociation from the
ory of development, Vygotsky stressed the critical family if he or she is not able to overcome the
role of social interaction in learning and develop- psychosocial crisis of identity versus identity confu-
ment. By interacting with more skilled others sion. Though healthy peer interaction is vital to the
(e.g., parents, peers, teachers), elementary mental adolescent’s developmental process, a stable family
processes give way to higher mental functioning life and parents who model connection and personal
(Vygotsky 1926). This development occurs when competence are also critically important.
the skilled other works within the child’s zone of A systems framework, such as Bronfenbrenner’s
proximal development. The zone represents what ecological systems model, can also provide thera-
the child is capable of accomplishing when pists with a more holistic developmental under-
assisted by the skilled other. The skilled other standing of couples and families. The integrated,
works within the zone by scaffolding or providing multidimensional nested system model can be
moment-to-moment adjusted support based on the applied to explain bidirectional interactions between
child’s current needs. family members, as well as within and among com-
plex systems. While a couple or family operates as
its own multifaceted microsystem, it is heavily
Relevance to Couple and Family Therapy impacted by the mesosystem and exosystem (e.g.,
work, neighborhood, mass media, social welfare,
As is evident in the previous section, developmental and legal systems) as well as the interactions
theories offer complex and varied conceptual lenses among them. For example, a woman in her late
for understanding and working with couples and 60s who recently retired from her long-term employ-
families. In order to select a theory to serve as an ment position and moves to a new town faces a
appropriate framework, therapists must be skilled in multitude of changes. She is navigating a new finan-
recognizing physical, cognitive, and socio- cial management system, and changes in her work
emotional developmental patterns in their clients and neighborhood dynamics. Furthermore, the
and applying them in conjunction with therapeutic macrosystem gives a therapist an opportunity to
interventions. Life span developmental theories examine the attitudes and ideologies of the cou-
offer therapists an opportunity to gain a rich under- ple or family’s culture, while also incorporating
standing of clients because they provide important concepts of systemic power and privilege,
contextual information on each individual, as well and sociopolitical impact. The final system,
as a framework for working with the couple and chronosystem, provides a family with a better
family at the systemic level. The previously sense of generational differences that may exist
between parents and children. Therapists are reframing each one, set individual and mutually
uniquely positioned to help couples and families attainable goals, and build family resilience.
recognize how the complexity of their develop- Furthermore, social roles within the family
ment over the life span can impact their overall will be examined to discover role strain and
health and well-being. conflict generated by expectations and compet-
ing demands for each family member. For exam-
ple, Jennifer and Markus face recent additional
Clinical Example of Application roles (e.g., additional caregiving requirements),
of Theory in Couples and Families as well as role loss (e.g., loss of previous gen- D
eration) that may be contributing to the marital
Markus and Jennifer are a late-40s couple who have disengagement and parenting challenges.
been married for 18 years. They initially seek ther- Erikson’s psychosocial theory will be used to
apy for their two children: Nora, a 16-year-old high determine the impact each family member’s
school student, and Andrew, a 7-year-old elemen- developmental stage has on relationships and
tary school student. Nora presents as a highly anx- overall dynamic. Andrew may face the threat
ious, combative adolescent who has recently been of inertia, as evidenced by his externalizing
suspended from school for assaulting a classmate. behaviors, due to his sense of inferiority from
Andrew, who was adopted into the family 2 years his adoption transition. Nora’s psychosocial cri-
ago, is exhibiting regressive behavior, including sis involves a sense of alienation as she strug-
nighttime bed-wetting and frequent temper tan- gles to find her identity as an adolescent within a
trums. Markus and Jennifer attribute their children’s family in flux. Her dissociation from the family
recent externalizing behaviors to the death of is likely resulting in aggressive behaviors
the maternal grandmother who took on a role as an toward peers. Jennifer and Markus face a desire
afterschool caregiver while they worked in their to be productive at work, create meaningful
respective jobs. change in their community, and contribute to
Initial assessment with the couple indicates the next generation through parenting. Their
that the parents are struggling to cope with the role strain is contributing to a sense of stagna-
loss of Jennifer’s mother. Jennifer indicates she is tion given the multiple challenges and respon-
experiencing mild depression and both parents sibilities they must take on. Though each
acknowledge distancing in their marriage. Further individual presents with different crises, as a
data is collected from school counselors at family, they must also confront the consequence
Andrew and Nora’s schools, including discipline of relational interactions stemming from each
referrals and behavioral interventions. unique psychosocial stage. Furthermore, the
The therapist determines that whole family ther- ABC-X model of family stress and crisis can
apy is ideal given their immediate concern with their be applied to examine both normative develop-
children’s well-being, as well as a belief that recent mental stressors (e.g., adolescent’s search for
marital strain is due to acute grief and loss. There- identity; parents seeking work satisfaction) and
fore, a humanistic person-centered family therapy is nonnormative stressors (e.g., loss of their grand-
most appropriate, coupled with cognitive- mother and adoption of a child). Though there
behavioral interventions (CBT). Therapy goals are many strengths and coping resources within
include building empathy and family connected- the family, sessions focused on developing
ness, treating Nora’s anxiety and Jennifer’s mild healthy perceptions and collaborative working
depression, processing grief resulting from the loss mindsets to the stressors will be necessary.
of the grandmother, and providing CBT strategies This integrated therapeutic model allows the
and techniques aimed at decreasing disruptive family to consider developmental factors impacting
school behaviors. Cognitive, affective, and behav- their individual journeys, as well as the relational
ioral coping strategies will give the family the ability impact on the whole family. In conjunction with a
to redefine or reappraise situations by positively supportive, genuine person-centered approach and
754 Dialogical Practice in Couple and Family Therapy
proactive cognitive-behavioral interventions, a Dreman, S. (1997). The family on the threshold of the 21st
developmental framework both supports and century: Trends and implications. Mahwah: Erlbaum.
Duvall, E., & Miller, B. (1984). Marriage and family
strengthens the therapeutic outcomes. development (6th ed.). New York: Harper Row.
Erikson, E. H. (1963). Childhood and society. New York:
Norton.
Farver, J. M., & Frosch, D. L. (1996). L.A. stories: Aggres-
Cross-References sion is preschoolers’ spontaneous narratives after the
riots of 1992. Child Development, 67, 19–32.
▶ Attachment Theory Freud, S. (1920). A general introduction to psychoanalysis.
▶ Boundary Making in Couple and Family New York: Horace Liveright.
Gerson, R. (1995). The family life cycle: Phases, stages,
Therapy and crises. In R. H. Mikesell, D. D. Lusterman, &
▶ Bowlby, John S. H. McDaniel (Eds.), Integrating family therapy:
▶ Bronfenbrenner, Urie Handbook of family psychology and systems theory.
▶ Circle of Security: “Understanding Attachment Worcester: American Psychological Association.
Helms, H. M., Walls, J. K., Crouter, A. C., & McHale,
in Couples and Families” S. M. (2010). Provider role attitudes, marital satisfac-
▶ Exosystem in Family Systems Theory tion, role overload, and housework: A dyadic approach.
▶ Family Life Cycle Journal of Family Psychology, 24, 568–577.
▶ Family Rules Hesse, E., & Main, M. (2006). Frightened, threatening, and
dissociative parental behavior in low-risk samples:
▶ Feedback in Family Systems Theory Description, discussion, and interpretations. Develop-
▶ Learning Theory in Couple and Family ment and Psychopathology, 18, 309–343.
Therapy Jacobvitz, D., Leon, K., & Hazen, N. (2006). Does expec-
▶ Mesosystems in Family Systems Theory tant mothers’ unresolved trauma predict frightened/
frightening maternal behavior? Risk and protective fac-
▶ Modeling in Couple and Family Therapy tors. Development and Psychopathology, 18, 363–379.
▶ Negative Reinforcement in Social Learning Parsons, T., & Bales, R. F. (Eds.). (1955). Family sociali-
Theory zation and interaction process. Glencoe: Free Press.
▶ Operant Conditioning in Couple and Family Piaget, J. (1952). The origins of intelligence in children.
New York: International Universities Press.
Therapy Piaget, J., & Inhelder, B. (1958). The growth of logical
▶ Positive Reinforcement in Couples and thinking from childhood to adolescence. In A. Parsons
Families & S. Seagrin (Trans.). New York: Basic Books.
▶ Psychoanalytic Couple and Family Therapy Skinner, B. F. (1975). The steep and thorny road to a
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▶ Social Learning Theory Vygotsky, L. S. (1926). Educational psychology. Delray
▶ System in Family Systems Theory Beach: St. Lucie Press.
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References
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S. (1978). Patterns of attachment: A psychological
study of the strange situation. Hillsdale: Erlbaum.
Bandura, A. (1977). Social learning theory. Englewood
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Cliffs: Prentice Hall. and Family Therapy
Boss, P. (2002). Family stress management: A contextual
approach (2nd ed.). Thousand Oaks: Sage. Peter Rober
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment.
KU Leuven, Leuven, Belgium
Brim, O. G. (1966). Socialization through the life cycle. In
O. G. Brim & S. Wheeler (Eds.), Socialization after
childhood: Two essays. New York: Wiley. In recent years interest the concept of dialogue has
Broderick, C. B. (1993). Understanding family process:
Basics of family systems theory. Newbury Park: Sage.
bloomed in the family therapy field (e.g., Seikkula
Bronfenbrenner, U. (1979). The ecology of human devel- and Olson 2003; Rober 2005b). Guilfoyle (2003)
opment. Cambridge, MA: Harvard University Press. even identifies a distinct kind of family therapy
Dialogical Practice in Couple and Family Therapy 755
that he calls dialogical therapy. This approach Bakhtin’s Influence

grew out of the collaborative postmodern family
therapy (e.g., Anderson 1997) and social con- Bakhtin used the concept dialogue in two distinct
structionist thinking (e.g., Gergen 1999), and ways: as a prescriptive concept and as a descrip-
came to bloom mostly in Europe where the post- tive concept (Stewart et al. 2004). When dialogue
modernist and social constructionist ideas devel- is used as a prescriptive concept the term refers to
oped further through revolutionary new practices a particular kind of interaction of a high quality.
in the mental health field (e.g., Andersen 1987; Dialogue then is the opposite of monologue. As
Seikkula et al. 1995), as well as through Stewart, Zediker & Black (2004) write, in pre- D
Russian/European philosophical inspirations. scriptive approaches to dialogue ethics is central.
Especially, the influence of the Russian philoso- In the marital and family therapy (MFT) liter-
pher Mikhail Bakhtin brought about a new and ature, the concept of dialogue is often used in such
enriching perspective in the field that especially in a prescriptive way, highlighting the ethical ideal,
Europe became particularly influential. and defining dialogue as the opposite of mono-
logue. However, Bakhtin did not always describe
dialogue as a prescriptive concept. In fact, first
and foremost he presented dialogue as a descrip-
Dialogue tive concept. In that way, the concept focuses on
epistemological and existential issues as it high-
A lot of philosophers have written about dia- lights the dialogical nature of all human interac-
logue. Maurice Merleau-Ponty’s phenomeno- tion: All language is dialogic.
logical critique of dualism, for instance, In the context of this descriptive view of dia-
positions individuals as body subjects in a dialogue, Stewart et al. (2004) highlight the impor-
logical relationship with the surrounding world, tance of tensionality in Bakhtin’s work.
with knowledge that is inherent in their actions According to Bakhtin, in an ongoing conversa-
(Merleau-Ponty 1962). Martin Buber’s philoso- tion, there is a continuous dynamic tension
phy of dialogue (Buber 1923, 1947) is also well between the monological and the dialogical func-
known. He distinguished the I–Thou relation- tions, of which Bakhtin scholar Caryl Emerson
ship from the more objectifying I–It relationship writes: “Dialogue is by no means a safe or secure
and described how the growth of a person is not relation. Yes, a ‘thou’ is always potentially there,
accomplished in relation to oneself, but instead but it is exceptionally fragile; the ‘I’ must create it
in the dialogical relation between the I and the (and be created by it) in a simultaneously mutual
other. Also other thinkers have devoted part of gesture, over and over again, and it comes with no
their work to the theme of dialogue (e.g., special authority or promise of constancy. . . .
Levinas 1969; Gadamer 1988; Derrida 1978; Imbalance is the norm” (Emerson 1997,
Habermas 1971). p. 229–230). According to Bakhtin, life is an
The approach of dialogical practice in the ongoing, unfinalizable dialogue continually tak-
field of marital and family therapy leans heavily ing place (Morson and Emerson 1990). The word
on the work of the Russian thinkers Bakhtin unfinalizable is essential in Bakhtin’s thinking
(1981, 1984, 1986) and Volosinov (1973). (Bakhtin 1981). He does not characterize dialogue
Also the work of psychologist John Shotter as an endpoint of a process, as something peaceful
needs to be mentioned here. He evolved from or at rest. Instead he calls dialogic life “agitated
being one of the originators of social and cacophonous” (Bakhtin 1981, p. 344) and he
constructionism (e.g., Shotter 1993), through describes dialogue as a never-ending, tension-
his study of the ideas of Bakhtin and Volosinov filled process.
to become one of the most influential thinkers in Besides unfinalizability, also responsivity is
the approach of dialogical practices (e.g., an important characteristic of dialogue. Utter-
Shotter 2000, 2011, 2015, 2016). ances in dialogue are other-oriented (Bakhtin
1986). Whatever is said is always said in Responsive Understanding

response to what has been said before (Linell
2009). Also, everything that is said is an invita- According to Shotter (2015), being a dialogical
tion to the others to respond. In that way, the therapist means moving toward a responsive
participants shape the dialogue together. This understanding. He refers to Bakhtin (1986), in
responsivity is selective (Linell 2009) in the whose view understanding is essentially an active,
sense that it is impossible to respond to every- responsive process: “. . . all real and integral
thing, but that there is always a selection in our understanding is actively responsive, and consti-
responses: to some things we respond, while tutes nothing other that the initial preparatory
other things we neglect. stage of a response” (Bakhtin 1986, p. 69). In his
This responsiveness is also embodied and view, real understanding does not duplicate some
spontaneous (Shotter 2015): when we are in knowledge of the speaker in the mind of the
dialogue we are immersed in an intra-mingling listener. Dialogical understanding creates
flow of unfolding activities, in which our bod- something new.
ies spontaneously respond to the other, antici- Bakhtin (1986) stresses the importance of
pating what will come next, and attuning to the outsideness in dialogical understanding.
context that we are for each other as we are in According to him to see the world through the
dialogue together. In such an attunement, there other’s eyes “is a necessary part of the process of
is no law, no certainty, and no control over what understanding,” and then he adds: “but if it were
will happen or what will be said or done. In the only aspect of this understanding, it would
order to characterize what is needed for such merely be duplication and would not entail any-
an attuned dialogue to unfold, Bakhtin (1993) thing new or enriching” (Bakhtin 1986, p. 7).
uses the word “faithfulness,” and he writes that Bakhtin is not satisfied with understanding that
he refers to the word as it is used “in reference is mere duplication, because according to him, the
to love and marriage” (Bakhtin 1993, p. 38). speaker “does not expect passive understanding
What he means is that we have to be “in touch that, so to speak, only duplicates his own idea in
with the other” (Shotter 2015), not only in our someone else’s mind” (Bakhtin 1986, p. 69).
words but in our being in the moment: we are Instead, the speaker is oriented toward a respon-
oriented toward each other, recognizing the sive, creative understanding. That is why, “[I]n
other as other and as like-me (“you are unique, order to understand, it is immensely important
but because you are unique you are like me, for the person who understands to be located
because I am unique too”). In fact we continu- outside the object of his creative understanding”
ally reassure each other that we are not alone, (Bakhtin 1986, p. 7, italics in original). Bakhtin
that we will not hurt each other, and that we will (1986) even calls outsideness “the most powerful
take our responsibility (response-ability) in factor in understanding” (p. 7), because only
playing our part in the unfolding flow of going outsideness – or a position of difference – creates
on together (Shotter 2011). It is clear that these the possibility for an enriching dialogue.
ethical-philosophical ideas about dialogue
inspired by Bakhtin’s thinking come very
close to the work of philosophers like Martin The Dialogical Self
Buber, Emmanuel Levinas, and Jacques Der-
rida. Not surprisingly, these philosophers have Bakhtin (1984, 1986) has developed a model of
had a big impact of the work of dialogical selfhood in terms of inner speech. He describes
family therapists (e.g., Brown 2015; Larner the self as a complex inner dialogue: “often a
2004, 2015; De Haene and Rober 2016; Rober struggle of discrepant voices with each other,
2017). voices (and words) speaking from different
positions and invested with different degrees and Goolishian 1992), to a focus on the process of
kinds of authority” (Morson and Emerson 1990, embodied attunement of the therapist with the
p. 218). According to Bakhtin, the self resembles family members (e.g., Seikkula et al., 2015) and
the novel that, like the self, is a complex dialogue on the therapist as an active, responsive partner in
of various voices and ways of speaking, each that process (e.g., Rober 2005a).
incorporating a special sense of the world While Mikhail Bakhtin is the most important
(Morson and Emerson 1990). Bakhtin studied philosophical inspiration for the dialogical
novels of Dostoyevski, Tolstoy, Cervantes, and approach in family therapy, arguably the Norwe-
many others. In his book on Dostoyevski gian psychiatrist Tom Andersen is the most D
(Bakhtin 1984) he, for instance, studied the inner important inspiration as practitioner. While he is
conversation of the student Raskolnikov from best known as the pioneer who invented the
Crime and Punishment. Raskolnikov receives a reflecting team (Andersen 1987), his influence
letter from his mother, and he understands that his and inspiration is much broader than that (e.g.,
sister’s marriage is her sacrifice done on his Andersen 1991, 1992, 1995, 1997). For instance,
behalf. In his inner speech the voices of his he stressed the importance of reflecting processes
mother, his sister, and other people mentioned in (Andersen, 1991), he was one of the first to talk
the letter can be heard, as well as the voices of about inner dialogues (Andersen, 1991), and
anonymous others. Raskolnikov’s inner speech about the wisdom of feelings, the body and
consists of a polyphonic symphony of replies breathing (Andersen, 1995).
and reactions to the voices of others that he has
recently heard, read, or imagined (Bakhtin 1984). Open Dialogue
The dialogical self is a concept that refers to the Tom Andersen’s ideas about reflective processes
self as a polyphony of discrete inner voices that are some of the main sources of inspiration for the
are positioned in time and space and that are in Open Dialogue approach (Seikkula 2007a, b).
interaction with each other: one voice evoking a The vast influence of Bakhtin on the Open Dia-
second voice, siding with a third one, and while logue approach is evidenced by the Open Dia-
suppressing a fourth. In the dialogical self, like in logue principles: tolerance of uncertainty,
a dialogue between persons, besides the multiplic- dialogism, and polyphony (Seikkula and Olson
ity, the tensionality is a crucial characteristic: 2003). Tolerance of uncertainty implies the estab-
without tension, polyphony is impossible, as all lishment of a safe and trustworthy therapeutic
meaningful differences would be wiped away and context, because only in such a context partici-
only monologue would remain. pants to the dialogue can tolerate uncertainty.
Dialogism refers to the contribution of the lis-
tener: The listener’s active presence is what dis-
Dialogical Practices in Marital and tinguishes dialogue from monologue (Bakhtin
Family Therapy 1986). Polyphony (Bakhtin 1984) means that
every conversational participant is invited to
The ideas of Bakhtin (1981, 1984, 1986) opened enter the dialogue in his/her own way. Listening
new perspectives in the field of family therapy as is encouraged and all voices are given room to
they have proven to be very useful to catch some- exist.
thing of the complexity of multiactor dialogues The Open Dialogue approach refers to a spe-
(Seikkula et al. 2012). Furthermore, his ideas cific and elaborate way to deal with acute psy-
helped to reconceptualize the therapeutic relation- chotic crises that has been used for years in
ship: under the influence of his ideas the emphasis Kerapudas hospital in Tornio, Western-Lapland.
of dialogical therapists moved away from a focus Swift intervention of the team and working with
on the client as the expert (Anderson and the social network of the patient are central in this
approach (Seikkula et al. 1995; Seikkula 2002). the concept of not-knowing (Anderson and
The Open Dialogue approach is characterized by Goolishian 1992): The therapist takes a not-
open meetings with the psychotic patient, the knowing stance in the session, not because of the
family, the network, and the therapeutic profes- emptiness of his/her inner conversation, but
sionals. All present are encouraged to give – in because of its polyphonic richness. Being not-
their own language – their perspective on what is knowing as a therapist, then, means avoiding
happening in the family. These different voices monological inner conversations and staying in
are listened to by the professionals. The questions touch with the complexity, the uncertainty, and
of the professionals are as open as possible, to the unfinalizabilty that is the result of the multi-
give the family maximum opportunity to say plicity of voices in the therapist’s inner conversa-
what they want to say (Seikkula and Olson tions (Rober 2005a).
2003). The psychotic patient is involved as much
as possible. Psychosis is understood as a language Dialogical Practices in Practice
in crisis (Seikkula and Arnkill 2006). A psychotic While it is clear that the dialogical approach in
crisis is an unbearable experience for which one family therapy is deeply rooted in philosophical
has no words. In dealing with a psychotic crisis, refection (Bakhtin, Buber, etc.); first and foremost
the therapeutic team invites everyone who is it is a practice that has inspired more and more
involved in the crisis to speak. By listening to therapists in Europe (e.g., Bertrando 2015;
everyone, and by exploring the meanings, it is Davolo and Fruggeri 2016), but also in the USA
intended to create a common language for the (e.g., Olson 2015), and in Australia (e.g., Hartman
experience embodied otherwise just inside the and De Courcey 2015; Mikes-Liu 2015).
psychotic voice and in hallucinations. Unlike a The No Kids in the Middle approach of the
traditional medical view that focuses on interven- Dutch psychologist Justine van Lawick and her
tion in order to cure, in an Open Dialogue team is a good example of the way in which
approach an attempt is made to create a common dialogical philosophical ideas can be put to prac-
language that allows to clarify the meanings of tice. In Holland, like in a lot of Western countries,
one’s suffering in the social network (Seikkula high-conflict divorces, complicated by endless
and Olson 2003). The focus in these meetings is legal disputes, are very complex challenges for
not in the first place on assessment or on control- family therapists. The suffering of the children,
ling the symptoms, but rather on strengthening the silenced by the violence between their
adult side of the patient, breaking the isolation in demonizing parents, is evident for the therapist,
the system, and reestablishing network connec- while attempts to help the children to deal with
tions (Seikkula and Arnkill 2006). their silent suffering often prove to be futile in
light of the pervasiveness of the parent’s conflict.
The Therapist’s Inner Dialogue This often left the practitioner feeling impotent
Bakhtin’s ideas about the inner dialogue contrib- and exhausted. Inspired by dialogical ideas, as
ute to a richer understanding of the therapist’s part well as by ideas about other family therapy
in the therapeutic dialogue. Already in the 1980s, approaches, van Lawick and her team developed
Anderson and Goolishian (1988) had stated a group treatment protocol in which both parents
that the therapist maintains a dialogue with and children are involved (van Lawick and Visser
him/herself, which is the starting point of his/her 2015; van Lawick 2016). Keeping the children in
questions. Later, this dialogue has been called the mind throughout the whole process, the therapeu-
therapist’s inner conversation (e.g., Rober 2005a, tic work is done in a group of parents, a group of
2008). The concept of the therapist’s inner con- children and in network meetings, as well as in the
versation refers to Bakhtin’s view of the self as a dialogues between these groups. While the usual
polyphony of inner voices (Bakhtin 1981, 1984; family therapeutic approaches often collide with
Voloshinov 1973). This view of the therapist’s self the distrust, violence, and defensiveness of the
as a polyphony can be seen as an enrichment of parents, seriously complicating the development
of a safe therapeutic alliance, this approach can Wilson 2013) and propose alternatives that are
sometimes create a context for these families in more compassionate and humane. It is no sur-
which the voices of the children are heard and in prise that the dialogical approach in family ther-
which the children’s well-being becomes the par- apy resonates with the Recovery Movement
ents’ first concern again. (Mikes-Liu 2015), as well as with voices that
are critical toward diagnosis and medication as
Dialogical Practices and the Process of potentially colonizing and objectifying mental
Humanization health practices (e.g., Good 2001).
Central to the dialogical orientation in family D
therapy is the Bakhtin inspired responsiveness to
others, and the process of attunement in which Conclusion
therapist and client are immersed. As Wilson
(2015) writes “. . .the practitioner is not only curi- The dialogical family therapist can be described as
ous about another person’s life but openly an active, responsive therapist oriented toward the
engages as a human being who is also a profes- different voices present in the family, as well as
sional helper” (p. 7). The practitioner’s focus is on toward his/her own inner voices. The therapist –
inviting and valuing the contribution of as many in the midst of complexity and from within
voices (inner and outer) as possible in the dialog- the unique never before encountered circum-
ical flow of the session. In essence, this means that stances (Shotter 2011) – actively explores and
we have to see the others as subjects and try to tries to develop dialogical contexts in which not
avoid to see them as objects. only the loud and obvious voices in the family are
This comes close to Buber’s philosophy of invited but also the suppressed, the faint,
the dialogue. According to Buber we are essen- and the brittle voices (e.g., the voices of
tially beings-with-others (Buber 1923, 1947). psychotics, of children, of refugees, of criminals) –
He made a distinction between the I-Thou rela- often nonverbal or silent – are listened and
tionship and the more utilitarian I-It relation- responded to.
ship, in which the other is related to as if Dialogue is not seen as a forum of agreement
he/she were an object. Interestingly, for Buber and serenity, in which kindness and gentleness
the I is different in the I-Thou relationship than rule (and suppress other voices). Instead, besides
in the I-It relationship: our being depends on the kind and gentle voices, also voices of anger, con-
way we relate to others. In recognizing the other fusion, fear, doubt and disappointment are invited
as a subject, we become a subject (Buber 1923). and welcomed by the therapist. While some of
If we want to relate with our clients in an I-Thou these voices might be challenging or hard to
relationship, this means that we have to meet our bear, the therapist tries to be open and curious.
clients as suffering persons in search of mean- He/she tolerates his/her confusion (Shotter 2016)
ing, compassion, and relief, instead of as and uncertainty (Seikkula and Olson 2003) and
malfunctioning machines in need of repair dwells in the tension of the session, humanizing
(Frankl 1970). This view, of course, is in tension each voice through a relationship of being-with or
with the diagnose-and-fix ideology that rules in what Shotter calls “withness thinking” (Shotter
the mental health field in the USA, as well as in 2011). In dialogical family therapy, tension
Europe and Australia. For Wilson (2015), between the different voices in the family session
inspired by the Brazilian educationalist Paulo is to be expected; rather than avoided. The aim is
Freire, this means that dialogical therapy not to solve the tension between the different
involves a process of humanization, in which voices but rather to find ways in which the family
oppressive practices are countered. Further- can tolerate their polyphony, their (internal and
more, it means that we as practitioners have external) ambivalences and their uncertainty, and
the responsibility to question and critique in which they can better deal with the tensions and
taken for granted practices in our field (e.g., go on together with their lives.
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family therapy with refugee families. In I. McCarthy &
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Shotter, J. (1993). Conversational realities. London: Sage.
Shotter, J. (2000). From within our lives together: Wittgen- Dr. Diamond is a Professor Emeritus at the Uni-
stein, Bakhtin, and Voloshinov and the shift to a partic- versity of Pennsylvania School of Medicine and
ipatory stance in understanding understanding. In Associate Professor at Drexel University, with
L. Holzman & J. Morss (Eds.), Postmodern psycholo-
gies, societal practice and political life (pp. 100–129). over 75 publications on psychotherapy outcome,
London: Routledge. process, and dissemination research. He is a
762 Diamond, Guy
licensed clinical psychologist in Pennsylvania Treatment (CSAT), and several private foundations.
with a strong, externally funded NIH research At CFIS, Dr. Diamond has mainly focused on the
track record supporting the family-based treat- development, testing, and dissemination of
ment of adolescent suicide, depression, and sub- Attachment-Based Family Therapy (ABFT) for
stance abuse with multicultural families. depressed and suicidal youth. To assist with recruit-
ment for his psychotherapy research, Dr. Diamond
developed the Behavioral health Screen (BHS). The
Career BHS is a web-based screening tool, initially used in
primary care settings. Use of this tool has since
Dr. Diamond received his doctorate in clinical expanded to emergency rooms, colleges, schools,
psychology at the California School of Profes- crisis teams, outpatient mental health programs, and
sional Psychology. During graduate school, he residential treatment facilities. Due to these research
laid the foundation of his career in two psycho- efforts, ABFT enjoys the distinction of being an
therapy research programs. First, he worked with empirically supported treatment on SAMHSA’s
Guillermo Bernal on a NIDA-funded study to test NREPP website. In addition, CFIS now hosts the
the efficacy of Contextual Family Therapy for international ABFT Training Program, directed by
heroin addicts in a methadone clinic. Then he Dr. Suzanne Levy, PhD. The program has trained
worked with Howard Liddle for many years, at over 1000 clinicians in 10 countries and continues
the UCSF Medical Center. Dr. Diamond was a to expand and research these dissemination efforts.
therapist and researcher on Dr. Liddle’s first Based on his life’s professional work,
NIDA-funded clinical trial to test multi- Dr. Diamond recently received the distinguished
dimensional family therapy. He also served as research career award from the American Foun-
the first editorial assistant, helping to found the dation for Suicide Prevention. As the director of
Journal of Family Psychology. CFIS, he aims to provide training for the next
For his predoctoral internship, Dr. Diamond generation of empirically informed family therapy
worked on the inpatient unit, at the Philadelphia researchers to bring further support to family ther-
Child Guidance Center. He worked under the apy practices.
tutelage of Joe Micucci, Wayne Jones, John
Brendler, and Jon Sarget, all second-generation
clinicians who had trained with Minuchin, Cross-References
Montalvo, and Haley. Dr. Diamond then procured
a two-year postdoctoral position in the Depart- ▶ Attachment-Based Family Therapy
ment of Psychiatry at the University of Pennsyl- ▶ Depression in Couple and Family Therapy
vania, one of the great meccas of psychotherapy ▶ Liddle, Howard
research. In 1996, he became an assistant profes- ▶ Montalvo, Braulio
sor in psychiatry where he worked for 22 years, ▶ Multidimensional Family Therapy
and first established the Center for Family Inter-
vention Science (CFIS). The center recently
moved to Drexel University. References
Diamond, G. S., & Josephson, A. (2005). Family-based

treatment research: A 10-year update. Journal of the
Contributions American Academy of Child and Adolescent Psychia-
try, 44(9), 872–887. https://doi.org/10.1097/01.
CFIS has received funding from the National Insti- chi.0000169010.96783.4e.
tute of Mental Health (NIMH), Substance Abuse Diamond, G. S., Levy, S. A., Bevans, K. B., Fein, J. A.,
Wintersteen, M. B., Tien, A., & Creed, T. A. (2010a).
and Mental Health Services Administration
Development, validation, and utility of the web-based
(SAMSHA), Centers for Disease Control and Pre- behavioral health screen for adolescents in ambulatory
vention (CDC), Center for Substance Abuse care. Pediatrics, 126, 163–170. PMID: 20566613.
Dickerson, Victoria 763
Diamond, G. S., Wintersteen, M. B., Brown, G., Diamond, of family therapy. In that brief episode that opened
G. M., Gallop, R., Shelef, K., & Levy, S. (2010b). the workshop, clinical and teaching skills came
Attachment-based family therapy for suicidal adoles-
cents: A randomized controlled trial. Journal of the together, drawing workshop participants into sig-
American Academy of Child and Adolescent Psychia- nificant questions about the relational ethics of our
try, 49(2), 122–131. https://doi.org/10.1097/00004583- practice.
201002000-00006. The workshop episode was at a narrative ther-
Attachment based family therapy for depressed adoles- apy conference, and it is as a narrative therapist,
cents. Washington, DC: American Psychological writer, and teacher that Vicki Dickerson has made
Association. perhaps her most significant contributions to fam- D
Diamond, G., Russon, J., & Levy, S. (2016). Attachment- ily therapy. Her teaching encourages therapists to
based family therapy: A review of the empirical sup-
port. Family Process, 55(3), 595–610. https://doi.org/ develop fine attunement to the lives and experi-
10.1111/famp.12241. ences of clients, by demonstrating ways of doing
so herself.
Dickerson, Victoria Career
Kathie Crocket Vicki Dickerson obtained her master’s degree

Faculty of Education, University of Waikato, in counseling psychology from Santa Clara
Hamilton, Waikato, New Zealand University. She studied family therapy at the
Mental Research Institute in Palo Alto and at
the University of Calgary, receiving her doctoral
Name degree in clinical psychology from Pacific
Graduate School. She has directed two training
Victoria (Vicki) Dickerson, PhD centers, the Bill Wilson Centre, affiliated with
Santa Clara University, and the Bay Area Fam-
ily Therapy Training Centre, and has held
Introduction adjunct positions at Santa Clara University,
Palo Alto University, University of San
A Conference Story: On a very warm summer Francisco, San Jose State University, Johns
afternoon in Adelaide, Australia, an audience Hopkins University, and Mercy College,
gathers for a conference workshop. Vicki NY. She teaches professional workshops in the
Dickerson’s co-presenter stands at the lectern USA and internationally.
and asks, “Has anyone seen Vicki Dickerson?” Growing Narrative Therapy: Shaped by the
The audience looks around. Again, he asks, dominant systems and strategic models of the
“Has anyone seen . . .?” We look around, a little 1970s–1980s, Vicki Dickerson practiced from a
puzzled. “Who you looking for?” calls a voice – strong interest in relational patterns in couple and
casual, off-hand – from the back of the audito- family relationships (Zimmerman and Dickerson
rium. The person comes forward, cap angled 1993a, b). She took an early interest in the devel-
down over eyes, hands in pockets, a swaggering opments that became known as narrative therapy,
slouch – the stance of a young person who knows learning from the work of antipodeans Michael
how to do cool. White and David Epston (1990). In clinical prac-
Catching the audience unawares, the workshop tice, and beyond, Vicki Dickerson drew creatively
was already under way. Vicki Dickerson, the cool on narrative therapy developments, for example,
dude with the cap, had indeed showed up, in writing a popular book for young women,
demonstrating – through voice tone, posture, offering a self-help, deconstructive perspective
cap, movement, gesture – a refined attunement to on the gender stories that shape (young) women’s
the lived experience of a young person, a client lives (Dickerson and Fine 2004).
764 Dickerson, Victoria
As narrative therapy evolved in the North Cross-References

American context, Vicki Dickerson shared emerg-
ing ideas and practices with others, teaching both ▶ Absent But Implicit in Narrative Couple and
new and experienced therapists. She wrote a Family Therapy
number of journal articles, along with a ▶ Combs, Gene
co-authored overview book on narrative therapy ▶ Deconstruction in Narrative Couple and Family
(Dickerson 2004; Dickerson and Zimmerman Therapy
1992, 1996; Zimmerman and Dickerson 1994, ▶ Deconstructive Listening in Couple and Family
1996a, b). Continuing to engage in and lead pro- Therapy
fessional community, Vicki Dickerson has more ▶ Epston, David
recently opened publishing opportunities for other ▶ Externalizing in Narrative Therapy with Cou-
family therapists, for example, in her role as ples and Families
Social Media/Communications Strategist for the ▶ Freedman, Jill
Family Process Institute, where she organizes and ▶ Narrative Couple Therapy
moderates a Webinar Series with the Ackerman ▶ Narrative Family Therapy
Institute. ▶ Poststructuralism in Couple and Family
Through her strong professional networks and Therapy
committed editorial work, Vicki Dickerson has ▶ Problem-Saturated Stories in Narrative Couple
encouraged other narrative therapists to publish, and Family Therapy
fostering international connections: for example, ▶ Weingarten, Kaethe
in special sections in Family Process (Dickerson ▶ White, Michael
2009; see Lebow 2016) and in an edited Springer
Brief (Dickerson 2016). Just as the Adelaide con-
ference workshop episode, re-told above, References
involved creativity in a demonstration of the clin-
Dickerson, V. (2004). Young women struggling for an
ical skill she was teaching, Vicki Dickerson’s identity. Family Process, 43(3), 337–348.
contributions to the professional community live Dickerson, V. (2007). Remembering the future: Situating
out the ethics and relational emphasis of clinical oneself in a constantly evolving field. Journal of Sys-
practice. temic Therapies, 26(1), 23–37.
Dickerson, V. (2009). Introduction to the special section.
While she has specialized in narrative prac- Continuing narrative ideas and practices: Drawing
tices, Vicki Dickerson has remained multi-lingual, Inspiration from the legacy of Michael White. Family
through tracing lines of evolution in the wider Process, 48(3), 315–318.
context of family therapy (Dickerson 2010, Dickerson, V. (2010). Positioning oneself within an epis-
temology: Refining our thinking about integrative
2014); in leading e-technology developments; approaches. Family Process, 49(3), 349–368.
and particularly through professional governance. Dickerson, V. (2014). The advance of poststructuralism
Her many contributions to the American Family and its influence on family therapy. Family Process,
Therapy Academy were recognized with the Life- 53(3), 404–414.
Dickerson, V. (Ed.). (2016). Poststructuralism and narra-
time Achievement Award in 2012, and she is tive thinking in family therapy. New York: Springer.
currently 2017–2019 President. She continues to Dickerson, V., & Fine, C. (2004). Who cares what you’re
contribute actively to the Family Process Institute supposed to do?: Breaking the rules to get what you
Board. want in love, life, and work. New York: Perigee.
Dickerson, V., & Zimmerman, J. (1992). Families with
The words Vicki Dickerson chose for the title adolescents: Escaping problem lifestyles. Family
of a 2007 article – “Remembering the future: Process, 31(4), 341–353.
Situating oneself in a constantly evolving Dickerson, V., & Zimmerman, J. L. (1996). Myths, mis-
field” – serve as an apt description of her own conceptions, and a word or two about politics. Journal
of Systemic Therapies, 15(1), 79–88.
contributions to the field of family therapy, over Lebow, J. (2016). Narrative and poststructural perspectives in
time, through practice, teaching, publication, pro- couple and family therapy. Family Process, 55(2),
fessional networking, and governance. 191–194.
Differentiation of Self in Bowen Family Systems Theory 765
White, M., & Epston, D. (1990). Narrative means to Description

therapeutic ends. New York: Norton.
Zimmerman, J., & Dickerson, V. (1993a). Bringing forth
the restraining influence of pattern in couples therapy. Bowen theory is regarded as a comprehensive
In S. Gilligan & R. Price (Eds.), Therapeutic conver- explanation of psychological health and function-
sations (pp. 197–214). New York: Norton. ing from a systemic and multigenerational per-
Zimmerman, J., & Dickerson, V. (1993b). Separating spective (Titelman 2014). Bowen theory
couples from restraining patterns and the relationship
discourse that supports them. Journal of Marital and provides a rich foundation for the field of family
Family Therapy, 19(4), 403–413. therapy that renders it distinct from individual
Zimmerman, J., & Dickerson, V. (1994). Using a narrative theories. Its central construct, differentiation of D
metaphor: Implications for theory and clinical practice. self, reflects the development of mature and
Zimmerman, J., & Dickerson, V. (1996a). If problems healthy functioning, and is defined as the extent
talked: Narrative therapy in action. New York: to which one is able to balance (a) intellectual and
Guilford Press. emotional functioning, and (b) intimacy and
Zimmerman, J., & Dickerson, V. (1996b). Situating this autonomy in one’s significant relationships
special issue on narrative. Journal of Systemic
Therapies, 15(1), 1–4. (Bowen 1978). On an intrapsychic level, differen-
tiation refers to the ability to distinguish thoughts
from feelings and to choose between being guided
by one’s intellect or one’s emotions (Bowen 1976,
1978). Greater differentiation allows one to feel
Differentiation of Self in strong affect or engage in logical reasoning when
Bowen Family Systems Theory circumstances dictate, and to take “I-Positions” or
to maintain a clear sense of self in the midst of
Maria Schweer-Collins1, Brianna Mintz2 and turmoil or shifting, uncertain circumstances. Dif-
Eizabeth A. Skowron3 ferentiation involves a capacity to manage one’s
1
Prevention Science, University of Oregon, own anxieties and to resist reacting to anxiety in
Eugene, OR, USA others. Bowen theorized that more highly differ-
2
Counseling Psychology, University of Oregon, entiated individuals can mindfully engage the
Eugene, OR, USA thinking and feelings systems that govern behav-
3
Counseling Psychology and Prevention Science, ior. Thus, even under periods of stress or conflict,
University of Oregon, Prevention Science more differentiated individuals can thoughtfully
Institute, Eugene, OR, USA self-reflect and act in accordance with their own
values and convictions while remaining open to
the ideas of others. In contrast, less differentiation
Introduction is characterized by emotional reactivity and the
tendency to make snap decisions on the basis of
Differentiation of self is a fundamental concept in what “feels” right (Bowen 1976, 1978). Less dif-
Bowen’s family systems theory. In Bowen theory, ferentiated individuals live in a “feeling-
families are conceptualized as emotional units and dominated world” where autonomic reactivity
individual functioning is thought to be best under- determines behavior. Thus, undifferentiation is
stood in the context of relationship processes within thought to reflect “fusion” of intellect and
nuclear and multigenerational family systems emotion.
(Bowen 1976, 1978; Titelman 2014). Bowen recog- On an interpersonal level, Bowen theorized that
nized that human behavior is influenced and shaped differentiation reflects a dialectical balance between
by the fundamental need for both autonomy/self- two fundamental life forces: autonomy/indepen-
determination and connection in relationships, and dence and togetherness/connection with others
he conceptualized heterogeneity in the functioning (Bowen 1976, 1978; Titelman 2014). More differ-
of individuals and systems along a continuum of entiated persons can be a “self” in their significant
health in terms of differentiation of self. relationships without experiencing fears of being
766 Differentiation of Self in Bowen Family Systems Theory
abandoned or excluded, and can achieve emotional Further, a growing body of research is supporting
intimacy in relationships without concerns of losing the cross-cultural relevance of differentiation of
a sense of oneself or of feeling smothered. Thus, self as a construct that is associated with psycho-
greater differentiation permits greater independence logical health and maturity among individuals
while allowing for intimate contact, and enables one from diverse ethnic/racial groups in the USA
to maintain connections with those who disagree or (Titelman 2014).
hold different opinions and resist use of emotional According to Bowen (1976, 1978), individuals
distancing to maintain a sense of self (Kerr and are thought to gravitate toward partners function-
Bowen 1988). According to Bowen, as humans ing at similar levels of differentiation, and enter
evolved to live within larger social groups, we romantic relationships with differentiation levels
developed increasing sensitivities to social cues that have been laid down in their own families of
such as acceptance, approval, and belonging in origin over generations. At the outset of a roman-
order to maintain connection and proximity with tic relationship, each individual typically puts his
the group, and thus survive (Kerr and Bowen or her best foot forward, and acts in ways that he
1988; Noone and Papero 2015). However, these or she believes the other would like them to be
evolutionary forces for “togetherness” at times com- (Kerr 1988). This type of self-presentation
promise one’s ability to be a self, and lead to fusion involves what Bowen (1976) termed “pseudo-
or emotional cutoff (Kerr and Bowen 1988). Less self,” or pretend self, originally developed in the
differentiated individuals tend to engage in emo- family of origin, and shaped through emotional
tional cutoff to calm or stabilize self during periods pressure on individual members to enact roles – as
of high stress or anxiety (Schnarch 1998; Skowron stronger or weaker, boisterous or retiring, more or
and Friedlander 1998). Individuals who engage in less capable or attractive – in order to maintain
emotional fusion hold few beliefs and convictions, harmony in the family system (Bowen 1978; Kerr
tend to be either dogmatic or compliant, and seek and Bowen 1988). Greater prevalence of pseudo-
out acceptance, approval, and belonging above all self in one’s family of origin, in turn, leads to
other goals (Bowen 1976, 1978). Energy is spent greater problems in differentiating a self, and
keeping harmony in relationships or avoiding inti- more borrowing or trading of “self” in intimate
macy altogether, so there is less space to pursue life- relationships (Bowen 1978).
directed goals. In contrast, emotional cutoff is per- Some borrowing and trading of “self” is typ-
sonified by the reactive emotional distancer, who ically seen in the early stages of romantic rela-
may appear isolated from others and display an tionships, and it is not necessarily harmful in
exaggerated façade of independence. Note that small doses. In healthy, flexible romantic rela-
both the fused person who experiences separation tionships such exchanges are brief (Kerr 1988).
as threatening and the emotionally cutoff person However, when the anxiety in the system
who finds intimacy overwhelming are each poorly exceeds the capacity to bind it, less differenti-
differentiated. ated couples are thought to rely more heavily on
According to Bowen theory, levels of differen- borrowing and trading of self to maintain stabil-
tiation are stable across generations and have a ity (Kerr and Bowen 1988). Spouses who have
number of important health consequences for experienced greater difficulty differentiating a
individual and relationship functioning. Empirical self in their families of origin tend to pass more
research has found that adults with greater levels “pseudo-self” back and forth between them.
of differentiation of self report fewer psychologi- This borrowing and trading of self is thought
cal symptoms and physical health problems to account for artificial increases and decreases
(Titelman 2014). Children of more differentiated observable in spousal functioning. That is, a
parents displayed more pro-social behavior, better more functional-appearing partner may acquire
cognitive functioning, higher self-esteem, and “self” at the expense of the adaptive partner,
less anxiety and aggression relative to children who gives up “self” (Bowen 1978; Kerr and
of less differentiated parents (Titelman 2014). Bowen 1988).
Differentiation of Self in Bowen Family Systems Theory 767
Relevance to Couple and Family Therapy assist the client in identifying this predictable
change-back response from the system, and to
According to Bowen family systems theory, dif- coach the client to utilize strategies to push for
ferentiation of self is considered fundamental to growth in spite of homeostatic forces in the sys-
long-term emotional maturity, and intimacy and tem (McGoldrick and Carter 2001).
mutuality in romantic relationships. Many clients Therapists who elect to work on ‘differentiat-
present to therapy with symptoms that they attri- ing a self’ in their own family systems are thought
bute entirely to individual factors (e.g., I am to be more capable of assisting their clients with
depressed) or environmental factors (e.g., I am their differentiation efforts (Kerr and Bowen D
unhappy with my job), and Bowen family thera- 1988). More differentiated therapists can maintain
pists incorporate information about the client’s emotional objectivity while engaging with a client
level of differentiation and family relational pro- and their family emotional system. When engag-
cesses to determine how they may contribute to or ing with members of a couple in conflict, differ-
inadvertently maintain the presenting problem. entiated therapists manage their emotional
Couples in committed relationships tend to reactivity in the face of heightened emotional
express differentiation problems in one of four intensity or cutoff in sessions. For a therapist,
ways: through marital conflict, emotional distanc- efforts to raise one’s own level of differentiation
ing or cutoff, dysfunction in a spouse, or dysfunc- are thought to be essential to avoid therapeutic
tion in a child (Bowen 1978; Kerr and Bowen mishaps driven by emotional reactivity to the
1988). Each of these mechanisms is thought to client system (e.g., seeing villains and victims in
bind or manage anxiety in the system. A client the family; jumping in to fix problems or change
might exhibit lower differentiation in subtler the topic when anxiety is high; McGoldrick and
ways. Instead of completely cutting off from fam- Carter 2001; Nichols 1987).
ily members, the client might actively avoid
connecting in relationships by engaging in avoid-
ance behaviors. Alternatively, the client might Clinical Case Example
become emotionally overinvolved in the lives of
their loved ones. Louisa, a middle-class 34-year-old married
Family therapists informed by Bowen theory woman, presented in therapy with symptoms of
will focus on strengthening client differentiation depression and stress. She reported that she had
of self by coaching individuals to develop solid recently returned to the workplace full-time after
self in the context of their nuclear and extended spending the past 3 years at home following the
families (McGoldrick and Carter 2001). The first birth of her first child. She expressed feeling easily
step involves coaching clients to become curious overwhelmed, and experiencing sadness, tearful-
and engaged in understanding the emotional pro- ness, and difficulty sleeping. She also felt confused
cesses within their family system (McGoldrick and angry that her partner had not taken on more
and Carter 2001). In Bowen therapy, the majority responsibility in the home during this transition.
of therapeutic change takes place outside of the During the first 3 years of their son’s life, Louisa
therapy room while clients engage with their part- had assumed a role as the primary caregiver and
ner, parents and extended family members, and household manager. Louisa stated that she had
their children (Kerr 1988; Nichols 1987). Thera- taken those roles by choice, and that even when
pists assist their clients in planning authentic, her husband offered to share responsibility, she felt
person-to-person contact with family members. that he was often too tired or too stressed to be both
Individuals undertaking concerted efforts to attentive at home with her and their son, and pro-
change will very often face resistance and a ductive at work. She noted feeling ashamed of her
“change-back” response from others to remain in struggles in handling the transition from staying
old, predictable role(s) and continue old automatic home to her new role as a working mother. When
behaviors (Kerr 1988). It is the therapist’s task to the therapist probed, Louisa reported she had not
768 Differentiation of Self in Bowen Family Systems Theory
shared her struggles with anyone, including her their son’s life, Louisa, an over-functioner, had
husband, whom she felt was too stressed by a taken on more responsibility in the home as her
recent increase in his job responsibilities to burden. husband experienced heightened stress at work.
Initial sessions focused on gathering relevant As anxiety in the system heighted, Louisa fell into
information about the presenting concerns. The cli- a pattern of being both primary house manager
ent and therapist discussed other stressful times in and parent. Now that Louisa was back at work
Louisa’s marriage, how family responsibilities are full-time, the couple was unable to manage in this
shared in the relationship, and their communication state of over- and under-functioning.
patterns. As information was gathered around the Family therapy that focuses on strengthening
couple’s timeline of major life events (births, deaths, differentiation of self levels involves mobilizing
illnesses, job transitions, and moves), it became clients to accept personal responsibility and make
apparent that as Louisa’s husband experienced the changes in self that are necessary to bring
work-related stressors, Louisa also felt more anxious one’s actions in line with one’s values. Louisa
about her responsibilities and therefore automati- was coached to thoughtfully plan ways to step
cally responded to her husband’s stress by feeling back from over-functioning in the relationship,
a need to protect her husband and over-manage at and to take more of an “I-position” in sharing
home. This pattern of emotional reactivity is char- her needs and desires in her marriage. These ses-
acteristic of partners with lower levels of differenti- sions included strategizing new ways for Louisa
ation where there is less emotional maturity, and less to make small steps toward becoming more auton-
ability to thoughtfully choose their actions. omous from and more connected with her hus-
Information gathered in a family diagram band through open communication and
revealed that Louisa’s parents engaged in signifi- expression of vulnerability. Louisa was able to
cant marital conflict marked by volatile verbal share her needs with her husband and was clearer
fights, sometimes ending with Louisa’s mother in defining what were and were not her responsi-
leaving the home for a few days. During those bilities. She was coached to plan for her own
times Louisa took care of household responsibil- emotional reactions to relinquishing control over
ities and “held things together.” As therapy pro- household tasks and to the possibility that her
gressed, Louisa developed an awareness of her husband may also have resistance to new roles
hesitancy to express herself in her marriage and and responsibilities. Together, she and her hus-
her fear of conflict. She explored her beliefs about band created a more equitable division of house-
being abandoned as a potential consequence of work and parenting responsibilities. These
conflict, which stemmed from family-of-origin changes opened up room for Louisa’s husband to
patterns of emotional cutoff. The first focus of enter the relationship and contribute to both the
coaching was to assist Louisa in becoming aware household and co-parenting. She reported that her
of her automatic tendency to avoid any hint of husband felt more included and no longer seemed
conflict, and to coach her to take an “I- Position” to be pulling away. Louisa felt less overburdened
in her relationship by managing her anxiety, and and less anxious as a result.
thoughtfully and calmly sharing her needs and
experience with her partner. As Louisa became
less emotionally reactive and communicated her Cross-References
needs more directly, she found herself more able
to consider her husband’s experience as well, and ▶ Bowen Family Systems Therapy with Couples
gained greater understanding of his tendency to ▶ Bowen Family Systems Therapy with Families
withdraw. Louisa noticed, for example, that he ▶ Emotional Cutoff in Bowen Family Systems
often seemed to feel left out of nighttime rituals Theory
with their son. Unknowingly, Louisa and her hus- ▶ Family of Origin
band had been engaging in the borrowing and ▶ Marital Fusion in Couples
trading of self-in-relation. In the early years of ▶ Triangles in Bowen Family Therapy
Directives in Couple and Family Therapy 769
References natural for a parent to direct a child or a friend to

make a suggestion to a friend who is experiencing
Bowen, M. (1976). Theory in the practice of psychother- a problem or concern. It is natural for therapists, at
apy. In P. J. Guerin Jr. (Ed.), Family therapy: Theory
least at times, to do the same – to give a directive.
and practice (pp. 42–90). New York: Gardner Press.
Bowen, M. (1978). Family therapy in clinical practice. Directives in therapy range from mundane things,
New York: Jason Aronson. like “Why don’t you sit by the table, so you will
Kerr, M. W. (1988, September). Chronic anxiety and defin- have a place to put your coffee,” to the structuring
ing a self. The Atlantic Monthly, 9, 35–58.
of an enactment, such as “Talk with your partner
Kerr, M. E., & Bowen, M. (1988). Family evaluation: An
about how you see this,” to the suggestion of what D
approach based on Bowen Theory. New York: W. W.
Norton. clients do between sessions, for example, “Each
McGoldrick, M., & Carter, B. (2001). Advances in time you begin to escalate to raised voices,
coaching: Family therapy with one person. Journal of
I would like you to take what we call a time out.”
Nichols, M. P. (1987). The self in the system: Expanding A directive is one of three basic speech acts in
the limits of family therapy. New York: Brunner/Mazel. therapy. A therapist can ask a question, make a
Noone, R. J., & Papero, D. V. (Eds.). (2015). The family statement, or give a directive (Breunlin et al.
emotional system: An integrative concept for theory,
1992). As a class of speech in therapy, a directive
science, and practice. Lanham: Lexington Books.
Schnarch, D. (1998). Passionate Marriage. New York: is very broadly defined and includes all of the
W. W. Norton. examples provided above. This entry, however,
Skowron, E. A., & Friedlander, M. L. (1998). The differ- will discuss a more circumscribed definition of
entiation of self inventory: Development and initial
directive, excluding in-session directives such as
validation. Journal of Counseling Psychology, 45,
235–256. enactments and focusing specifically on directives
Titelman, P. (Ed.). (2014). Differentiation of self: Bowen as suggestions given by therapists for clients to do
family systems theory perspectives. New York: something between sessions. Directives include
Routledge.
both specific things that therapists ask clients to
do and plans that are developed more collabora-
tively within the therapeutic conversation.
Directives in Couple and
Family Therapy
William P. Russell
The Family Institute at Northwestern University, Although asking clients to do something between
Evanston, IL, USA sessions is currently a common practice in the
fields of psychotherapy and couple and family
therapy, early psychoanalytic and psychodynamic
Name of the Strategy or Intervention models were organized primarily around the pro-
cess of developing insight and not typically
Directive focused on prescribing particular changes in
behavior. Similarly, nondirective models such as
the client-centered approach (Rogers 1951) did
Synonyms not feature directives as a significant part of prac-
tice. Behavior therapy (Wolpe 1969), behavioral
Experiment; Homework; Task couples therapy (Jacobson and Margolin 1979),
strategic family therapy (Haley 1976), structural
family therapy (Minuchin 1974), and task-
Introduction centered casework (Reid and Epstein 1972) were
largely responsible for the introduction and pro-
The act of suggesting what someone should do liferation of a more directive therapy that includes
would seem to be as old as the human species. It is specific plans that clients implement between
770 Directives in Couple and Family Therapy
sessions. Over the years, the practice of directing a directives (homework), and their theoretical ori-
client to execute a plan, do “homework,” or try an entation (cognitive behavioral, experiential, post-
“experiment” has made its way into eclectic, inte- modern, psychodynamic, systemic) has not been
grative, and model-specific practice. Thus, no found to distinguish the frequency of usage
particular theoretical frameworks own the practice (Datilio et al. 2011).
of giving directives, though such frameworks may The transtheoretical model and alliance theory
influence both the role of directives in therapy and inform the current-day approach to using direc-
the form those directives take. tives. The transtheoretical model specifies stages
Within the field of couple and family therapy, of change and suggests that clients will not do
Haley’s (1976) problem-solving approach pro- things that they are not ready to do. Thus, thera-
vided an early articulation of how to formulate pists are encouraged to assess readiness to change
and provide directives. Haley distinguished and intervene to help clients develop motivations
straightforward directives which represented for change before expecting clients to take direct
what the therapist wanted the family to do, as action (Prochaska et al. 1992). Alliance theory
well as indirect (paradoxical) directives which suggests that the therapeutic alliance is built by
prescribed that the family continue the problem aligning tasks (including directives) to fit the
in some way, an outcome the therapist did not goals established by the client (Pinsof 1994).
actually want. The latter approach depends on Attempts to get clients to do things they do not
the family resisting the directive and thus improv- want to do will challenge or damage the alliance
ing or solving the problem. The ultimate goal of which, in turn, will limit therapeutic progress and
both types of interventions was to modify the possibly lead clients to drop out of therapy.
sequences of behavior and interaction that com-
prise or maintain the problem. Although influen-
tial in its emphasis on changing sequences of Rationale for the Strategy or
interaction to solve problems, Haley’s approach Intervention
to directives is out of step with current, more
collaborative patterns of practice in that it put the Kazantzis and Lampropoulos (2002) in a review
therapist in charge of changing families and often and synthesis of the research on homework in
fostered a secret therapeutic agenda. Some individual psychotherapy concluded that there is
approaches to couple and family therapy, such as sufficient evidence that homework assignments
integrative systemic therapy (Pinsof et al. in improve therapy outcomes and that compliance
press), explicitly maintain Haley’s systemic goal with homework predicts outcome in therapy.
of modifying problem sequences but design tasks There is limited research on homework
in a collaborative manner that is sensitive to client (directives) in couple and family therapy, and its
feedback and carefully considers the role of effectiveness has not been systematically
cognition and emotion in the targeted sequences. investigated.
Encouraging behavior change by means of Although the use of directives has yet to be
enactment and directive is considered a common shown to improve therapy outcomes, clinical
factor in couple and family therapy (Sprenkle logic provides a compelling rationale for their
et al. 2009). Sprenkle (2002) found that empiri- use. Since relational therapy seeks to understand
cally validated relational therapies typically inter- and modify the patterns of interaction in client’s
vene to disrupt patterns of interaction. Cognitive- lives, why not ask clients to observe those patterns
behavioral couple therapy, emotionally focused and make changes in them? Asking clients to do
therapy, and internal family systems therapy all so extends the influence of therapy to the very
utilize cognitive, affective, and behavioral realm it purports to influence. Clients do not
interventions – including directives – to disrupt attend therapy to make changes in the therapy
relational patterns or cycles. More than half of office, they want things to change in their lives.
couple and family therapists have reported using Giving directives links the in-session work with
Directives in Couple and Family Therapy 771
the out-of-session work and keeps the therapy which the therapist and clients discuss courses of
alive between sessions, giving the message that action that may lead to a solution or improvement
clients are expected to actively engage in therapy in the clients’ presenting concerns.
and assume responsibility for making the changes Framing a directive as an experiment can
they seek. reduce the top-down associations with the word
Clients’ feedback on their experience with a “homework” and produce a win-win mindset that
directive provides important information about sees performance of the task as success and non-
their system. For example, clients may report performance as an opportunity to learn more
that they did not do the task because it did not about factors constraining the client system and D
feel natural or authentic to them. This helpful make decisions about how therapy will proceed.
feedback invites the therapist to pay more atten- Perhaps the most important preconditions for a
tion to how these clients feel about tasks and to directive are that it be clearly related to what
make a greater effort to ensure that the process of clients want to accomplish in therapy and that it
developing a directive is sufficiently collabora- be supported by a rationale that indicates the pos-
tive. Additionally, clients’ feedback on out-of- sible gain from its implementation. Why else
session tasks can provide data that helps the ther- would clients want to take it on? It should be
apist monitor progress toward the goals of ther- offered to the clients or co-constructed with
apy. This is illustrated by a therapist who them, paying careful attention to the therapeutic
encouraged a divorced father of two adult sons alliance and giving due consideration to whether
to take more responsibility for initiating time with the clients are on board with the task. This
them. The father agreed, and an action plan was includes attention to their cultural context, values
made and then monitored in subsequent sessions. and beliefs, financial limits, and fears or concerns
Over the next few months, as the father and sons they might have about the task. Thus, the therapist
reported increased time together and increased collaborates with clients to ascertain that the task
comfort with that time, the therapist interpreted is reasonably within their capacity and
this as progress toward one of the goals of therapy disposition.
(improved relationship between father and sons). As a directive is being designed or offered,
Given the clinical logic supporting the use of particular attention should be paid to establishing
directives and the widespread utilization of them clients’ commitment to it. Formulating a clear,
by couple and family therapists (Datilio et al. specific description of the task gives clients the
2011), it is reasonable to think that well- opportunity to understand what is involved with
formulated directives enhance the effectiveness it. Then the therapist can ask the clients to think
of therapy and it is appropriate to encourage the ahead about the task. Do they think they can do it?
scientific investigation of this hypothesis. Do they imagine any obstacles to its performance?
Do they have ideas about how they deal with the
obstacles? Do they anticipate any negative conse-
Description of the Strategy or quences from following the directive?
Intervention Some directives can be rehearsed during the
session. For others a careful description is suffi-
Directives may involve an established procedure cient. Written instructions can add clarity in some
or be specifically designed to address the particu- situations. The therapist can ask clients how on
lars of a client situation. As assessment tools, they board they are with a directive and may ask them
are used to learn more about clients’ presenting to rate how sure they are that they can and will do
concerns and how these concerns are embedded in the task. Formulating a directive, particularly one
the sequences of interactions that occur within the aimed at producing change, requires careful atten-
system. As interventions, directives are used to tion and discussion. Thus, it is important to allow
modify the sequences of interaction. These inter- sufficient time in session for design, review, and
ventions result from therapeutic conversation in commitment.
772 Directives in Couple and Family Therapy
An essential requirement for the use of direc- helpful, though Kim wondered if stopping the
tives is the therapist’s follow-up in the next ses- conflict would stop her from having her say.
sion. Follow-up is associated with compliance in The therapist suggested that there was a proce-
that the clients see that the therapist takes the tasks dure that could help them protect their relation-
seriously. In asking about the task, the therapist ship from high conflict and allow them to address
seeks to build the alliance and learn more about their issues and each have their say. Additionally,
the system. If clients executed the task, the thera- the therapist committed to make sure their issues
pist can emphasize their success and look for ways were addressed in session, as well. The therapist
to build on it. If clients partially did the task, the provided some psychoeducation on the effects of
therapist can highlight their good work, identify heightened conflict on communication and the
constraints they encountered, and ask if they need to be calm enough for effective communica-
would like to go further with it. If clients did not tion to occur. Then the therapist introduced a
do the task, the therapist maintains a curious, “time-out” procedure. The procedure was care-
respectful position and asks them what kept fully described and discussed, including stages
them from doing it. It is reasonable for the thera- of recognizing when to take a time-out (raised
pist to ask if they had second thoughts about voices, physiological cues), how to request it
whether the task was right for them and to empha- (acknowledgment that the other has important
size that it is important that the therapy find tasks things to say and respectful expression of own
that fit well for them. Therapist and clients collab- need to calm down), how to calm and self-assess
orate to decide whether to repeat, refine, or drop during the time-out, when to return to conversa-
the task. tion (agreed on one hour, unless not practical),
who initiates the return (the one who requested
it), and how to repair and resume the discussion
Case Example (each owning responsibility for their part in
escalating).
Kimberly (age 39) and Jason (age 41), a European At the therapist’s request, the couple practiced
American, heterosexual, cisgender married cou- the procedure in session. The therapist asked
ple, initiated therapy with concerns about their whether they anticipated any obstacles to the pro-
escalating conflicts. In the first session, the thera- cedure. None were noted so the therapist asked if
pist gathered information about the couple, they were ready to experiment with it at home.
inquired about the problem and related interac- Jason and Kim agreed to do so.
tional sequences, determined that there was no In the third session the therapist asked the
history or perceived risk of violence, and commu- couple to report on what they learned from the
nicated concern for their pain and struggle. In the experiment. Kim reported that during an argu-
second session the couple fell into a conflictual ment Jason stormed out of the room, stating that
interaction that escalated. The therapist let it con- he was taking a time-out. The therapist
tinue briefly in order to observe its pattern and acknowledged Kim’s frustration and Jason’s
then intervened to stop it, encouraging each party need for the time-out and then respectfully
to take a deep breath and calm themselves. Then explored what kept Jason from following the
the therapist asked a series of questions, the procedure. He stated that he waited too long to
answers to which indicated that the conflicts ask for the time-out. The rest of the session
rarely ever led to a resolution and typically left focused on helping them each identify the phys-
them feeling distant and angry. The therapist iological signs of escalation in order to recog-
stated that conflict can feel irresistible and that it nize better when to take a time-out. The whole
was impressive that they were able to stop it when procedure was reviewed and practiced. Then the
asked to do so. The therapist then asked if they therapist reemphasized the benefits of time-out
thought it would be helpful, if they could stop and asked if they would commit to try it again.
conflicts at home. They agreed that it would be Kim and Jason agreed to do so.
Discernment Counseling in Couple and Family Therapy 773
Cross-References Prochaska, J. O., DiClemente, C. C., & Norcross, J. C.

(1992). In search of how people change: Applications
to addictive behaviors. American Psychologist, 47,
▶ Behavioral Couple Therapy 1102–1114.
▶ Cognitive Behavioral Couple Therapy Reid, W., & Epstein, L. (1972). Task-centered casework.
▶ Cognitive-Behavioral Family Therapy New York: Columbia University Press.
▶ Emotionally Focused Couple Therapy Rogers, C. (1951). Client-centered therapy: Its current
practice, implications and theory. Boston: Houghton
▶ Enactment in Couple and Family Therapy Mifflin.
▶ Homework in Couple and Family Therapy Sprenkle, D. H. (Ed.). (2002). Effectiveness research in
▶ Integrative Problem-Centered Metaframeworks marriage and family therapy. Alexandria: The Ameri- D
▶ Integrative Systemic Therapy can Association for Marriage and Family Therapy.
Sprenkle, D., Davis, S., & Lebow, J. L. (2009). Common
▶ Internal Family Systems in Family Therapy factors in couple and family therapy: The overlooked
▶ Stages of Change in Couple and Family foundation for effective practice. New York: Guilford.
Therapy Wolpe, J. (1969). The practice of behavioral therapy.
▶ Strategic Family Therapy New York: Pergamon Press.
▶ Tasks in Couple and Family Therapy
Therapy Discernment Counseling in
References William J. Doherty

University of Minnesota, St. Paul, MN, USA
Breunlin, D. C., Schwartz, R., & Mac Kune-Karrer,
B. (1992). Metaframeworks: Transcending the
models of family therapy. San Francisco: Jossey- Introduction
Bass.
Datilio, F. M., Kazantzis, N., Shinkfield, G., & Carr, A. G.
(2011). A survey of homework use, experience of bar- Discernment counseling is a short-term inter-
riers to homework, and attitudes about homework vention for “mixed-agenda” couples where one
among couples and family therapists. Journal of Mar- partner is leaning out of the relationship and is
ital and Family Therapy, 37(2), 121–136.
Haley, J. (1976). Problem-solving therapy. San Francisco:
ambivalent about doing couples therapy, and the
Jossey-Bass. other partner wants to preserve the relationship
Jacobson, N. S., & Margolin, G. (1979). Marital therapy: and start couples therapy. Therapists often
Strategies based on social learning and behavior struggle with these couples because there is no
exchange principles (Wiley series on personality pro-
cesses). New York: Brunner/Mazel.
common commitment to therapy (Crosby 1989).
Kazantzis, N., & Lampropoulus, G. K. (2002). Reflecting Discernment counseling is a “pre-therapy” pro-
on homework in psychotherapy: What can we conclude tocol in which the goal is to help the spouses
from research and experience? Journal of Clinical Psy- develop greater clarity and confidence about a
chology/In Session: Psychotherapy in Practice, 58(5),
577–585.
direction for the marriage, based on a deeper
Minuchin, S. (1974). Families and family therapy. Cam- understanding of what’s happened to the mar-
bridge, MA: Harvard University Press. riage and each partner’s contributions to the
Pinsof, W. M. (1994). An integrative systems perspective problems. It is intended for couples who are
on the therapeutic alliance: Theoretical, clinical, and
research implications. In A. O. Horvath & L. S.
married or have otherwise made a permanent
Greenberg (Eds.), The working alliance: Theory, commitment. The focus is not whether to
research, and practice (pp. 173–195). Oxford, UK: divorce or stay married for life, but whether to
Wiley. divorce or carve out a 6-month period of all-out
Pinsof, W., Breunlin, D. C., Russell, W. P., Lebow, J.,
Rampage, C., & Chambers, A. (in press). Integrative
effort in couples therapy to restore the marriage
systemic therapy. Washington, DC: American Psycho- to health, with divorce off the table during
logical Association (APA) Books. that time.
774 Discernment Counseling in Couple and Family Therapy
Prominent Associated Figures threat of divorce makes it difficult to hold onto a

differentiated self, thereby leading to responses
William Doherty and Steven Harris like emotional reactivity, blaming the spouse,
and triangulating with third parties. Because in
these situations it is quite difficult to take respon-
Theoretical Framework sibility for one’s own feelings and actions, dis-
cernment counseling focuses on self-
The rationale for discernment counseling comes differentiation during an attachment crisis. Dis-
out of the clinical observation, backed by cernment counseling challenges each person to
research, that in divorce decision-making, couples accept responsibility for his/her contributions to
are generally not in the same place. There is usu- problems in the relationship and to take responsi-
ally an initiator of the divorce idea and a responder bility for deciding where to take the relationship.
who is reluctant to end the marriage (Vaughn
1986). When these mixed-agenda couples present
for couples therapy, they create a challenge that Populations in Focus
current models of couples therapy do not offer a
systematic way of addressing. Because each part- Discernment counseling is for couples where
ner is in a different emotional and motivational there has been a permanent commitment
stance, the major adaptation of discernment (married or otherwise) where one spouse is seri-
counseling is to work with each spouse separately, ously considering divorce and is ambivalent about
with orchestrated sharing with their partner, working on the relationship in couples therapy,
toward a resolution of the impasse. and the other spouse does not want to be divorced
Although discernment counseling developed and is open (or eager) to begin couples therapy.
as a pragmatic strategy to help couples who pre- Rule outs for discernment counseling are (a) when
sent a difficult clinical challenge, the approach is the leaning-out spouse has made an irrevocable
informed by adult attachment theory and differen- decision to divorce and just wants a venue to help
tiation theory. Adult attachment theory the other spouse accept that decision or (b) when
(Miculincer and Shaver 2012; Rholes and there is coercion to participate in discernment
Simpson 2006) offers a framework for under- counseling (such as legal threats) or risk of harm
standing human pair-bonding based on infant/ from violence.
caregiver attachment. The theory helps explain
the intense attachment and ambivalence among
people approaching divorce, reactions that may Strategies and Techniques
be heightened in people with anxious attachment.
Although the person not wanting the divorce The immediate decision to be “discerned” is framed
would presumably have greater attachment loss as three alternative paths rather than as a dichoto-
fears than the initiator of the divorce, adult attach- mous decision between staying together or divorc-
ment theory helps explain why it is common for ing. Path one is to stay the course – remain married
even the initiator to have intense positive and as things have been and not do couples therapy. Path
negative feelings about the idea of getting two is separation or divorce. Path three is an all-out
divorced (Weiss 1975). Discernment counseling commitment to 6 months of couples therapy (and
is a specialized way to work with attachment sometimes other services) with divorce off the table,
ambivalence in marriages on the brink of divorce. in order to see if the couple can make their relation-
According to Bowen’s Family Systems theory ship work in a healthy way for both of them. (It is
(Bowen and Kerr 2009), lack of differentiation of important to help clients understand that discern-
self (knowing and being able to asserts one’s ment counseling is not marital treatment; it is
thoughts and feelings) leads to emotional reactiv- designed to help them decide whether to try the
ity during crises. The anxiety connected to the treatment. A medical analogy often helps here:
Discernment Counseling in Couple and Family Therapy 775
couples therapy is like an antibiotic to see if an The discernment counselor works with each
infection can be cured, but the couple have not yet spouse differently. With the leaning-out spouse,
started it in discernment counseling and thus cannot the focus is on the decision-making process about
expect to have seen improvement in their problems.) the three paths, on personal contributions to the
After 6 months, both partners can evaluate whether problems, and on the potential benefits of couples
to make a permanent commitment to the relation- therapy. With the leaning-in spouse (who usually
ship or move toward divorce. If the couple chooses comes in wanting path three therapy), the focus is
path three, discernment counseling transitions to on “getting” the partner’s pain and complaints
couples therapy, usually with the same therapist about the relationship, on eliminating counterpro- D
who did the discernment counseling but possibly a ductive behavior such as pursuing or scolding the
referral therapist. partner for considering a divorce, and on using
Discernment counseling involves one to five this crisis as a wake-up call to learn about self and
sessions with a structure that differs from conjoint develop goals for personal change whether or not
couples therapy. As stated, although both partners the marriage survives.
come together for all sessions, the intensive work If the ultimate decision is to try to reconcile
occurs in separate individual conversations (with (path three), discernment counseling transitions
the other spouse out of the room), plus brief, to couples therapy. If the decision is to divorce
carefully orchestrated sharing of individual learn- (path 2), the discernment counselor offers assis-
ings when both people are together in the room. tance and referrals for the transition to divorce. If
There are no couple interventions (e.g., attempts the decision is to stay together without therapy
to facilitate connection and intimacy), and couples (path one), the discernment counselor offers to be
are encouraged not to expect improvements in a resource in the future.
their relationship problems during discernment In the discernment counseling protocol, the
counseling. The reasons for not doing couple first session is 2 h, and the subsequent sessions
therapy interventions are that there is no contract are an hour and a half each. (The first session is
for relationship improvement interventions and longer because of time needed to get background
that the therapy-ambivalent spouse may declare information.) Both parties decide each time
change attempts a failure if nothing is improving whether to have a subsequent discernment
at home. Couples are continually reminded that counseling session, up to a limit of five. This
discernment counseling is not couples therapy. approach is designed to invite buy-in from the
In addition to the three paths, the individual leaning-out spouse who has to explicitly agree to
conversations emphasize self-differentiation and continue in the discernment counseling process.
self-responsibility as means toward determining The flow of the sessions is as follows: couple time
the future of the relationship. This focus encour- at the beginning (very brief after the first session),
ages both partners to take responsibility for their followed by an individual conversation, a brief
part in the decline of the health of the relationship summary by each partner to the other of what
instead of focusing on the spouse’s failures. This that individual has learned in the individual time,
self-focus benefits them whether they decide to do then a conversation with the other spouse,
therapy or end the relationship. (One of the say- followed by that person’s summary, and ending
ings in discernment counseling is “You can’t with brief remarks by the discernment counselor.
divorce yourself.”) The other emphasis during
individual conversations is on helping clients see
their joint interactional patterns or “dances.” Research about Discernment Counseling
Understanding how they have co-created their
relationship problems helps both partners become Research on discernment counseling is in its
more open to seeing their own role and then early stages. Doherty et al. (2016) followed
sometimes become inclined to try path three cou- and evaluated outcomes for 100 consecutive
ples therapy. cases in their Minnesota Couples on the Brink
776 Discernment Counseling in Couple and Family Therapy
Project clinic. These were all couples on the worked hard on the relationship either and
brink of divorce, with at least one spouse con- thought his wife exaggerated the impact of his
sidering divorce and reluctant to do traditional depression on the marriage.
couples therapy. (Many had prior experience During three sessions of discernment counsel-
with couples therapy.) They were referred by ing, the discernment counselor worked with
lawyers (half had seen a lawyer), other thera- Jessica to understand her own pattern of over-
pists, and self-referrals (the largest category). functioning and how she had come to see herself
They were a highly distressed group, with mar- as his teacher (hence, critic). The counselor chal-
ital satisfaction scores well below published lenged Robert to acknowledge how his
averages for clinical couples entering couples underfunctioning and lack of self-responsibility
therapy research studies. for his depression (he had refrained from getting
The primary outcome evaluated was the three treatment for several years) was contributing to
paths. Findings showed that about half of the the marital problems – and encouraging her to
couples (47%) chose the reconciliation path, become his caretaker/critic that turned him off.
41% chose separation/divorce, and the remainder They were both able to share these insights with
opted for the status quo. Longer-term outcomes each other during the summary times in the ses-
were assessed an average of 2 years later. About sions, each being surprised with the openness of
42% had succeeded in reconciliation or were still the other to acknowledge personal contributions
working on reconciliation. A similar number to the problems.
(45%) had divorced or were in the divorce pro- A key moment in this case came when Jessica
cess, and a smaller subset (13%) was on hold, realized that that she did not want to give up on the
neither in crisis nor particularly satisfied with marriage without trying couples therapy (which
their situation. Summarized differently, a little they had never done before) and that even if it did
less than half of the couples who tried to reconcile not work out, she could benefit during the therapy
ended up divorced within an average of 2 years, from finding her voice and having better bound-
and most of the rest had reconciled. The authors aries in the marriage. They both developed per-
concluded that a real discernment process had sonal agendas for change (which included Robert
occurred, with couples choosing different paths returning to treatment for his depression) and
that suited them based on what they learned in embarked on couples therapy, with both on
discernment counseling. board for that work.
Case Example Cross-References
Jessica and Robert had been married for ▶ Attachment Theory

16 years and had three young children. Jessica ▶ Circle of Security: “Understanding Attachment
was considering divorce, she said, because of in Couples and Families”
years of emotional distance related to Robert’s ▶ Differentiation of Self in Bowen Family Sys-
chronic depression. She was burned out from tems Theory
trying to get him to function better as a husband ▶ Divorce in Couple and Family Therapy
and father. Although she was working on herself
in therapy, and believed she was making
changes, she was skeptical that couples therapy References
could improve the marriage. For his part, Robert
did not want a divorce and preferred to try cou- Bowen, M., & Kerr, M. E. (2009). Family evaluation. New
York: W. W. Norton.
ples therapy to see if the marriage could be made
Crosby, J. F. (Ed.). (1989). When one wants out and the
healthy again after years of his wife putting all other doesn’t: Doing therapy with polarized couples.
her energy into the kids. He admitted he had not New York: Brunner/Mazel.
Disengagement in Couples and Families 777
Doherty, W. J., Harris, S. M., & Wilde, J. L. (2016). Family Systems separates family interactions into
Discernment counseling for “mixed-agenda” couples. three dimensions: family cohesion, flexibility, and
https://doi.org/10.1111/jmft.12132. communication. Disengagement is rooted in the first
Miculincer, M., & Shaver, P. R. (2012). Adult attachment dimension – family cohesion or togetherness –
orientations and relationship processes. Journal of which is defined as “the emotional bonding that
Family Theory and Review, 4, 259–274. https://doi. family members have towards one another” (Olson
org/10.1111/j.1756-2589.2012.00142.
Rholes, W. S., & Simpson, W. J. (Eds.). (2006). Adult 2000, p. 145). The Circumplex Model assesses
attachment: Theory, research and clinical applications. togetherness on a continuum of four subgroups of
New York: Guilford. family cohesion: disengaged (very low), separated D
Vaughn, D. (1986). Uncoupling: How relationships come (low to moderate), connected (moderate to high),
apart. New York: Oxford University Press.
Weiss, R. W. (1975). Marital separation. New York: Basic. and enmeshed (very high). In addition to dividing
family cohesion into four subgroups, Olson et al.
(1979) developed various cohesion dimensions that
can further evaluate and distinguish the various
Disengagement in Couples levels of cohesion within a system. These dimen-
and Families sions include independence, time, coalitions, family
boundaries, space, friends, decision-making, and
Emily Wilensky1 and Adam R. Fisher1,2
1 interests and recreation.
Evanston, IL, USA
2
Description
Disengagement can be problematic – and even

Name of Concept
pathological – in some couple and family systems
(Olson et al. 1979). Members of these systems are
Disengagement in Couples and Families
highly independent and do not invest time
in one another. These systems do not have strong
bonds or coalitions, and often one member of
Introduction
the system is scapegoated. Regarding boundaries,
disengaged couples and families have open bound-
Disengagement is one of the classifications and
aries outside their system, closed boundaries within
dimensions of boundaries and connectedness in a
their system, and rigid boundaries between genera-
couple or family, and it is exhibited by low con-
tions of their system. Similarly, these systems max-
nectedness and high autonomy within the system
imize both physical and emotional space between
(Olson et al. 1979).
members and often remain distant from one another.
Disengaged couples and families interact with
friends individually rather than having a shared
Theoretical Context for Concept group of friends. Decisions are also made on an
individual basis, and interests and recreation are
In structural family therapy, Salvador Minuchin often pursued without family involvement and
classified family boundaries on a continuum from support.
disengaged or inappropriately rigid boundaries
to enmeshed or diffuse boundaries (Minuchin
1974). David Olson then adapted Minuchin’s clas- Application of Concept in Couple and
sification of boundaries to create a perspective used Family Therapy
in assessing and intervening with couple and family
systems based on how they interact with one Disengagement can present in a variety of ways
another. The Circumplex Model of Marital and in couple and family therapy. With couples, one
778 Divorce Ideation
partner can be disengaged, while the other attempts ▶ Russell, Candyce

to connect. In families, one parent, a parent dyad, ▶ Sprenkle, Douglas
or a child in the system can all be disengaged. Since ▶ Structural Family Therapy
disengaged systems are conflict avoidant, the ther-
apist’s job is to encourage dialogue between mem-
bers to work through differences and communicate References
each person’s needs rather than isolating from one
another (Nichols and Davis 2017). Minuchin, S. (1974). Families and family therapy.
Cambridge: Harvard University Press.
Concepts and methods. Boston: Pearson.
Olson, D. H. (2000). Circumplex model of marital and family
Clinical Example systems. Journal of Family Therapy, 22(2), 144–167.
Olson, D. H., Sprenkle, D. H., & Russell, C. S. (1979).
Alison and Logan started family therapy with Circumplex model of marital and family systems:
their 11-year-old daughter, Ilana, to address I. cohesion and adaptability dimensions, family types,
and clinical applications. Family Process, 18(1), 3–28.
Ilana’s problematic behaviors at home and school.
When the therapist asked Alison and Logan
to describe Ilana’s behaviors, they were both
scrolling through emails and texting, while Ilana
was off in the corner of the room playing with a
Divorce Ideation
toy. After being asked to put their phones away,
Alan J. Hawkins1, Sage Erickson Allen1,
Alison expressed, “we just want you to teach
Kelly Roberts2, Steven M. Harris3 and
her how to behave; she is so attention-seeking.”
Sarah M. Allen4
The therapist then asked Ilana what she thought 1
about the way she was behaving, to which she 2
University of North Texas, Denton, TX, USA
replied, “What do you expect? My parents don’t 3
University of Minnesota, Minneapolis, MN, USA
pay any attention to me; they are always on their 4
Montana State University, Bozeman, ST, USA
phones. If I behaved how they wanted me to, they
would pay even less attention to me than they do
now.” The therapist then helped facilitate a con-
Name of Concept
versation between the parents and child about
their lack of connection and involvement with
Divorce Ideation.
one another. This allowed the family to work
through some of their differences, and articulate
their needs, which created a more secure sense of
Synonyms
cohesiveness among the system.
Divorce decision-making; Divorce thinking
Cross-References
Introduction
▶ Autonomy in Families
▶ Boundaries in Structural Family Therapy Demographers estimate that 40–50% of first
▶ Circumplex Model of Marital and Family marriages and 60% of second marriages end
Systems, The in divorce (Kennedy and Ruggles 2014;
▶ Enmeshment in Couples and Families Kreider and Ellis 2011). But there is a curious
▶ Minuchin, Salvador research gap on divorce ideation and decision-
▶ Nichols, Michael making. What are people thinking when they
▶ Olson, David are thinking about divorce? How many people
Divorce Ideation 779
are thinking about divorce? How frequent and report that in the past (but not recently) they
serious are their thoughts? How static or stable thought their marriage was in serious trouble and
is their thinking? What do they do to try to had thoughts about divorce. Nearly 90% of them,
repair the relationship? however, report that they are glad they are still
Until recently, there was little research on married. A noteworthy proportion of the married
these questions. But some answers to these population goes through periods of marital dis-
questions are available from a recent study with tress but survives and even thrives with a mixture
a nationally representative sample of 3,000 mar- of patience, promises, perseverance, and perspira-
ried individuals of ages 25–50 (Hawkins et al. tion. (Note, however, that those who had already D
2017b; National Divorce Decision-Making divorced are not captured in these numbers.)
Project 2015). This study also included a 1-year In addition, 25% report thinking about divorce
follow-up survey and repeated in-depth inter- in the last 6 months. Forty percent of recent
views with a subsample of 30 individuals thinking thinkers say they have talked to their spouse
about divorce. about their thoughts about divorce; another 40%
say they have not talked to their spouse, while
20% say, “Maybe, we sort of talked about it,”
Theoretical Context for Concept indicating perhaps vague conversations about
marital prospects without directly mentioning
There is limited theoretical work trying to divorce. Also, divorce ideation rates do not
understand how individuals think about and begin to decline until 15 years of marriage. Most
make difficult decisions about divorce or current thinkers have been thinking about divorce
staying together (Allen and Hawkins 2017). for more than a year. Demographic differences in
Work grounded in rational frameworks inevita- divorce ideation are not common and small when
bly force-fit messy, emotional, nonlinear pro- they do appear.
cesses into tidy, linear, and self-interested For most thinkers (70%), their thoughts about
ones. Interpretive frameworks are vulnerable divorce are infrequent, and they are generally
to ways in which individuals reframe, reinter- pretty happy and hopeful about the future of
pret, and re-tell events in ways that make sense their marriage. So for most thinkers, their
with their current understanding of a situation, thoughts do not seem to indicate impending mar-
reducing ambiguity and inconsistencies and ital demise. Also, 43% of current thinkers say they
minimizing instances of nonlinearity. There is do not want a divorce and want to work hard to
a need for theoretical frameworks and method- stay together. About a quarter of thinkers report
ologies that can capture complexity in ways mixed feelings about a divorce, while another
that attend to the many rational elements of quarter say they would consider working on
divorce ideation but also to the nonrational, their marriage and not divorcing if their spouse
nonlinear, and emotional – that is, fully got serious about making some major changes.
human – ways in which individuals make Three distinct categories of thinkers can be
sense of their lives. Regardless of current theo- identified from these specific questions. One
retical and methodological challenges, divorce group consists of serious thinkers (46%). Half of
ideation needs a mapping of its basic, empirical them are thinking about divorce often. They have
contours. high levels of connection problems (e.g., growing
apart) in their marriages and modest levels of
instrumental problems (e.g., division of domestic
Description of Past and Recent Divorce labor). Conflict is a large concern for this group
Ideation (more than 84% reporting a problem), but they
report relatively low levels of intense problems
Thinking about divorce is common. Twenty-eight (e.g., adultery, abuse). They have the lowest
percent of married individuals of ages 25–50 scores of the three groups on relationship hope.
Still, few say they are done with the marriage serious problems. This group is the most religious
(5%). And they are struggling more than the of the three divorce ideation groups.
other groups to find clarity in their decision In-depth interviews with 30 thinkers paint a
about a divorce. So serious thinkers are feeling a more nuanced portrait of divorce ideation and
significant loss of connection, experiencing sub- decision-making than is provided in the quantita-
stantial conflict, and are thinking more about tive analyses. There is more of a continuum
divorce and are less committed, on average, to between soft and serious thinkers. And soft think-
working through their problems, although they ing does not preclude real, sustained frustration or
are struggling with the divorce decision. sense of being stuck. Thinkers struggle with var-
The second group is soft thinkers (48%), and ious tensions as they contemplate divorce. Per-
they are a strong contrast to the other two groups. sonal happiness versus children’s happiness,
More than 90% of this group say they have been love versus financial security, and rational versus
thinking about divorce only a few times recently. emotional thoughts are all things that thinkers
They have lower levels of reported marital prob- thought about extensively. These tensions com-
lems of all kinds, with connection issues being the bined to determine trajectories of relationship
most common problems; few report one of the growth, entropy, or maintenance of the status
more intense problems. Also, they are hopeful quo. In addition, there are core beliefs about mar-
about the future for their marriage. Seventy per- riage and divorce that people use as reference
cent say they do not want a divorce and are willing points for their thinking and decision-making.
to work hard to keep the marriage together, with Some of these reference points come from family,
another 11% saying they would work to save the friends, past experiences, and relationships, while
marriage if their spouse got serious about making others come from general societal and cultural
changes. Not surprisingly, then, this group reports messages. And throughout this divorce ideation
much more clarity about the divorce decision, process, people often struggle with clarity and
likely settled on not pursuing that course for confidence in a decision about which direction
now. So soft thinkers have only occasional they should take.
thoughts about divorce and are committed to What happens over a 1-year span? How stable
working on the marriage but are experiencing or dynamic is divorce ideation? Ninety-three per-
some connection problems. cent of thinkers are still married to the same per-
The smallest group is conflicted thinkers (6%). son 1 year later; 6% are divorced or separated.
They report the highest level of problems, includ- While most nonthinkers (64%) still are not think-
ing several of the more intense problems. And ing about divorce a year later, about one third of
they report the highest levels of conflict and, by them become thinkers and 2% are separated or
far, mental health problems affecting the mar- divorced, indicating that occasionally marital dis-
riage. About half have been thinking about solution comes quickly. And while most thinkers
divorce often. And about one third said they are are still thinking about divorce 1 year later (69%),
done with the marriage, by far the highest nearly a third of them are not thinking about
endorsement of this attitude among the three divorce. Still, marital dissolution is more common
groups of thinkers. But curiously, another third among thinkers: 11% are divorced or separated
said they want to work hard to save the marriage 1 year later.
and avoid a divorce. Also, this small group has the Also, personal attitudes about getting a
highest scores among thinkers on relationship divorce can change a lot over a year. Only one
hope. They also report feeling like a failure if third of thinkers report the same attitude about
their marriage were to end. So conflicted thinkers divorce a year later. For instance, among the
are experiencing the highest levels of serious thinkers who say they are done with the mar-
problems but remain hopeful about overcoming riage, just 29% report the same attitude 1 year
the problems, and they are conflicted about get- later, while 53% report different attitudes that
ting a divorce even though are experiencing suggest more openness to staying married,
Divorce Ideation 781
including 18% who say they have not had recent ideation. However, divorce ideation is not the
thoughts about divorce. same as divorce action. Many have thoughts
About half of soft thinkers remain soft thinkers about divorce, but the thoughts dissipate or they
1 year later, with about 10% becoming serious do not get to a decision point for years. At the
thinkers; a third have transitioned to nonthinkers same time, soft thinking does not mean that mar-
a year later while only 1% have divorced. Simi- ital problems are trivial and painless. While
larly, about half of serious thinkers remain serious thoughts about divorce are fleeting for some and
thinkers 1 year later, with 20% changing to soft the issues they raise can be straightforwardly
thinkers; 21% have transitioned to nonthinkers, addressed, some thinkers are frustrated and in D
while 5% are divorced within a year. The risk of pain even if they are not thinking seriously about
divorce is higher for conflicted thinkers – 6% getting a divorce right then. Moreover, divorce
divorced within a year. Nevertheless, a quarter ideation is dynamic; for many, thoughts fluctuate
transition from conflicted to nonthinkers. More- from month-to-month and even day-to-day.
over, the in-depth interviews with thinkers sug- Knowing what someone is thinking about divorce
gest even higher levels of fluctuation. Indeed, for at one time is useful, but it is not a clear indication
about half of thinkers, feelings about the marriage about the future. Finally, while most do make
ebb and flow monthly, weekly, and even daily. attempts to repair and strengthen the relationship,
When people are thinking about divorce, what most do so privately without engaging
actions do they take to repair their relationship? professional help.
Thinkers report relatively low levels of profes-
sional help-seeking, consistent with previous
research (Doss et al. 2009; Hawkins 2015; Application of Concept in Couple and
Lebow et al. 2012). Only 40% have sought some Family Therapy
kind of counseling (25% sought couple counsel-
ing). About 11% counsel with a religious leader. Divorce ideation is common but does not equal
Only 10% have taken a marriage-strengthening divorce action. Many have had thoughts about
class together. Also, about a third report talking divorce in the past but not recently and are
to others about improving their marriage. And happy they are still together. Many more have
about 40% report seeking help from self-help had recent thoughts but are not headed quickly
sources (e.g., books, websites). The most com- to a divorce. Couples therapists can use these
monly attempted repair behaviors, however, are findings to normalize divorce ideation. Moreover,
private or dyadic efforts, such as having a serious divorce ideation is dynamic, not static. Normaliz-
talk with a spouse (68%) or just working harder to ing this may help thinkers realize that there does
fix a problem (79%). Generally, it appears that not need to be a rush to premature decision-
people who are thinking about divorce do not making about the future of the marriage. Clients
often seek out professional help in a timely man- in distressed marriages can be overwhelmed by
ner. Instead, they engage in more private efforts to the current state of a relationship and lose a long-
fix their problems. term view. The use of couple counseling can help
In summary, current divorce ideation is com- couples get clarity about the best direction to go
mon. Perhaps, an inevitable feature of modern (Doherty et al. 2015).
marriages is that couples must struggle with the Marriage Education. Marriage education pro-
possibility of its demise. Within a culture of wide- grams can deal effectively with the common con-
spread acceptance of individualism and romanti- nection problems that thinkers reported, such as
cism, if a marriage is not fully satisfying, then being able to talk together, arguing too much, or
questions about its viability inevitably surface growing apart, as well as instrumental problems,
(Baxter 2010). Cultural beliefs about individual- such as balancing work and family issues
ism and romantic love (Swidler 2001) shrink the (Hawkins 2015). Marriage education has gener-
distance between disappointment and divorce ally been portrayed as preventative intervention.
Yet there is good evidence that distressed couples During that time, both spouses met individually
constitute a substantial portion of marriage edu- with the discernment counselor. After a few ses-
cation participants (Bradford et al. 2015) and that sions, Greta reported to their counselor that they
they often benefit more from it than nondistressed had mutually agreed to move into couple therapy
couples (Hawkins et al. 2017a). Scholars have and would give these efforts 6 months, seeking
stressed the need for prevention work with cou- more understanding of the problems they were fac-
ples “before [distress] happens, before it gets ing and working on solutions.
worse, and before it is too late” (Bradbury and
Fincham 1990, p. 376). Moderately distressed
couples are an important target audience for mar-
riage educators. Cross-References
▶ Discernment Counseling in Couple and Family

Clinical Example Therapy
▶ Divorce in Couple and Family Therapy
Jerome and Greta married 10 years ago after ▶ Divorced Families
cohabiting as a committed couple for almost ▶ Integrative Family Therapy for Difficult
6 years. They have two children. Having experi- Divorce
enced emotional distance for the past 4 years, they ▶ Post-Divorce Families in Couple and Family
described their marriage during an intake for Therapy
counseling as “distant, exhausting, and increasingly
conflicted.” Greta expressed being especially
“done” with their marriage after describing several References
examples of “trying everything she could” to help
them reconnect, including several attempts at cou- Allen, S. M., & Hawkins, A. J. (2017). Theorizing about
the divorce/reconciliation decision-making process.
ples therapy. Jerome was a reluctant participant in Journal of Family Theory and Review, 9, 50–68.
these efforts. Greta admits to thinking almost daily https://doi.org/10.1111/jftr.12176.
about filing for divorce. When prompted, Jerome Baxter, L. A. (2010). The dialogue of marriage.
concedes that he does not think he can change her Journal of Family Theory & Review, 2, 370–387.
https://doi.org/10.1111/j.1756-2589.2010.00067.x.
mind but never imagined being at this particular Bradbury, T. N., & Fincham, F. D. (1990). Preventing
juncture in his life. Both reference their children as marital dysfunction: Review and analysis. In
one of “the main reasons they are still together.” F. D. Fincham & T. N. Bradbury (Eds.), The psychology
As reflected by their counselor during intake, of marriage: Basic issues and applications
(pp. 375–401). New York: Guilford.
their marriage had experienced increasingly strained Bradford, A., Hawkins, A. J., & Acker, J. (2015). If we
couple identity with Jerome expressing varying build it, they will come: Exploring policy and practice
degrees of ambivalence and Greta clearly “leaning implications of public support for couple and relation-
out” of the marriage. The counselor explained how ship education for lower income and relationally
distressed couples. Family Process, 54, 639–654.
discernment counseling – a special counseling https://doi.org/10.1111/famp.12151.
method for working with “mixed-agenda” couples Doherty, W. J., Harris, S. M., & Wilde, J. L. (2015).
(Doherty et al. 2015) – worked. The counselor Discernment counseling for “mixed-agenda” couples.
explained that the purpose of discernment counsel- Journal of Marital and Family Therapy, 42, 246–255.
https://doi.org/10.1111/jmft.12132.
ing was not to begin working on solving couple Doss, B. D., Rhoades, G. K., Stanley, S. M., &
problems but to get some understanding in order to Markman, H. J. (2009). Marital therapy, retreats,
make a decision about three possible paths forward: and books: The who, what, when, and why of relation-
divorce/separation, stay the course (relationship sta- ship help-seeking. Journal of Marital and Family
Therapy, 35, 18–29. https://doi.org/10.1111/j.1752-
tus quo), or a commitment to 6 months of couple’s 0606.2008.00093.x.
therapy, with divorce off the table. The couple first Hawkins, A. J. (2015). Does it work? Effectiveness research
agreed to stay the course for a couple of weeks. on relationship and marriage education. In J. Ponzetti
Divorce in Couple and Family Therapy 783
(Ed.), Evidence-based approaches to relationship and for clients. According to a national survey, the
marriage education (pp. 66–73). New York: Routledge. divorce rate remains around 50 % (Copen
Hawkins, A. J., Erickson Allen, S. E., & Yang, C. (2017a).
How does couple and relationship education affect et al. 2012). Indeed, a legally married,
relationship hope? An intervention-process study with two-parent household with children is no longer
lower income couples. Family Relations. Advance representative of the typical American family.
online publication. https://doi.org/10.1111/fare.12268.
Hawkins, A. J., Galovan, A., Harris, S. M., Allen, S. E.,
Allen, S. M., Roberts, K. M., & Schramm, D. G.
(2017b). What are they thinking? A national- Theoretical Context for Concept
sample study of stability and change in divorce ideation. D
Family Process. Advance online publication. https://doi. Divorce and the transitions and reorganization of
org/10.1111/famp.12299.
Kennedy, S., & Ruggles, S. (2014). Breaking up is hard to family structure that follows have become a nor-
count: The rise of divorce in the United States, mative experience. In the United States, the term
1980–2010. Demography, 51, 587–598. https://doi. “divorce” is used to refer to the termination of
org/10.1007/s13524-013-0270-9. legal marriages, but it can also apply to the disso-
Kreider, R. M., & Ellis, R. (2011). Living arrangements of
children: 2009. In Current population reports lution of long-term committed relationships. This
(pp. 70–126). Washington, DC: U. S. Census Bureau. is of particular importance as more couples are
Lebow, J. L., Chambers, A. L., Christensen, A., & deciding to cohabitate as an alternative to mar-
Johnson, S. M. (2012). Research on the treatment of riage, not as a precursor to it (Cherlin 2004).
couple distress. Journal of Marital and Family Ther-
apy, 38, 145–168. https://doi.org/10.1111/j.1752- Therefore, while the legal aspects of divorce are
0606.2011.00249.x. unique to marriages, the discussion presented here
National Divorce Decision-Making Project. (2015). What also has relevance to relationship dissolution* of
are they thinking? A national survey of married indi- long-term committed relationships that involve
viduals who are thinking about divorce. Provo: Family
Studies Center, Brigham Young University. cohabitation.
Swidler, A. (2001). Talk of love: How culture matters. It is important to understand that divorce is
Chicago: University of Chicago Press. not a single, discrete event. Instead, the most
commonly accepted theoretical model of
divorce supports a process perspective (Amato
Divorce in Couple and Family 2010). Divorce is an ongoing couple and famil-
Therapy ial process that increases relational conflict and
emotional instability and inevitably involves the
Amy C. Wagner1 and Rachel M. Diamond2 dissolution of the partnered relationship and
1
The Family Institute at Northwestern University, original family that once existed. By holding
Evanston, IL, USA this perspective of divorce, it is understood
2
University of Saint Joseph, West Hartford, that clients can enter therapy at any point
CT, USA during the process. Client needs can vary
greatly based on where they present across the
transitional continuum: Clients may come to
Synonyms therapy contemplating divorce (e.g., prefiling
or separation), others may seek therapy in the
Marital and/or Relationship Dissolution and/or midst of the divorce (e.g., in unison with court
Termination proceedings), or others may enter therapy as a
means to assist with post-divorce adjustment
(e.g., post-legal divorce and/or following phys-
Introduction ical separation). Therapists who understand the
typical challenges and adjustments necessary at
Issues related to divorce in couple and family these various stages can more directly and
therapy are often challenging and complex and appropriately respond to both couple and family
are increasingly common presenting problems needs.
784 Divorce in Couple and Family Therapy
Description time. Therefore, it is not divorce per se, but the

family processes such as the increase in parental
Clinicians should consider each individual in the conflict around relationship dissolution* that are
family system, the interparental relationship, and linked to childhood adjustment difficulties. These
parent–child relationships when working with include both externalizing behavior (e.g., aggres-
divorcing families. Before initiating the process sion, delinquency, and conduct disorder) and
of relationship dissolution, one or both parents internalizing behavior (e.g., depression and anxi-
likely contemplated separation and/or divorce for ety), as well as physical health problems
some time. Typically upon beginning the physical (Fabricius and Luecken 2007). Children with
separation, parents inform their child(ren). While cooperative parents have better psychological
legal/court proceedings may move slowly for functioning and academic performance compared
many, the transitions in the family’s life often do to children with noncooperative parents
not follow the same timeline. Upon telling the (Hetherington et al. 1998). Indeed, the quality of
child(ren) of the relationship dissolution,* there the parental relationship has been linked to both
is typically a rapid series of transitions as the short- and long-term adjustment, regardless of
couple separates and begins any legal proceedings family type (Cummings et al. 2012).
and one parent may leave the family home. Dur- Additionally for parents to support children
ing the divorce process, children may experience and bolster their resilience post-divorce, the
other losses such as extended family members, parent–child relationship must remain warm and
their home, neighborhood, friends, and/or school. supportive (Amato 2010; Simons et al. 1999).
It is vital to support children in these losses and Parent–child conflict during stressful transitions
subsequent transitions. Throughout a divorce, like divorce is related to children’s abilities to
children often are exposed to high parental stress emotionally regulate and feel secure (Davies and
and/or conflict. This may tax parents’ abilities in Cummings 1994). The more positive the relation-
caretaking and responding to their children’s emo- ship a child has with his/her parents, the better the
tional needs. Parents need support in staying cen- child will adjust to divorce.
tered and competent in a leadership role in the face
of stress, change, and emotional turmoil.
The impact of divorce can vary based on a Application of Concept in Couple
variety of factors (Wagner and Diamond 2017). and Family Therapy
These include the ages and number of children,
the family’s financial situation, the existence of There are various models of therapy that can be
social support systems (e.g., extended family), appropriately applied to working with couples and
and the meaning of divorce to family members. families of divorce. However, it is advised that in
These beliefs are often related to culture, religion, this work a therapist take an integrative approach
and gender. Indeed, parents who divorce may live in order to address the range of distinct tasks
in a community where they feel stigmatized or across the transitional continuum (Lebow 2015).
judged because of their decision to end a marriage The major focus of couple and family therapy
and are concerned it will negatively impact their with this population is on facilitating family reor-
social standing. ganization, establishing a new binuclear family
Overall, research indicates that children raised structure with clearly defined boundaries and
in a two-parent family experience better psycho- roles, and facilitating healthy communication
logical, social, academic, and physical health out- between co-parents (Wagner and Diamond
comes compared to those children raised in 2017). Families who seek treatment during
divorced families, separated families, or never- divorce frequently experience periods of conflict
married single-parent households (Clarke-Stewart or turmoil. Often there is a lack of organization
and Brentano 2006). However, differences during the transition to a new, single-parent family
between groups are small and decrease over structure. Couple and family therapy focusing on
Divorce in Couple and Family Therapy 785
divorce is often complex due to these frequent subsequent sessions can include each parent and
periods of upheaval and transition. Thus, it is their child/children and/or the sibling subsystem.
imperative that the therapist provide clear struc- This method of working with each household
ture within the therapeutic setting while also allo- separately sets a clear boundary and reinforces
wing adaptation as the family transitions through family organization as a binuclear rather than
the divorce process. One of the most important nuclear family. There may be times when thera-
goals of therapy is to provide the family with pists work with the original family together; how-
stability in a time of often rapid change while ever, this should be attempted only after
also encouraging flexibility and adaptability emotional negativity has been reduced, and these D
(Wagner and Diamond 2017). sessions should focus on specific treatment tasks
It is essential to clarify legal agreements and goals.
regarding consent for treatment of minors before
beginning treatment, as laws may vary by state.
With that being said, having the cooperation and Clinical Example
participation of both parents maximizes the like-
lihood of a positive treatment outcome. When The following case example illustrates how to
beginning treatment, it is imperative to distin- therapeutically approach a family adjusting to
guish the role of the therapist and purpose of divorce. Since their separation 6 months ago,
therapy from that of couples counseling, custody Cindy and Mike are struggling with their school-
evaluation, or legal mediation to facilitate the age children’s adjustment to living in two different
establishment of a positive treatment alliance homes. They entered therapy at the suggestion of
with both parents with the goal of acting in the the school social worker, who was told by teachers
best interest of their child/children. While treat- that both their son, Jason, and daughter, Sally,
ment with the most members of the family system were missing assignments, coming to school
is generally the starting point for family therapy, late, and having behavior problems not exhibited
in divorcing families this is contraindicated due to prior to the parents’ separation. Cindy and Mike
the common presence of high emotional reactivity met with the therapist together. They reported
and conflict between divorcing partners. As there was not a consistent schedule and often the
divorce is often not a mutual decision by the kids forgot their homework or books at the other
couple, they each may need to first process their parent’s house. In addition, the couple was going
feelings individually with the therapist. Initially through a difficult divorce that had recently
meeting with each parent alone or with the parents reached an impasse. While they tried to keep
together prevents children from being further their differences from the children, the kids had
exposed to conflict and creates a safer therapeutic recently witnessed an argument during a drop off.
space. As parents may be actively involved in the Additionally, Cindy, the primary custodial parent,
legal system, a therapist should have a compre- felt overwhelmed getting the kids off to school in
hensive therapy contract to clarify agreements the morning and getting herself ready for work,
around confidentiality for parents and children. and Mike felt he had so little time with the kids he
There should be a clear expectation that the ther- didn’t want to spend it forcing them to do home-
apist will only share information from the children work and study. Cindy reported their son was
that will facilitate family treatment, without with- defiant with her and missed his dad; Mike reported
holding essential information. Even though for- their daughter often cried at night before bed and
mer partners may have negative emotions toward wanted to return to Cindy’s house.
each other, therapists ask parents to resolve, Facilitating family reorganization. Begin-
accept, or set aside these feelings in order to be ning tasks and goals in therapy involve supporting
functional, cooperative co-parents. After the and facilitating family reorganization (Wagner
parental subsystem is stabilized sufficiently so and Diamond 2017). These include establishing
that shared goals for therapy can be established, clear boundaries between households and
786 Divorce in Couple and Family Therapy
clarifying parenting schedules, rules, and other Developing healthy communication.

functional logistics. While daily routines may Research evidence supports that ongoing parental
vary in each binuclear household, they should be conflict and triangulation of children in parental
similar around important issues such as bedtime/ disputes is related to poor child adjustment. Chil-
curfew or expectations about homework and dren whose parents are involved in a highly con-
school performance. This clarity helps all family flictual divorce or ongoing custody litigation are
members better adjust to the changes in family especially vulnerable. The therapist advocated for
organization and increases a sense of safety and Cindy and Mike to protect their children from
predictability. parental conflict and having to “choose sides” so
For Cindy and Mike, this involved discussing Jason and Sally could continue to have a loving
practical issues in therapy, such as coordination of relationship with both parents. The therapist
school and extracurricular schedules, appoint- discussed how the children should not be treated
ments, transportation, and exchange of personal as buffers, mediators, or messengers; instead,
possessions during transitions between house- parental communication should occur directly
holds. The therapist explained that predictable between them. Both parents agreed that negative
routines and direct, consistent communication emotions were not only hindering each child’s
help children feel more in control and less anxious ability to adjust to the divorce, it was also inter-
or uncertain in their daily lives. Lastly, while most fering with their relationships with Cindy
parenting agreements require siblings to shift and Mike.
between parents homes in unison, given their Therapy also aided Cindy and Mike in making
concerns about the children’s distress and emo- joint parenting decisions and negotiating differ-
tional needs, the therapist discussed the impor- ences on topics such as healthcare, extracurricular
tance for each child to also have one-on-one activities, education, and behavioral expectations.
time with each parent. They agreed to focus on their children’s needs and
Redefining parental roles. Divorce involves that they were both committed to do what was best
redefining and renegotiating family roles; the for them. With this understanding they felt they
adults must transition from being romantic part- could use therapy as a safe place to problem solve
ners and parents to strictly being co-parents. The or resolve conflicts, rather than using attorneys
new logistics of solo parenting can be emotionally and the legal system to resolve disputes.
overwhelming with multiple responsibilities for Often boys and girls handle the stress and
childcare, logistics, or finances that had previ- transition of divorce differently, and same-sex
ously been shared. Unresolved issues and a lack siblings may have varying reactions based on
of acceptance and closure often interfere with their age and development. During parent–child
parents’ abilities to establish a cooperative (ren) sessions, therapists can help support children
co-parenting relationship. in expressing emotions to parents. Once Cindy
The therapist worked with Cindy and Mike to and Mike were more cooperatively co-parenting,
normalize these common divorce challenges and the therapist had family meetings with each parent
the inevitable adjustment period of confusion and and the children. In the family sessions Jason and
conflict. The therapist discussed ways they could Sally were able to express their sad, scared, and
be supportive co-parents and suggested the par- angry feelings about the divorce, while the thera-
ents utilize a software program designed to assist pist coached each parent in responding so the
parents of divorce with scheduling and communi- children felt accepted and understood. The thera-
cation (e.g., Our Family Wizard). With time, pist also helped Cindy and Mike recognize that
newly established emotional and physical bound- problematic behavior had underlying emotional
aries between Cindy and Mike became clearer as meaning. With time, this decreased Jason’s acting
the “new normal” was established, supporting the out and Sally’s withdrawal and increased Cindy
goal of having cooperative, competent leaders in and Mike’s feelings of competency in supporting
each household. their children.
Divorced Families 787
Over the course of treatment, Cindy and Mike hypothesis. Psychological Bulletin, 116, 387–411.
reported seeing indications that the children were https://doi.org/10.1037/00332909.116.3.387.
Fabricius, W. V., & Luecken, L. J. (2007). Postdivorce
better able to handle their transition between living arrangements, parent conflict, and long-term
households and their school performance physical health correlates for children of divorce. Jour-
improved. They reported that although they had nal of Family Psychology, 21, 195–205. https://doi.org/
conflict over divorce negotiations, they were both 10.1037/0893-3200.21.2.195.
Hetherington, E. M., Bridges, M., & Insabella, G. M.
committed to protecting the children from their (1998). What matters? What does not? Five perspectives
conflict. In addition, the children seemed happier, on the association between marital transitions and chil-
and while they still wished their parents would get dren’s adjustment. American Psychologist, 53, 167–184. D
back together, they were adjusting well to their https://doi.org/10.1037/0003-066X.53.2.167.
Lebow, J. L. (2015). Separation and divorce issues in couple
new schedules and routines. therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder
In conclusion, most children in divorced (Eds.), Clinical handbook of couple therapy (5th ed.,
families adjust well to a new binuclear family pp. 445–463). New York: The Guilford Press.
form over time. By understanding the predict- Simons, R. L., Lin, K. H., Gordon, L. C., Conger, R. D., &
Lorenz, F. O. (1999). Explaining the higher incidence
able systemic issues and transitional process of of adjustment problems among children of divorce
divorce, couple and family therapists can better compared with those in two-parent families. Journal
support their clients in successfully negotiating of Marriage and the Family, 61, 1020–1033. https://
the common developmental challenges associ- doi.org/10.2307/354021.
Wagner, A. C., & Diamond, R. M. (2017). Families and
ated with this journey of change. divorce. In S. Browning & B. Van Eeden-Morrhead
(Eds.), Contemporary families: At the nexus of research
and practice. New York: Routledge Press.
Cross-References
▶ Divorced Families
▶ Post-divorce Families in Couple and Family
Divorced Families
Therapy
Lee J. Dixon and Sarah A. Wilhoit
University of Dayton, Dayton, OH, USA
References
Amato, P. R. (2010). Research on divorce: Continuing

trends and new developments. Journal of Marriage Introduction
and Family, 72, 650–666. https://doi.org/10.1111/
j.1741-3737.2010.00723.x. Given the prevalence of divorce in most countries,
Cherlin, A. (2004). The deinstitutionalization of American
marriage. Journal of Marriage and Family, 66, 848–861.
and the fact that the dissolution of a marriage often
https://doi.org/10.1111/j.0022-2445.2004.00058.x. involves the entire family, it is important to have
Clarke-Stewart, A., & Brentano, C. (2006). Divorce: an understanding of the potential impact of
Causes and consequences. New Haven: Yale Univer- divorce. Although divorce is usually related to
sity Press.
detrimental experiences for both couples and
Copen, C. E., Daniels, K., Vespa, J., & Mosher, W. D.
(2012). First marriages in the United States: Data their children, this is not true in all cases. As is
from 2006–2010 national survey of family growth. In outlined below, research in this area has shone a
National health statistics reports (Vol. 49, pp. 1–22). light on for whom divorce has a more negative
Hyattsville: National Center for Health Statistics.
Cummings, E. M., George, M. W., McCoy, K. P., &
impact and for whom the opposite may be true.
Davies, P. T. (2012). Interparental conflict in kindergar- Given the ubiquity of divorce, it is imperative that
ten and adolescent adjustment: Prospective investiga- we understand its causes and influences and
tion of emotional security as an explanatory develop therapies and interventions that can help
mechanism. Child Development, 83(5), 1703–1715.
https://doi.org/10.1111/j.1467-8624.2012.01807.x.
to lessen the negative consequences it can have on
Davies, P. T., & Cummings, E. M. (1994). Marital conflict families. This entry will introduce the reader to
and child adjustment: An emotional security each of these three areas of study.
788 Divorced Families
Description (e.g., White 1991). However, it should be noted

that Orbuch et al. (2002) found that income alone
Although divorce rates in the United States did not predict divorce after accounting for the
peaked in the 1980s, they are still a very frequent effects of race and education. With regard to race,
occurrence, with the crude rate in 2012 being African American couples have been found to be
reported to be nearly three divorces per year per more likely to divorce than their Euro-American
1000 population (Organization for Economic counterparts (e.g., Orbuch et al. 2002), although
Cooperation and Development (OECD) 2015). the explanation for this finding is more likely due
The decline in the rate of divorce over the last to the influence of sociodemographic variables
few decades can partially be explained by the fact associated with race (e.g., premarital birth, cohab-
that the rate of marriages during that same time itation, etc.), rather than race itself. Amato and
has been decreasing (National Center for Health Previti (2003) found that the subjective causes of
Statistics (NCHS) 2015). Because crude rates can divorce most often reported by former spouses
be difficult to interpret, another way to understand include infidelity, incompatibility, drinking/drug
the frequency of divorce is to consider the fact that use, and growing apart.
in 2014 nearly one million divorces occurred in Another focus of research related to divorce is
the US (NCHS 2015). Although divorce rates the influence that it has on both the partners and/or
have fallen in the USA during the last decades, their children. Divorce has been rated as the most
the same is not true of many countries included in stressful life event one can experience (e.g.,
the OECD report, with the rates of divorce, on Dohrenwend and Dohrenwend 1974). Thus, it is
average, having risen in these countries during not surprising that the subjective well-being of
that same time period. Divorce oftentimes spouses tends to decrease as they approach
involves not only the divorcing partners, but divorce and remain relatively low during the
their children as well; it has been estimated that years following divorce (Lucas 2005). Along
approximately 40% of US children will experi- these lines, parents tend to experience detrimental
ence the divorce of their parents before reaching psychological and emotional consequences as a
adulthood (Bumpass 1990). result of divorce, such as higher levels of depres-
sion and anxiety (see Braver et al. 2006). Addi-
tionally, a family’s income tends to drop as the
Relevant Research transition to divorce occurs, as does the time that
parents have to spend with their children (Hanson
The causes, antecedents, and underlying pro- et al. 1997). With regard to children of divorced
cesses of divorce have long been a focus of parents, they too tend to experience negative con-
research (see Amato and Previti 2003; Rodrigues sequences, including behavioral, social, and psy-
et al. 2006). Given that marriage until more chological difficulties (Amato and Keith 1991),
recently has been a heterosexual institution, most although these effects may not be long lasting
research regarding divorce has focused on hetero- (Hetherington and Kelly 2002). Children of
sexual relationships (but see Oswald and Clausell divorce are more likely to contemplate divorce
2006). Wives have been found to be more likely as unhappily married adults (Amato and DeBoer
than husbands to initiate divorce; additionally, 2001) and are more likely to experience divorce
former wives more often cite negative qualities themselves (e.g., Glenn and Kramer 1985). How-
of their spouses as the cause for their divorce, ever, in some ways divorce may actually improve
whereas former husbands are more likely to the lives of some children. For example, Amato
blame factors outside the marriage (Kitson (2003) found a post-divorce increase in the well-
1992). One often-cited predictor of divorce is being of children whose parents experienced high
one’s socioeconomic status (SES; typically levels of conflict prior to divorcing. This finding
defined as level of income and education), with supports the notion that the quality of parents’
the risk of divorce being negatively related to SES relationship prior to divorcing may be more
Divorced Families 789
predictive of children’s experience of divorce than light of the commitment level of each partner to
the divorce itself (e.g., Sun 2001). It is worth the marriage. Indeed, there are times that, regard-
noting that partners and their children are not the less of the objective qualities and viability of a
only ones who experience the cost of divorce; one marriage, some partners see no alternative to
study found that taxpayers in Utah spend approx- divorce. In those instances, much attention should
imately $30,000 per divorce by way of food be paid to the therapeutic alliance in order to not
stamps, welfare, etc. (Schramm 2006). Having alienate either the couple and/or individual part-
said this, the cost may be worth bearing in some ners by invalidating their point of view. Objective
instances, especially when one considers the markers that signal the possibility that a marriage D
aforementioned research highlighting the poten- may, in fact, not be viable include contempt and/or
tial benefits of divorce in some children’s lives. stonewalling, coupled with low levels of positive
connection (Gottman and Notarius 2000).
Since there is such a pronounced difference
Special Considerations for Couple and between couples who divorce “well” vs. those
Family Therapy that do not, a therapist who can guide a couple
effectively through the process of divorce can
One study found that nearly half of the couples in have a very positive impact on all involved.
its sample reported seeking marital therapy due to Three methods for helping couples navigate
concerns related to either divorce or separation the divorce process are listed here. (Please see
(Doss et al. 2004). Given this finding, it is not Lebow 2015 for a more thorough description of
surprising that divorce is often a possible outcome these methods, as well as their appropriate
of marital therapy (Lebow 2015). However, as corresponding references). One method for guid-
Lebow mentions, little attention is paid in the ing divorcing couples is through group
literature to therapies that are focused specifically psychoeducational prevention programs, which
on divorce. One possible reason for this dearth in focus on educating couples/individuals about the
therapies focused on divorce is that the goal for process of divorce, what they can expect, and how
most therapies, couple focused or not, is that there to handle difficulties that often arise. These pro-
be marked improvement in client functioning. grams are often offered as an extension of the
When marital therapists view their “client” to be court and have been shown to have an ameliora-
the marriage itself, which is often the case, they tive effect on the divorce process. Another method
tend to focus on improving the functioning of the often used is mediation, which typically involves
relationship. However, such a focus can interfere formal meetings in which mediators help couples
with seeing the possibility that what is best for negotiate differences regarding legal issues that
some marriages, and the individuals affected by are often involved in the process of divorce,
the marriage, including spouses and children, is such as finances and child support and custody.
that the marriage cease to exist. It is in these cases Lastly, divorce therapy is another mechanism
that understanding how to best treat couples and through which couples can be helped through
families going through a divorce becomes the divorce process. As Lebow (2015) points
paramount. out, all therapies that focus on divorce must be
Lebow (2015) suggests that all couple thera- somewhat integrative in nature due to the “many
pists doing good work must not ignore the wish of quite distinct tasks involved that are intrinsic to
either one or both partners to divorce, and they this territory” (p. 451). Divorce therapists’
should “work to establish an empathic connection approach must take into consideration the prob-
and therapeutic alliance with both parties in the lems and/or conflicts between the clients; each
process of working with this issue” (p. 448). partner’s goals; the influence the divorce will
Lebow also points out that there seems to be have on others, including children; and the thera-
consensus among couple therapists regarding the peutic alliance with the couple as an entity and
need to first assess the viability of the marriage in each partner individually.
790 Doherty, William
References Organization for Economic Cooperation and Develop-

ment. (2015). SF 3.1. Marriage and divorce rates
Amato, P. R. (2003). Reconciling divergent perspectives: (Retrieved September 3, 2016, from Organization for
Judith Wallerstein, quantitative family research, and Economic Cooperation and Development, Directorate
children of divorce. Family Relations, 52, 332–339. of Employment, Labour and Social Affairs: http://
Amato, P. R., & DeBoer, D. D. (2001). The transmission of www.oecd.org/social/family/database.htm).
marital instability across generations: Relationship Oswald, R. F., & Clausell, E. (2006). Same-sex relation-
skills or commitment to marriage? Journal of Marriage ships and their dissolution. In M. A. Fine & J. H.
and Family, 63, 1038–1051. Harvey (Eds.), Handbook of divorce and relationship
Amato, P. R., & Keith, B. (1991). Parental divorce and the dissolution (pp. 499–514). Mahwah: Erlbaum.
well-being of children: A meta-analysis. Psychological Rodrigues, A. E., Hall, J. H., & Fincham, F. D. (2006).
Bulletin, 110, 26–46. What predicts divorce and relationship dissolution? In
Amato, P. R., & Previti, D. (2003). People’s reasons for M. A. Fine & J. H. Harvey (Eds.), Handbook of divorce
divorcing: Gender, social class, the life course, and and relationship dissolution (pp. 85–112). Mahwah:
adjustment. Journal of Family Issues, 24(5), 602–626. Erlbaum.
Braver, S. L., Shapiro, J. R., & Goodman, M. (2006). The Schramm, D. (2006). Individual and social costs of divorce
consequences of divorce for parents. In M. A. Fine & in Utah. Journal of Family and Economic Issues, 27,
J. H. Harvey (Eds.), Handbook of divorce and relation- 133–146.
ship dissolution (pp. 313–337). New Jersey: Lawrence Sun, Y. (2001). Family environment and adolescents’ well-
Erlbaum. being before and after parents’ marital disruption:
Bumpass, L. (1990). What’s happening to the family? A longitudinal analysis. Journal of Marriage and Fam-
Interactions between demographic and institutional ily, 63, 697–713.
change. Demography, 27(4), 483–498. White, L. (1991). Determinants of divorce: A review of
Dohrenwend, B. S., & Dohrenwend, B. P. (1974). Stressful life research in the eighties. In A. Booth (Ed.), Contempo-
events: Their nature and effects. New York: John Wiley. rary families: Looking forward, looking back
Doss, B. D., Simpson, L. E., & Christensen, A. (2004). (pp. 141–149). Minneapolis: National Council on Fam-
Why do couples seek marital therapy? Professional ily Relations.
Psychology: Research and Practice, 35, 608–614.
Glenn, N. D., & Kramer, K. B. (1985). The psychological
well-being of adult children of divorce. Journal of
Marriage and the Family, 47, 905–912.
Gottman, J. M., & Notarius, C. I. (2000). Decade review: Doherty, William
Observing marital interaction. Journal of Marriage
And the Family, 62(4), 927–947.
Elizabeth Doherty Thomas
Hanson, T. L., McLanahan, S. S., & Thomson, E. (1997).
Economic resources, parental practices, and children’s The Doherty Relationship Institute, Saint Paul,
well-being. In G. J. Duncan & J. Brooks-Gunn (Eds.), MN, USA
Consequences of growing up poor (pp. 190–238).
New York: Russell Sage Foundation.
Hetherington, E. M., & Kelly, J. (2002). For better or
worse. New York: Norton. Introduction
Kitson, G. C. (1992). Portrait of divorce: Adjustment to
marital breakdown. New York: Guilford. Doherty has made distinctive contributions in four
Lebow, J. L. (2015). Separation and divorce issues in
areas of couple and family therapy: medical fam-
couple therapy. In A. S. Gurman, J. L. Lebow, D. K.
Snyder, A. S. Gurman, J. L. Lebow, & D. K. Snyder ily therapy to treat couples and families dealing
(Eds.), Clinical handbook of couple therapy (5th ed., with medical illness; values-based couples ther-
pp. 445–463). New York: Guilford Press. apy; discernment counseling for couples on the
Lucas, R. E. (2005). Time does not heal all wounds:
brink of divorce; and community engagement
A longitudinal study of reaction and adaptation to
divorce. Psychological Science, 16, 945–950. work by couple and family therapists.
National Center for Health Statistics. (2015). National
marriage and divorce rate trends (Retrieved September
3, 2016, from http://www.cdc.gov/nchs/nvss/mar
riage_divorce_tables.htm).
Career
Orbuch, T. L., Veroff, J., Hassan, H., & Horrocks, J. (2002).
Who will divorce: A 14-year longitudinal study of Black After a background in a Catholic seminary,
couples and White couples. Journal of Social and Per- Doherty entered graduate school at the University
sonal Relationships, 19(2), 179–202.
of Connecticut in 1972 and earned his PhD in
Doherty, William 791
Family Studies in 1978. He took at faculty posi- began to question the conventional values of
tion in the Department of Family Practice at the neutrality of the couples therapy field on the
University of Iowa, where he taught family prac- issue of marital commitment and divorce – a neu-
tice residents. In 1983 he coauthored, with trality he came to view not as neutral but an
Macaran Baird, MD, the first book on family unacknowledged individualistic values stance.
therapy and family medicine. Subsequently, he This led him to write the book Soul Searching in
and Baird joined the faculty of the Department 1995. He later coined the term “marriage friendly
of Family and Community Medicine at the Uni- therapy,” a challenge to the field to embrace a
versity of Oklahoma. There he further developed balanced procommitment stance rather than a neu- D
collaborative work on the family systems dynam- tral stance toward whether marriages (and other
ics of illness and the relationships between health life-long committed relationships) endure, with
care professionals and families. In 1986, Doherty the therapist’s active help, or end in divorce.
decided to focus more on his original field of A year after Soul Searching was published,
couple and family therapists by taking a faculty Doherty (1995) was searching for a way to expand
position in the Department of Family Social Sci- on what he considered the most incomplete part of
ence at the University of Minnesota. From 1988 to the book – the chapter on commitment to commu-
2009, he directed the doctoral program in mar- nity. He encountered the work of political theorist
riage and family therapy and engaged in private and former Martin Luther King associate Harry
practice as a licensed psychologist and licensed Boyte, who mentored him on the idea of the
marriage and family therapist. In 2009 he founded “citizen professional” – a professional engaged
the Minnesota Couples on the Brink Project and in in promoting the larger public good and who
2010 the Citizen Professional Center, both at the views fellow citizens not just as consumers of
University of Minnesota. professional services but as cocreators of their
communities. Doherty developed the Families
and Democracy Model (also termed Citizen
Contributions Health Care) and launched the Citizen Profes-
sional Center to promote the role of the “citizen
Doherty sees his contributions as coming at times therapist” in cocreating social change action pro-
when he absorbed new influences from outside jects Doherty, Mendenhall & Berge (2010).
the field. First was his experience in primary Another turning point occurred in 2007 when
care medicine where he realized how little family Doherty was approached by family court judge
therapy had paid attention to problems of medical Bruce Peterson to help understand the “divorce
illness in families. As one of the pioneers in ambivalence” the judge was seeing when he met
family-centered health care, he partnered with with couples informally about their divorce. The
Susan McDaniel and Jeri Hepworth to launch assumption in the fields of couples therapy and
medical family therapy as a clinical domain in divorce practice was that once people filed for
the field McDaniel, Doherty & Hepworth (2014). divorce, any uncertainty about divorcing was
In the mid-1990s he was one of the founders of over and the task of professionals was to help
the Collaborative Family Health Care Associa- with an expeditious, constructive divorce process.
tion, a multidisciplinary organization promoting Doherty’s research with Judge Peterson and Brian
collaborative, family-centered health care. Willoughby showed surprising levels of ambiva-
Doherty’s next turning point came from lence among divorcing spouses and an openness
absorbing critiques of the psychotherapy field to consider services for their marriage. After
from scholars such as sociologist Robert Bellah 18 months of meetings with a group of Collabo-
who argued that therapists were unwittingly pro- rative divorce lawyers who were interested in
moting a form of “expressive individualism” – assessing divorce ambivalence in their practices,
akin to “economic individualism” – that eroded Doherty developed an intervention for these cou-
family and community commitments. Doherty ples called “Discernment Counseling,” and he
792 Dominance and Submission in Family Dynamics
began training couples therapists in this approach Doherty, W. J., & Harris, S. M. (2017). Helping couples on
to working with “mixed agenda” couples (one the brink of divorce: Discernment counseling for trou-
bled relationships. Washington, DC: American Psy-
spouse leaning out of the marriage and the other chological Association.
leaning in). Discernment counseling is a short- Doherty, W. J., Mendenhall, T. J., & Berge, J. M. (2010).
term intervention that aims for clarity and confi- The families and democracy and citizen health care
dence in a decision on whether to divorce or project. Journal of Marital and Family Therapy, 36,
389–402.
commit to six months of couples therapy with McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2014).
divorce off the table – a decision based on a Medical family therapy and integrative care (2nd ed.).
deeper understanding of what has happened to Washington, DC: American Psychological Association.
the marriage and each partner’s contributions to
the problems Doherty & Harris (2017). A key
feature is that, although couples come to each
session together, the bulk of the work is with the Dominance and Submission
leaning-in and leaning-out spouses separately, in Family Dynamics
because they have different needs and agendas.
His new work as of 2017 has been in response to Norah E. Dunbar
the social upheaval from the nomination and elec- Department of Communication, University of
tion of Donald Trump as President. Seeing ferment California Santa Barbara, Santa Barbara,
among therapists about how to deal with their cli- CA, USA
ents’ stress and about the public role of therapists in
troubled political times, he founded an organization
called Citizen Therapists for Democracy to promote Synonyms
the work of citizen therapists in helping clients with
public and political stress and promoting depolari- Power
zation in local communities and society at large.
And he co-founded Better Angels initiative that
extends principles of couple therapy to the work of Introduction
political depolarization at the community level.
Power* is one of the most important aspects of
all interpersonal interactions because it operates
Cross-References “under the surface,” affecting the communica-
tion choices we make even if conflict is not
▶ Discernment Counseling in Couple and Family overt. Power* is the capacity to produce
Therapy intended effects and, in particular, the ability
▶ Divorce in Couple and Family Therapy to influence the behavior of another person. In
▶ Ethics in Couple and Family Therapy contrast to power*, which may be latent and
▶ Health Problems in Couple and Family covert, dominance refers to behaviors that are
Therapy overt and visible (Dunbar 2015). Dominance, or
▶ Medical Family Therapy it’s corollary, submission, can be examined non-
▶ Values in Couple and Family Therapy verbally in a variety of ways including kinesic
cues (facial expressions, gestures, and body
posture), as well as through the use of personal
References space, touch, vocalics, and other contextual
cues of precedence and leadership (Hall
Doherty, W. J. (1995). Soul searching. New York: Basic et al. 2005). The aggressiveness of verbal mes-
Books.
Doherty, W. J. (2017). Psychotherapy’s pilgrimage: Shap- sages that are used as well as psychological or
ing the consciousness of our time. Psychotherapy Net- physical intimate partner violence would also be
worker, 41(1), 18. characterized as dominance strategies. In family
Dominance and Submission in Family Dynamics 793
conflicts, a variety of these dominance messages Similarly, Honeycutt et al. (1997) argue that quan-
can be used simultaneously. The messages can titative dominance is not sufficient because the
be coded for the purpose of examining the effect response from the partner is important to assess
of dominance on therapeutic processes and dominance-submission dyadically. They define
outcomes. dominance as unilateral (when a given family
member’s statements elicit a response from
another family member but not the reverse) or
Theoretical Context for Concept bilateral (where a person’s statements predict a
second person’s turn-at-talk who in turn also D
Power* and dominance are featured promi- elicits a response from the first person). Therapists
nently in several theories relating to interper- and researchers could use a variety of these mes-
sonal communication which is relevant to sages to examine the dominance that they are most
couple and family therapy. Dunbar (2015) interested in theoretically.
reviews several relevant theories including
social exchange approaches, interdependence
theory, normative resource theory, equity the- Application of Concept in Couple
ory, dyadic power theory, necessary conver- and Family Therapy
gence communication theory, bilateral
deterrence theory, the chilling effect, relational An example of how dominance coding can be
control approaches, and sex role theories. used in a therapeutic sample is provided by Vall
A variety of coding schemes consistent with et al. (2016). They used an example of four clin-
those theories have been used to examine dom- ical sessions with a couple using two therapists
inance maneuvers in conflicts such as the rela- and the Dialogical Investigations of Happenings
tional control coding scheme which has been of Change (DIHC) method. They coded the cou-
used to study a variety of settings including ple and the therapists for quantitative, topical, or
abusive couples (Sabourin 1995), a coding interactional dominance and had the partners rate
scheme of dominance-submission in verbal dis- the session on a variety of assessments afterward.
agreements developed for television dramas but They found female expression of power* was
could be applicable to real-life conflicts manifested through semantic dominance, whereas
(Barbatsis et al. 1983), and coding schemes for the male expression of power* was characterized
nonverbal cues of dominance which have been more by quantitative dominance, and the thera-
applied more broadly (Dunbar and Burgoon pists were responsible for more of the interac-
2005). tional dominance. The therapists’ control of the
conversation allowed the therapists to regulate the
speech and minimize the couple’s dominance and
Description reduce their reliance on a “power and control
game.”
While there are many different ways in which
dominance can be measured in a family therapy
setting such as examining the nonverbal cues, Clinical Example
verbal messages, or amount of talk that is uttered
by every family member, one way to determine Imagine a hypothetical scenario in which a couple
dominance is that used by Vall et al. (2016) in a is discussing the possibility of separating and
clinical setting. They measured (a) quantitative what would happen to the family home if they
dominance (who speaks the most), (b) topical or did. One possibility is for the house to be sold and
semantic dominance (having control over the each partner establish an independent household
topics of the conversation), and (c) interactional with the children spending time in each place.
dominance (control over the dialogue flow). Another option is for the couple to maintain the
794 Donor Conception in Couple and Family Therapy
family residence for the children with the parents pauses denoted by . . ., and facial uncertainty), then
alternating living there with the children. these could be coded as well to underscore their
A conversation like this could ensue: verbal dominance cues.
Husband: I would like to talk to you about the

Cross-References
living situation. I think we should
keep the house and basically leave
▶ Family Conflict in Couple and Family Therapy
the kids unchanged. We could split
▶ Power in Family Systems Theory
our time there or something and each
have our chance to be with them. . .
Wife: We wouldn’t share the same house
References
very well.
H: . . . And have another place. I don’t Barbatsis, G. S., Wong, M. R., & Herek, G. M. (1983).
really want to move the kids out of A struggle for dominance: Relational communication
their neighborhood. . .changing patterns in television drama. Communication Quar-
schools would be kind of hard (. . .) terly, 31(2), 148–155.
Dunbar, N. E. (2015). A review of theoretical approaches to
Therapist: And you would share the same interpersonal power. Review of Communication, 15(1),
second residence too? 1–18.
H: Yes Dunbar, N. E., & Burgoon, J. K. (2005). The measurement
W: We wouldn’t share the same of nonverbal dominance. In V. Manusov (Ed.), The
sourcebook of nonverbal measures: Going beyond
apartment well either. words (pp. 361–374). Mahwah: Lawrence Erlbaum
Associates.
Hall, J. A., Coats, E. J., & LeBeau, L. S. (2005). Nonverbal
In this example, the husband is referring to a behavior and the vertical dimension of social relations:
A meta-analysis. Psychological Bulletin, 131,
marital separation and a new living arrangement. 898–924.
In Vall et al. (2016) dominance coding scheme, he Honeycutt, J. M., Wellman, L. B., & Larson, M. S. (1997).
has quantitative dominance because he speaks more Beneath family role portrayals: An additional measure
(65 words) than the wife (18 words), and her two of communication influence using time series analyses
of turn at talk on a popular television program. Journal
speaking turns are essentially the same. However, of Broadcasting & Electronic Media, 41(1), 40–57.
Vall et al. argue that the wife has semantic domi- Sabourin, T. C. (1995). The role of negative reciprocity in
nance because she uses her statements to control the spouse abuse: A relational control analysis. Journal of
conversational topic by objecting to his suggestion Applied Communication Research, 23, 271–283.
Vall, B., Seikkula, J., Laitila, A., & Holma, J. (2016).
saying that the proposed arrangement would not Dominance and dialogue in couple therapy for psycho-
work. Her statements are declarative and have no logical intimate partner violence. Contemporary Fam-
hedging language, while the husband’s statements ily Therapy, 38(2), 223–232.
do contain hedges like “basically” or “or some-
thing” which make them seem less forceful and
dominant than the wife’s. Her use of repetition also Donor Conception in Couple
gives the impression that her decision is non- and Family Therapy
negotiable and therefore more dominant. While we
are lacking the nonverbal cues that accompany this Jean Benward
particular example, if her statement is said as force- San Ramon, CA, USA
fully as it sounds (e.g., with direct eye contact,
eyebrows that come down and together, or a
lowered chin, a firm tone of voice, and a downward Introduction
inflection at the end) and the husbands’ lack of
certainty contained more submissive cues (such as With about seven million women or one in eight
gaze avoidance, upward inflection in the voice, long couples in the United States (USA) experiencing
Donor Conception in Couple and Family Therapy 795
difficulty conceiving a child, many will turn to commonly, in conflict about disclosure to others,
assisted reproductive technology (ART) to have including their children. Becoming a parent
children. Some can become parents only with through gamete donation, like parenting after
“third-party reproduction,” using eggs, sperm, or adoption, entails acceptance of losing a genetic
embryos from another person. Using donor sperm connection with one’s child and shifting the goal
to bypass male infertility has a 100-year history, from having a genetic child to creating a family
becoming more widely used since the 1960s. and parenthood.
Further developments in ART have made possible
the use of donor eggs and embryos, increasing the D
number of people who will use gamete donation Therapy Before Parenthood
for family building. Besides its use by heterosex-
ual couples suffering from male infertility, lesbian Counseling patients about the psychosocial
couples and single women increasingly use donor implications of gamete donation, now strongly
sperm, with single mothers and same-sex couples recommended by professional groups, is a central
now making up a significant percentage of people feature of infertility care in most ART programs in
who use donor sperm. the USA (Sachs andToll 2015). Patients undergo-
ing in vitro fertilization (IVF) with egg or embryo
donation are usually required to meet with a mental
Description: Donor-Conceived Families health professional for one pretreatment session
in Couple and Family Therapy (Benward 2015a). Counselors typically address
anxieties and provide emotional support, informa-
The historical advice to keep the gamete donation tion, and referrals to community resources.
secret, combined with feelings of shame and Recipients of sperm donation, which generally
stigma, left families isolated from social and emo- occurs outside an ART program, are rarely
tional support. Professionals presumed that par- referred to counseling even though professional
ents would forget about using a donor, and the guidelines now recommend counseling for all
donor-conceived had no need for information donor gamete recipients. The difference reflects
about the donor or their genetic origins. In recent the institutional settings (sperm bank vs. ART
decades, the work of researchers and clinicians program), a longer history of secrecy in sperm
along with personal accounts by the adult donor- donation, and a disparity in professional referral
conceived and parents has led to the recognition for counseling for couples facing male factor
that family building with gamete donation is com- infertility.
plex with long-term psychosocial meaning and
impact on the family (Daniels 2015).
The decision to use donor gametes is usually Information Sharing in Donor
difficult. Family building this way can create emo- Conception
tional distress as couples and individuals contend
with feelings of loss and lack of social support. As acceptance of ART has increased and the
Individuals and couples, heterosexual or gay and stigma of infertility lessened, donor conception
lesbian, face a multitude of decisions, uncer- is now more openly discussed in society and
tainties, and expenses. Parents fear insecure bond- within individual families. Changes in legal, pol-
ing between the child and the nongenetic parent; icy, and clinical practice have led to support for
fear that others, including the child, will not see disclosure of donor conception and in providing
the nongenetic partner as the “real parent”; and information about gamete donors (ASRM 2013).
fear the stigma associated with gamete donation. Preconception therapy should include discussion
Couples can experience conflict in decision- about whether to be open with others about using
making, in different ways of coping with stress, a donor. Decisions about whether to tell, whom to
in expectations about sharing feelings, and, most tell, what information to share, and when,
especially regarding their children, are emotion- can affect the parents’ relationship in both the
ally charged issues for parents, especially for the short and long term. The shared experience of
nongenetic parent. Parents respond well to infor- conceiving a child can strengthen a couple’s rela-
mation about outcomes, about strategies, and dis- tionship and increase commitment, but using
cussion that recognizes their particular fears, donor gametes carries a risk of psychological
without pressure to follow any particular path or distress and exacerbation of previous problems.
decision. Since decisions to not disclose are often During medical treatment, relationship issues
fear based, especially for heterosexual couples, often take a backseat to the concrete tasks of
therapy can minimize some of the fear and reduce selecting a donor and navigating the costs
anxiety, regardless of the parents’ decisions about and logistics of inseminations or IVF, leaving
disclosure. Without an opposite sex partner, par- unresolved relationship stress. Some couples will
ents in lesbian couple families and single-parent seek therapy, although they may not identify use
families are by default more open about donor of donor gametes as a source of difficulty. A large
gametes. Despite this, lesbian couples and single body of research confirms that therapy and
parents can still struggle with how to share infor- counseling for persons using medically assisted
mation with their child and others and can benefit reproduction provides effective assistance,
from assistance. reduces levels of anxiety and depression, and
Many therapists recommend parents share increases coping (Benward 2015a).
information about donor conception when chil- Concerns about gamete donation resurface
dren are in preschool and school-age years, before throughout the family’s life cycle. Couple and
puberty, so the child can absorb that information family therapy can help the parents communicate
over time and the child “always knows (Daniels about unresolved conflict or anxiety from gamete
2015; Iliol et al. 2017).” The information sharing donation especially about secrecy or disclosure.
focuses on “how we became a family” and is not a Because parents’ feelings about disclosure can be
single event, but part of an ongoing process. different over time, those who had not disclosed
Young children respond neutrally, with curiosity, may change their mind and seek help. Questions
or pleasure, rather than distress. Parents generally from their children and others about “family
feel positive about having shared the information, resemblances” and inherited traits can prompt
although with feelings of sadness. Later disclo- parents to think about disclosure. It is common
sure, in adolescence or adulthood, can lead to in donor-conceived families, especially with het-
confusion and anger for the donor-conceived, erosexual couples, for parents to manage these
generally because of parental deception, rather “resemblance” questions by avoidance. Their
than use of donor gametes itself. Despite the children and young adults however often observe
risks with later disclosure, research has found no hidden cues, such as facial expressions, changing
consistent association between age of disclosure the subject, and vague or unsatisfactory answers
and family or offspring functioning, suggesting to their questions (Daniels 2015; Paul and Berger
that factors other than age at disclosure contribute 2008). Family therapy can help parents identify
to well-being (Benward 2015b). and process their fears and increase their confi-
dence in discussing donor conception. Disclosure
can be a relief to these families.
Couple Therapy During and After Family Parents who originally intended to disclose may
Formation continue to postpone it. These couples might seek
help when internal conflict intensifies as their chil-
Although donor-conceived families overall func- dren approach adulthood or prepare to leave home.
tion well and couples undergoing medical treat- Parents who consider disclosure when their children
ment with donor gametes tend not to differ from are adolescents or young adults are usually more
the general population, infertility and/or stresses worried and ambivalent about it than those who seek
associated with medically assisted reproduction help when their children are young.
Donor Conception in Couple and Family Therapy 797
In non-disclosing families, maintaining the not reflect problematic parenting and the adoles-
secret about donor conception rests on topic cent is not looking for the “real parent” but
avoidance and withdrawing from a conversation looking to understand him/herself better. Commu-
about certain subjects. Topic avoidance can lead nicative openness about the adolescent’s concerns
to a more general psychological distancing and will have a positive effect, independent of what
compromise family communication. Helping cou- information is available about the donor.
ples increase their communication openness is a
relief to parents and may be as important to family
functioning as specific communication to children Relevant Research D
of donor conception.
Because genetics are central to the cultural A large body of research has looked at the well-
definition of family, these families often need being of parents and children and the quality of
help in creating a family narrative in which a their relationships in donor-conceived families.
genetic tie to a stranger outside the family is These families typically have stable marriages
acknowledged but balanced, knowing that kinship and good parent–child relationships. Overall,
and family are based on more than genetics. there are few differences between donor-
Parents can benefit from guidance in creating a conceived families compared with families who
family narrative that describes the desire for chil- conceived naturally. Longitudinal studies have
dren, the need for help from a donor, and the found few differences between donor-conceived
creation of a family with “real parents.” Therapy children and naturally conceived children on
can help parents accept, and explain, how their scales of emotional symptoms, conduct problems,
family is different but the same as other families or peer relationships. These findings apply to all
(Daniels 2015). family types, including heterosexual couples, gay
Another juncture for family therapy can occur and lesbian couples, and single parents.
when the donor-conceived child reaches adoles- While openness and acceptance of donor con-
cence, sometimes, because of depression or acting ception have increased, there remains religious,
out. Therapists should be alert for signs they are cultural, and social disapproval that can make
working with a family who has not disclosed, but families choose nondisclosure. Research has
the adolescent has an unconscious awareness of found that generally there are no overall differ-
their donor conception. When parents have shared ences between disclosing and non-disclosing
information about donor conception, adolescence families in parent–child relationships, child func-
can be a time of heightened questioning and tioning, or marital satisfaction (Iliol and Golombok
exploration. The adolescent may be curious 2015). Some researchers have reported that within
about the person who gave the eggs or sperm, disclosing families, parent–child relationships may
including the donor’s name, what the donor have less conflict, less maternal stress, and more
looks like, or if they can meet the donor. This satisfaction than in non-disclosing ones.
interest in the donor reflects making sense of
their identity. Some adolescents are also interested
in contacting genetic siblings (i.e., offspring con- Special Consideration for Couple and
ceived using the same donor) growing up in dif- Family Therapy
ferent families. This interest in meeting genetic
siblings commonly reflects a hope for information Twenty years of research with donor-conceived
about the donor through identifying shared families confirms that a genetic link is unneces-
characteristics with other offspring. Adolescent sary for healthy parent–child relationships or child
questioning and information seeking can create development. But genetic links can hold psycho-
family stress and may be something the parents logical significance, an outgrowth of which is that
have feared. Therapy can help parents understand some parents seek other families who used the
that questioning or searching is normal and does same donor, some offspring look for donors,
and/or others conceived with the same donor Cross-References

(Freeman et al. 2014). This trend can be seen in
one Internet-based nonprofit organization that has ▶ Infertility and Pregnancy Loss in Couple and
helped connect over 16,000 donor-conceived with Family Therapy
genetic siblings and/or donors. Motivations for
seeking facilitated or mutually requested contact
are primarily psychosocial support and genetic References
knowledge. Among those who make contact,
relationships can be close or distant; like friends American Society for Reproductive Medicine. (2013).
Informing offspring of their conception by gamete or
or family; or positive or disappointing. Therapy
embryo donation: A committee opinion. Fertility and
can provide a safe and neutral setting to explore Sterility, 100, 45–49.
the meaning of these potential contacts, how both Benward, J. (2015a). Disclosure: Helping families talk
genetics and relationships contribute to identity about assisted reproduction. In S. Covington (Ed.),
Fertility counseling: Clinical guide and case studies
and negotiate new kinship connections. Research
(pp. 252–263). Cambridge: Cambridge University
findings about contact are small, although grow- Press.
ing and available as a resource for therapists who Benward, J. (2015b). Mandatory Counseling for gamete
see these families. donor recipients: ethical dilemmas. Fertility and Steril-
ity, 104(3), 507–512.
Historically the vast majority of gamete donors
Berger, R., & Paul, M. (2008). Family secrets and family
in the USA have been anonymous. The growth of functioning: The case of donor assistance. Family
direct-to-consumer genetic testing along with the Process, 47, 553–566.
creation of large genealogy databases has made it Daniels, K. (2015). Understanding and managing relation-
ships in donor assisted families. In K. Fine (Ed.), Donor
possible for the donor-conceived to discover their
conception for life: Psychoanalytic reflection on new
genetic origins, sometimes as an unwelcome shock. ways of conceiving the family (pp. 181–208). London:
DNA testing potentially allows the donor-conceived Karnac Books.
and donors to discover information about each Freeman, T., Graham, S., Ebtehaj, F., & Richards, M.
(2014). Relatedness in assisted reproduction: Families,
other, about others conceived with the same donor,
origins and identities. Cambridge: Cambridge
and about other genetic relatives. Eventually, this University Press.
raises questions about the viability of anonymity Golombok, S. (2015). Modern families: Parents and
and of nondisclosure (Harper 2016). children in new family forms. Cambridge: Cambridge
University Press.
Harper, J.C., Kennett, D., & Reisel, D. (2016). The end of
donor anonymity: how genetic testing is likely to drive
anonymous gamete donation out of business. Human
Conclusion Reproduction, 31(6), 1135–1140.
Ilioi, E., Blake, L., Vasanti, J., Roman, G., & Golombok, S.
Using donor egg, donor sperm, or donor embryo (2017). The role of age of disclosure of biological
has made parenthood possible for many who can- origins in the psychological wellbeing of adolescents
conceived by reproductive donation: A longitudinal
not achieve it through natural conception. The
study from age 1 to age 14. Journal of Child Psychol-
positive research findings about donor-assisted ogy and Psychiatry, 58(3), 315–324.
families further support the use of donor gametes Ilioi E.C., & Golombok, S. (2015). Psychological Adjust-
for family building. Therapy for this population is ment in adolescents conceived by assisted reproduction
techniques: a systematic review. Human Reproduction,
not about a specific theoretical or methodological
21(1), 84–96.
approach to treatment. It is more important that a Nordqvist, P., & Smart, C. (2014). Relative strangers:
therapist understands the range of issues, unique Family life, genes and donor conception. Basingstoke:
history, and experiences these couples and fami- Palgrave Macmillan.
Sachs, P., & Toll, C. (2015). Counseling recipients
lies can bring to therapy. Therapy can support
of anonymous donor gametes. In S. Covington (Ed.),
these families before conception and throughout Fertility counseling: Clinical guide and case studies
the family life cycle. (pp. 97–108). Cambridge: Cambridge University Press.
Double Bind Theory of Family System 799
bind, communication patterns are common.

Double Bind Theory of Family Thus, the double bind theory of family systems
System was created. Although the theory was highly
controversial at the time and the idea that
Samuel Major1 and Adam R. Fisher1,2 double-binds specifically cause schizophrenia
1
The Family Institute at Northwestern University, has been widely rejected (Wetchler and Hecker
Evanston, IL, USA 2015), the double bind theory continues to play
2
Brigham Young University, Provo, UT, USA a role in modern therapy as it points therapists
to a common communication pattern in dysfunc- D
tional families (Gibney 2006).
Name of Theory
Double Bind Theory of Family Systems Prominent Associated Figures
Gregory Bateson, Jay Haley, Don Jackson, John

Synonyms Weakland
Double bind hypothesis; Double bind theory

of paradoxical communication; The double bind Description
theory of schizophrenia
The double bind theory of family systems is a
culmination of several concepts found in cyber-
netics that were combined to explain what double-
Introduction binds are and how they can play a prominent role
in dysfunctional family systems. Gibney (2006)
During the advent of the field of marriage and stated:
family therapy in the 1950s, Gregory Bateson
The essential hypothesis of the double bind theory
assembled the Palo Alto Group – a team of scien-
is that the ‘victim’ – the person who becomes psy-
tists and psychiatrists to further study the nature of chotically unwell – finds him or herself in a com-
communication as it related to self-regulating sys- municational matrix, in which messages contradict
tems via mechanisms of information, control, each other, the contradiction is not able to be com-
municated on and the unwell person is not able to
and feedback (Gibney 2006). This group from
leave the field of interaction (p. 50).
Palo Alto, California, was particularly interested
in communication patterns in families where a Nichols and Davis (2012) summarized the
member had developed schizophrenia, hoping to double-bind phenomenon by describing the vic-
reject the strictly biological model of schizophre- tim as “[receiving] two related but contradictory
nia that was popular during that time (Nichols and messages on different levels but [finding] it diffi-
Schwartz 2001). As a result, the group produced cult to recognize or comment on the inconsis-
the landmark report Toward a Theory of Schizo- tency” (p. 14). Or even more simply put,
phrenia (Bateson et al. 1956), which offered “families produced schizophrenia by simulta-
the hypothesis that schizophrenia was not biolog- neously calling for two contrary ways of being”
ically caused, rather it was “caused and/or (Lebow 2014) for the identified patients.
promoted by irresolvable communicational In order to further understand the components
conundrums in families” (Gibney 2006, p. 48) and processes that constitute a double-bind, it is
known as double-binds. In other words, they important to first understand what is meant by
understood schizophrenia to make sense in a different levels of communication. According to
familial context where paradoxical, or double- Bateson, all communications between individuals
800 Double Bind Theory of Family System
had content that was stated (i.e., report) and a important relationship in which trust has been
second more abstract message that conveyed established. Third, the receiver of the message
how the communication was to be taken or under- cannot comment on the perceived, though not
stood by the individual receiving the message always understood, paradox of the message in
(i.e., command; Nichols and Schwartz 2001). order to escape the double-bind. The double bind
The simple example of a mother telling her child theory posits that within a family in which those
to clean his room illustrates that there is the report characteristics are found, it makes sense that the
(“please clean your room”) and the command (“I individual caught in the double-bind would
am in charge, therefore do what I say”). When develop psychotic symptoms.
putting forth the double bind theory, Bateson and
his colleagues worked from the assumption that
all communications in families had these two Relevance to Couple and Family Therapy
levels and that contradictions between either the
same level or differing levels could create misun- The double bind theory is relevant and valuable
derstanding between individuals. to the field of marriage and family therapy in
However, it is easy to misuse the concept of a regards to its historical, theoretical, and clinical
double-bind as merely a contradictory message significance (see Gibney 2006 for a more in depth
from which an individual is able to freely choose list of its significance). Historically, the double
either alternative (e.g., “stand up for yourself” but bind theory was one of the first attempts to break
also “don’t be rude”). To clarify the difference, free from the primarily biologically based expla-
Bateson and his colleagues enumerated six nations of its day in order to propel the field of
components that constitute a double-bind marriage and family therapy into a more promi-
(Nichols and Schwartz 2001): nent position in the social sciences (Nichols and
Davis 2012). It was also one of the first attempts to
1. Two or more persons in an important conduct a research project that applied cybernetics
relationship. and systems theory to the study of communication
2. Repeated experience. (Wetchler and Hecker 2015). Relatedly on a the-
3. A primary negative injunction, such as “Don’t oretical level, the double bind theory pointed ther-
do X or I will punish you.” apists to look at how many psychiatric symptoms
4. A second injunction at a more abstract level made sense in the context of pathologic family
conflicting with the first, also enforced by pun- communications (Nichols and Schwartz 2001). In
ishment or perceived threat. other words, psychiatric problems were no longer
5. A tertiary negative injunction prohibiting conceptualized strictly in terms of individual
escape and demanding a response. Without deficits but could instead be conceptualized in
this restriction, the “victim” won’t feel bound. terms of interactional patterns between individ-
6. Finally, the complete set of ingredients is no uals in the contexts of their families and other
longer necessary once the victim is condi- social groups. Clinically speaking, the double
tioned to perceive the world in terms of double bind theory created a way of helping therapists
binds; any part of the sequence becomes suffi- to label and understand what was happening intra-
cient to trigger panic or rage (p. 13). psychically during an interaction common in
therapy (Gibney 2006). The theory also confirmed
Highlighting the essentials of a double-bind for the idea of levels of communication which is
clinical application, Piercy et al. (1996) simplified foundational to understanding the messages and
the six components of a double-bind into three narratives experienced by individuals in their fam-
primary characteristics. First, a paradoxical mes- ilies. In other words, it brought clinical awareness
sage is conveyed between two individuals at dif- to a systemic perspective that was beneficial to
ferent levels of abstraction. Second, the two therapy. Double-binds were later found to be clin-
individuals are in a long-term, emotionally ically useful as a type of intervention common to
Double Bind Theory of Family System 801
strategic family therapy (Wetchler and Hecker tell him that she was not sure she could trust and
2015). For example, in order to upset a family’s be in a relationship with him unless they are
own paradoxical interactions, a therapist could engaged. Often, the couple did not even have to
give a directive that puts that family in a therapeu- follow the pattern, and mere mention of the topic
tic double-bind forcing them to solve their inter- of their engagement brought Jason to a point
actions. Such as directing the clients to continue of rage.
on with their symptoms (i.e., a no-change pre- After observing their interaction, the thera-
scription) when clients insist they cannot change, pist recognized that Jason was in a double-bind
which if followed, paradoxically infers that they and mapped it into the following injunctions, D
are in fact capable of making the choice to change each with their corresponding report and
or not change. command:
Primary Injunction: “Don’t tell me what you are

Clinical Example planning for our proposal, I want it to be a
surprise” (Report). “I trust you to surprise
Jason and Monica are a heterosexual couple that me, so you had better not let me down”
came into therapy seeking help to prepare them (Command).
for their intended wedding in a year. They pri- Secondary Injunction: “I hate not knowing stuff, it
marily wanted to address communication issues causes me to panic” (Report). “You had better
but were most concerned with Jason’s recent tell me what you are doing or else I’ll blame
increase in anger outbursts over the past couple you for my anxiety” (Command).
of months, which had made it difficult for them Tertiary Injunction: “I’m not sure I can trust you
to discuss serious matters about their intended until we are engaged” (Report). “Don’t delay
wedding. The couple told the therapist of their the proposal or else I will leave you”
intention to soon be engaged, but that Jason’s (Command).
anger outbursts made them both feel like they
should reconsider the permanence of their In an individual session with each client, the
relationship. therapist highlighted the mixed messages that
The couple stated that historically they had felt were being given and received. The therapist
connected with each other and had been able to pointed out that the first message to not reveal
talk seriously about almost anything, but that over the planned proposal was innocent enough on its
the past couple of months they had been unable to own (i.e., at the level of report), but that it
talk due to Jason’s anger. The therapist discussed contradicted the implied message (i.e., the com-
with the couple their pattern of communication, mand) of the second statement she was making.
and if there was a given context when Jason’s The therapist also noted to himself that the com-
anger was most apparent. The couple identified mand of the primary injunction contradicted the
the topic of their engagement was central to the report of the tertiary injunction, potentially creat-
anger outbursts. When asked to enact a discussion ing another double-bind.
about their engagement over several sessions, the In order to resolve the double-bind, the thera-
therapist observed the following pattern that held pist worked with Monica on tolerating her anxiety
similarly across all enactments. First, Monica about not knowing, and he worked with Jason on
would tell Jason that he should not tell her when being able to comment on and express his feelings
or how he was going to propose to her. However, concerning the contradiction in her messages that
she would casually remind him that she has panic were now apparent to him. They also worked on
attacks whenever she has to wait for something to helping Jason empathize with Monica’s anxiety
happen. Jason would act confused and ask about the proposal. Together, the couple worked
Monica to stop bugging him so much about the on more clear and direct communication about
engagement. Monica would then act very hurt and their feelings and expectations.
802 Doubling in Couple and Family Therapy
Cross-References alter ego – a double – expressing what the protag-

onist might be holding back or unable to say.
▶ Bateson, Gregory When adapted for use in couple or family
▶ First Order Cybernetics therapy, the therapist does the doubling and
▶ Haley, Jay takes the role of one partner talking to the
▶ Jackson, Donald other or one family member talking to one or
▶ Palo Alto Group, The more other family members. Instead of standing
▶ Schizophrenia in Couple and Family Therapy behind the partner or family member, however,
▶ Second-Order Cybernetics in Family Systems the therapist typically remains seated in their
Theory chair. The therapist says something like,
▶ Strategic Family Therapy “Okay, so I guess you’re saying___” or “Here,
▶ Systems Theory I’ll be you talking to Glen and for you I’ll say,
▶ Weakland, John ‘Glen, I____’.” If the therapist wants to increase
the dramatic effect of the intervention, they
wheel their chair over to the person for whom
References they are speaking (or kneel or sit in a stool or
chair next to this person), looking directly at the
Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956). other partner (or family member), and deliver
Toward a theory of schizophrenia. Behavioural Sci-
their doubling from there.
ence, 1, 251–264.
Gibney, P. (2006). The double bind theory: Still crazy-
making after all these years. Psychotherapy in
Australia, 12(3), 48–55. Theoretical Framework
Lebow, J. (2014). Couple and family therapy: An integra-
tive map of the territory. Washington, DC: American
Psychological Association. Doubling can be employed in any couple or
Nichols, M. P., & Davis, S. D. (2012). Family therapy: family therapy approach to interrupt counterpro-
Concepts and methods (11th ed.). Hoboken: Pearson ductive partner or family exchanges and to model
Education.
the kind of relating the therapist adopting
Nichols, M. P., & Schwartz, R. C. (2001). The essentials of
family therapy. Boston: Allyn and Bacon. that approach seeks to promote: making “I” state-
Piercy, F. P., Sprenkle, D. H., & Wetchler, J. L. (1996). ments, confiding attachment wishes or fears,
Family therapy sourcebook (2nd ed.). New York: taking personal responsibility, turning toward
Guilford Press.
rather than away or against, making repair efforts,
Wetchler, J. L., & Hecker, L. L. (2015). An introduction to
marriage and family therapy (2nd ed.). New York: establishing boundaries, looking at things from
Routledge/Taylor & Francis Group. the other person’s point of view, bringing in
family-of-origin, externalizing the problem, and
so forth.
Many therapists use doubling occasionally in
Doubling in Couple and their work. Some therapists, such as Gottman
Family Therapy and Gottman (2008) and Harville Hendrix, use it
more systematically. Doubling is the signature
Daniel B. Wile method of my approach, Collaborative Couple
Oakland, CA, USA Therapy (Wile 1981, 1993, 2002, 2008, 2011),
and flows naturally out of the fundamental goal
of the approach, which is to increase the cou-
Doubling is a technique developed by Jacob ple’s ability to have the conversation needed to
Moreno for use in his group method of psycho- deal with what comes up moment to moment in
drama. A member of the group stands behind the the relationship. The therapist uses doubling to
protagonist (the person who defines the dramatic demonstrate how such a conversation might
agenda and narrative) and acts as an auxiliary or look and feel.
Doubling in Couple and Family Therapy 803
To simplify presentation, I will talk here only A third couple cycle – pursuit and withdraw –
about couples. However, what I say applies develops out of the almost inevitable situation in
equally to families. which one partner (the pursuer) has a greater
desire than the other (the withdrawer) for sex,
time together, intimate conversation, or other
Rationale for the Intervention type of connection. The more the pursuer presses
for what they want, the more the withdrawer feels
Speaking as one partner talking to the other allows suffocated and backs away. The more the
the therapist to enter directly into the couple inter- withdrawer backs away, the more the pursuer D
action in order to shift the direction of the conver- feels deprived and lonely and presses.
sation, interrupt an escalation, infuse life into a At some point, the pursuer gets frustrated,
devitalized exchange, or jumpstart an intimate con- leading to a fourth vicious circle: attack-
versation. The therapist shows how it might sound withdraw. The pursuer now responds to the other
if partners were to find words for what they have partner’s withdrawal by attacking. The other part-
been struggling to say and speak from a place of ner responds to the first partner’s attack by
greater vulnerability and generosity of spirit. withdrawing.
Taking the role of a partner collapses the space
between that partner and the therapist, an effect
that is intensified if the therapist moves next to the
partner. Doubling – using the first person “I” – can Description of the Intervention
create a mysterious intimacy. The partner softens
and, in response, the therapist does also. The The task in couple therapy is to shift partners
partner gains a spokesperson, translator, and out of the particular vicious circle in which they
advocate. The therapist develops a more palpable are caught (attack-attack, withdraw-withdraw,
sense of the partner’s struggle and helps each pursue-withdraw, or attack-withdraw) and into
partner make her or his point, which often the virtuous cycle of confide-confide – a collab-
includes figuring out with them what that point is. orative cycle (Wile 2013). In a collaborative
Doubling – speaking as one partner talking to cycle, each partner confides heartfelt feelings,
the other – enables the therapist to enter directly makes acknowledgments, reassures, gives the
into the couple system. Looked at from a systems other the benefit of the doubt, and looks at
point of view, a couple relationship can be seen as things from the other’s point of view in response
consisting of a number of self-reinforcing cycles. to the other doing the same. Each partner turns
When partners are caught in an adversarial the other into an ally and confidant.
cycle – a fight – each attacks and defends in Doubling – taking the role of one partner
response to the other doing the same. Both feel talking to the other – is a powerful means for
too unheard to listen, too misunderstood to be jumpstarting a collaborative cycle. The therapist
understanding, and too provoked by what the takes the fight-inducing or withdrawal-inducing
other just said to do anything other than resist comment a partner just made and translates it
and retaliate. In this vicious circle, each partner into an intimacy-inducing one. The therapist
turns the other into an enemy. accomplishes this transformation by:
When partners are caught in a withdrawn
cycle, each partner’s silences, monosyllabic 1. Changing the tone – replacing the partner’s
replies, distant manner, devitalized tone, avoid- harsh tone of voice with a friendly one or
ance of controversial topics, talking around distant tone with an engaged one.
things, and strained attempts to engage in a con- 2. Introducing vulnerable feelings – turning the
versation stimulate the same in the other much as partner’s angry complaint into a wish, fear, or
whispering stimulates whispering. Each partner other vulnerable feeling or devitalized com-
turns the other into a stranger. ment into a heartfelt one.
804 Doubling in Couple and Family Therapy
3. Making acknowledgments. A colleague, someone we could really love. We never thought

Dorothy Kaufmann, pointed out the crucial we would. But because it’s been your lifelong
dream to have a baby and I can’t bring myself to
role of acknowledgment in doubling. When having another – I’ve already had three with my
partners fight, neither gets the satisfaction of ex – we might lose it all.
having the other agree with or acknowledge
anything – which is what fuels the fight.
When partners withdraw, they are, of course, I try to show how it might look if these
not tuned into each other. As the therapist, partners were to step back from the intensity of
I do the agreeing, acknowledging, and tuning the situation, view themselves and their partner
in for them. compassionately, recognize the “couple predica-
When I double for partners deep in argument,” to use Erik Grabow’s words, and appreci-
ment, I begin if possible with, “You’re right ate each partner’s struggle.
that. . ..” and then go on to acknowledge what
I imagine that person I’m speaking for does
agree with. My “You’re right” breaks the spell Case Example
of the partners’ reflexive rejection of every-
thing the other one says. My upbeat words When doubling for a partner, the therapist restates
make them aware, by contrast, of the grim, what that partner just said in a way that is more
giving-no-quarter state they’ve been in. satisfying to that partner and easier for the other
If I can’t think of anything that a partner, partner to hear.
let’s call her Marianne, agrees with in what her
Jack (to Anna): You fuss too much with the baby.
partner, Lynne, is saying, I acknowledge on You –
Marianne’s behalf that she has at least heard
what Lynne has said. Speaking as Marianne From what I know of this couple, Anna is
talking to Lynne, I say something like, “I get almost certain to react angrily, and the two are
what you’re saying, which is____. And what about to slip into the kind of escalated exchange
I’m trying to say is_____” or “I’m getting that they’ve come to therapy to stop. I pre-empt
frustrated because I can’t get you to see the fight by moving in and replacing Jack’s com-
that____. Of course, you might be equally plaint with a vulnerable feeling, his “you” state-
frustrated because you can’t get me to see ment with an “I” statement.
that____.” Such even-handed representation Dan: Jack, let me soften that and see what you
of each partner’s message can at times break think. Here, I’ll be you talking to Anna. And for
the logjam. you, I’d say, “Anna, I miss the alone time we used to
be able to have before Ella was born.”
4. Reporting the couple predicament. When part-
ners fight, they are down in the muck having it Since I’m making a speculation – although an
out. When they withdraw, they are essentially informed one – I quickly add, “Where am I right
absenting themselves from the scene. When and where am I wrong in my guess about how you
I double for them, I show how it might look if feel?”
they were to step up, as if on a platform, and, in Anna is almost certain to find my restatement
the words of Finkle et al. (2013), adopt “the easier to hear. She’s likely to turn to Jack and
perspective of a neutral third party who wants say something like, “It would make all the differ-
the best for all involved.” ence if you put it that way” or “Is that how you
feel?” I prepare for the possibility, however,
Dan (speaking as Juanita talking to David): We’re
stuck again in this painful vicious circle in which
that she might say to Jack, “He said that, you
you withdraw when I get critical and I get critical didn’t!” My task then would be to double for her.
when you withdraw. It’s caused us a lot of misery. “Anna, are you saying, ‘Jack, it’s too good to
Dan (speaking as Sid talking to Amelia): It’s heart- believe that you might actually feel that way, but
breaking. We’ve finally found in each other it would be wonderful if you did’.” I’d be reshaping
Doubling in Couple and Family Therapy 805
Anna’s fight-inducing comment into an intimacy- • Interrupts an escalating exchange (and, in other
inducing one, as I did a moment before for Jack. cases, breathes life into a devitalized one)
Again, I’d add, “Anna, where am I right and where • Turns what the couple is concerned about or
am I wrong in my guess about how you feel?” struggling with at the moment into an oppor-
But how does Jack feel about my replacing tunity for intimacy
his “You fuss too much with the baby” with • Ends each doubling statement by asking in one
“I miss the alone time we used to be able to form or another, “Where am I right and where
have”? He might welcome it, seeing that my am I wrong in capturing how you feel?”
translation is more likely to get Anna to listen. D
He might feel relief in having his tender feelings But is it such a good idea to skip over Jack’s
brought into the open. complaint that Anna fusses too much over Ella
I’m using an example – missing alone time and to suggest the issue is also within him?
with Anna – to suggest the range of soft under- Couldn’t he feel embarrassed or undercut?
belly feelings. I’m saying in essence, “Jack, Couldn’t he believe I’m siding with Anna and
there’s a whole different angle from which to putting the blame on him? He could. Accordingly,
look at this situation – the angle of vulnerable before making my intervention, I ask myself, “Is
feelings. For example, maybe you miss the alone there a chance that my comment will alienate Jack
time you used to be able to have with Anna. If that in a way I can’t easily repair?” If I believe there is,
doesn’t capture how you feel, is there a vulnerable I content myself with a less chancy intervention
feeling of another sort that does?” such as:
Jack might not want at the moment to talk
about vulnerable feelings. He might say, “What Dan: Here, I’ll be you, Jack, talking to Anna. And
I feel is that Anna fusses over the baby too much” for you, I’d say, “Anna, I know we disagree about
Ella, but don’t you wonder sometimes whether
or “No, you’ve got it all wrong. It’s what I said, there might be at least a little something to my
which is. . ..” But let’s say he welcomes the oppor- concern?”
tunity to confide his softer feelings. Turning to Or:
Anna, he says:
Dan: “Anna, I wish I had a way to talk with you
about Ella that didn’t just lead to an argument –
• “I feel foolish being jealous of my own because it’s hard for me to believe I’m entirely
daughter.” wrong about you being overly involved with her.”
• or “I miss the intimacy that you get breast feed- Or, demonstrating how it might sound if Jack were
ing Ella. I feel so left out.” to acknowledge Anna’s point of view.
• or “I wish my mother had been a fraction as
concerned about me as you are about Ella.” Dan: “Anna, I get what you’re telling me, which is
that how we treat Ella now will greatly affect her
whole life. She needs our attention. What I want to
tell you is that there’s a possibility of overdoing it.”
Jack would be confiding feelings in a way that
(To Jack) And you might want to add – you tell me –
could jumpstart an intimate conversation. This “If we’re to do our best for Ella, we need to keep
brief exchange demonstrates how in doubling things alive in our own relationship.” I made that
the therapist: up, Jack. You tell me if there’s anything to it at all.
Or, reporting the couple predicament.
• Provides an in vivo demonstration of intimate Dan: “It’s difficult when we disagree about some-
talking thing so important. We each want to do right by Ella
• Serves as spokesperson, translator, and advo- and we have such different ideas at the moment
cate for each partner what that means. It’s so important that it’s hard not
to get upset with each other. This is tough.”
• Recasts what each partner says in an effort to
make it more satisfying to that partner and I’m getting behind Jack in what he has been trying
easier and/or more positively engaging for the to say, but reshaping his angry statement into one
other partner to hear that might actually start a conversation. Instead of
806 Dulwich Centre
pressing his case, which is what he is doing, handbook of couple therapy (4th ed., pp. 138–164).
I show how it might look if he were able to step New York: Guilford Press.
Wile, D. B. (1981). Couples therapy: A nontraditional
back from the intensity of the moment and present approach. New York: Wiley.
what he wants to say in a more disarming and less Wile, D. B. (1993). After the fight: Using your disagree-
accusing way. ments to build a stronger relationship. New York:
If I stick more closely to what Jack has been Guilford.
Wile, D. B. (2002). Collaborative couple therapy. In
saying – if I meet him where he is and pay atten- A. S. Gurman & N. S. Jacobson (Eds.), Clinical
tion to what he’s trying to express – he may be handbook of couple therapy (3rd ed., pp. 281–307).
able to look at his vulnerable feelings, if not New York: Guilford.
immediately, perhaps later in the session or in Wile, D. B. (2008). After the honeymoon: How conflict can
improve your relationship, revised edition. Oakland:
future sessions. People need to feel heard in Collaborative Couple Therapy Books.
order to feel safe enough to confide their vulner- Wile, D. B. (2011). Collaborative couple therapy. In
able feelings or even just recognize that they D. K. Carson & M. Casado-Kehoe (Eds.), Case
have them. studies in couples therapy: Theory-based approaches
(pp. 303–316). New York: Routledge.
Doubling reveals to partners the problematic Wile, D. B. (2013). Opening the circle of pursuit and
aspects of their way of relating. By giving the distance. Family Process, 52, 19–32.
partners examples of what confiding, acknowl-
edging, and listening look like, the therapist
shows by contrast how they have been accusing,
dismissing, and not listening. Dulwich Centre
For many couples the experience is enlighten-
ing. They enjoy the better conversations the ther- Cheryl White
apist helps them have and, after a while, begin to Dulwich Centre, Adelaide, Australia
improve their conversations at home. A few cou-
ples never quite get the hang of what the therapist
is doing. For some couples, the experience is Name of Organization or Institution
transformative. They quickly see what they’ve
been doing and go on to adopt their own version Dulwich Centre
of this more productive way of relating.
Introduction
Cross-References
Dulwich Centre in Adelaide, Australia, is one of
▶ Collaborative Couple Therapy the key “homes” of narrative practice and is
▶ Collaborative and Dialogic Therapy with Cou- involved in narrative therapy, community work,
ples and Families training, publishing, supporting practitioners in
▶ Emotionally Focused Couple Therapy different parts of the world, and cohosting inter-
▶ Gottman Method Couples Therapy national conferences.
▶ Psychodrama in Family Therapy Dulwich Centre is a place of innovation and
creativity. Throughout the time that Michael
White was involved at Dulwich Centre (from
References 1983 until his untimely death in 2008), he was
continually developing new forms of narrative
Finkle, E. J., Slotter, E. B., Luchies, L. B., Walton, F. M., & practice to challenge and inspire and to invite the
Gross, J. J. (2013). A brief intervention to promote field to think beyond what was already known.
conflict reappraisal preserves marital quality over
time. Psychological Science, 24, 1595–1601.
Practices such as externalizing conversations
Gottman, J. M., & Gottman, J. S. (2008). Gottman (which involve locating personal and family prob-
method couple therapy. In A. S. Gurman (Ed.), Clinical lems in broader social contexts including gender,
Dulwich Centre 807
race, class, sexual identity), therapeutic documen- Jane Hales has worked at Dulwich Centre since
tation, re-authoring conversations, saying hello 1983 as receptionist, administrator, typesetter, and
again/remembering conversations, and outsider- proofreader and is the coeditor of the book, The
witness practice all evolved during Michael Personal is Professional: Therapists reflect on
White’s time at Dulwich Centre and in collabora- their families, lives and work.
tion with David Epston (who visited regularly). Dulwich Centre has a long history of partner-
ship with the Just Therapy Team of Aotearoa
New Zealand: Charles Waldegrave, Taimalieutu
Location Kiwi Tamasese, Flora Tuhaka and Warihi D
Campbell.
Dulwich Centre is located at 20 St John Street, Key current members of the Dulwich Centre
Adelaide, South Australia. This is on the lands of national and international faculty include Jill
the Kaurna (Aboriginal) people. Freedman, David Epston, Carolyn Markey, Chris
The Dulwich Centre is also located online at Dolman, Gaye Stockell, Mark Hayward, Ncazelo
www.dulwichcentre.com.au. Ncube-Mlilo, Tileah Drahm-Butler, Angel Yuen,
Ruth Pluznick, Sekneh Beckett, Manja
Visschedijk, Loretta Pederson, David Newman,
Prominent Associated Figures and Poh Lin Lee.
Over three decades, there have been so many
Michael White, cofounder along with David other people who have contributed to Dulwich
Epston of narrative therapy, was a director at Centre in diverse ways. Dulwich Centre has
Dulwich Centre from 1983 until his death in been a foundation or stepping stone for people to
2008. As a family therapist, teacher, community train, work, move on, and start their own pro-
worker, and writer, Michael White’s work trans- grams and centers all over the world.
formed conventional notions of therapy.
Cheryl White is a codirector of Dulwich Centre,
founder of Dulwich Centre Publications and editor Contributions
and initiator of projects. Cheryl is the author of A
Memory Book for the Field of Narrative Practice During the 1990s, collective projects, such as: the
and Conversations about Gender, Culture, Violence Dulwich Centre alternative community mental
& Narrative Practice: Stories of hope and complex- health project; narrative community gatherings,
ity from women of many cultures. including those in partnership with Aboriginal
Barbara Wingard is a senior Kaurna communities; and more recently, cross-cultural
(Aboriginal) elder. She is a coauthor, with Jane inventions such as the Tree of Life and Team of
Lester, of the influential book, Telling our Stories Life narrative approaches, continue to push the
in Ways that make us Stronger, and coauthor, with field of narrative practice in new directions.
Carolynanha Johnson and Tileah Drahm-Butler, This commitment at Dulwich Centre to contin-
of the book Aboriginal Narrative Practice: ually extend what is known as narrative practice is
Honouring storylines of pride, strength and now enhanced through the Master of Narrative
creativity. Therapy and Community Work, which is offered
David Denborough is a codirector of Dulwich in collaboration with the University of Mel-
Centre, community worker, teacher, and writer/ bourne. This program requires participants to
editor. His books include Retelling the stories of innovate local forms of culturally respectful
our lives: Everyday narrative therapy to draw forms of narrative practice. The master program
inspiration and transform experience and Collec- is designed so it is accessible to practitioners
tive narrative practice: Responding to individ- wherever they are based and has had graduates
uals, groups, and communities who have from Singapore, Canada, Australia, Spain, Hong
experienced trauma. Kong, Israel, Tanzania, Ireland, Chile,
808 Dulwich Centre
South Africa, Denmark, Mexico, New Zealand, body of work written by narrative therapists and
and the UK. Dulwich Centre also cohosts long- community workers published in different parts of
term training programs in Turkey, Singapore, the world. Dulwich Centre Publications has
Greece, Hong Kong, and mainland China. One published over 25 books and countless journal
week intensive workshops, One year programs, articles and stories of practitioners’ work. If a
and short workshops are also offered locally in therapist is seeking writing about the use of nar-
Adelaide. rative approaches with someone experiencing a
As well as seeking to spark innovation, Dul- particular difficulty, there is a good chance such
wich Centre has also sought to create forums to a piece of writing now exists (see narrative ther-
sustain conversations between practitioners and apy bibliography: http://www.narrativethera-
build and support a community of ideas. In pylibrary.com/bibliography).
1983, Cheryl White initiated a series of free events Dulwich Centre Publications remains an inde-
on Friday afternoons. These “Friday afternoons at pendent, feminist-informed publishing house,
Dulwich” would begin at 4.30 pm so that people headed by Cheryl White, that publishes writings
dropped by on their way home after the working that represent a diversity of cultures and sexual
week. They always consisted of a good speaker and gender orientations and which stretch and
sharing some aspect of their practice that was challenge dominant cultural understandings of
currently intriguing and challenging to them and the worlds in which we live and work. The Inter-
which was then followed by rigorous debate and national Journal of Narrative Therapy and Com-
discussion. Eventually these events became too munity Work is a peer-reviewed journal produced
popular to continue in person, but with the advent by Dulwich Centre Publications.
of the internet, Friday afternoon forums now take Dulwich Centre Foundation supports workers
place online. On the last Friday of every month, a and communities in different parts of the world
free video is streamed on www.dulwichcentre. who are responding to significant trauma. This
com.au. A rigorous free introductory course on involves:
narrative therapy is also available online, which
provides ideas and resources to practitioners who • Direct counselling and community work with
otherwise could not access them. The “commu- individuals, groups, and communities
nity of ideas” associated with narrative practice is • Developing respectful, effective, and culturally
now nurtured online as well as through events, appropriate methodologies to respond to com-
trainings, and publications. munity mental health issues and collective
In the 1980s there was so much energy and trauma
interest in the early Friday afternoon presentations • Working in partnership with local communities
that it seemed a good idea to write these down, to engage with children, young people, and
and a small news-sheet was developed for this adults using these methodologies
purpose. Links were generated between a range • Building the capacity of local mental health
of local practitioners and these first news-sheets workers/community members to address men-
were simply a way to continue the conversations. tal health issues in a range of contexts.
Over time, people from other places requested
copies of the news-sheet, which gradually turned Crucially, this work involves cross-cultural
into a journal. Interest in the ideas continued to partnerships, processes to avoid or minimize the
grow and, in 1989, Dulwich Centre Publications chance of psychological colonization, and the
published its first book, Literate means to thera- cross-cultural inventions of new ways of working
peutic ends, by David Epston and Michael White (such as the Tree of Life and Team of Life narra-
(which was then republished as Narrative means tive approaches).
to therapeutic ends by W. W. Norton). Fast for- Dulwich Centre Foundation has a history of
ward to the present and there is now a substantial working in partnership with colleagues and
Dulwich Centre 809
organizations in Palestine, Rwanda, Uganda, • To create an opportunity for participants to

Bosnia, Israel, India, Sri Lanka, Kurdistan build a sense of connectedness and to con-
(Iraq), and within Australia with asylum tribute to the building of a community of
seekers, refugees, young people, and Aboriginal ideas
communities. Current projects within Australia • To provide the opportunity and support neces-
focus on using narrative practices to facilitate sary for individuals and groups who have never
the sharing of stories of “survival skills” and presented before at conferences (and indeed
“life-saving tips” between diverse groups of may never have told their stories in front of
young people. Enabling young people from an audience) to present the stories of their lives D
diverse backgrounds to make contributions to and their particular knowledges and skills in
each other is a powerful force for social cohe- keynote addresses
sion. When young people experience that their • To create an atmosphere that is non-
skills and knowledge can contribute to others hierarchical, with no pronounced difference
who are going through hard times, then their between presenters and participants
own experiences of negotiating isolation, mar- • To provide a forum for conversations that are
ginalization, and cultural and/or religious intol- expanding the field (not confirming it or simply
erance take on a different meaning. By eliciting, reiterating what is already known)
documenting, and sharing “survival skills” • To decenter the conference collective in both
between young people, this builds their capacity the lead-up and during the conference itself so
to respond to hardship in their own lives and that the focus remains on everyone’s contribu-
enables a sense of inclusion and acknowledg- tions to a community event
ment through making a contribution. Through
these social projects, Dulwich Centre Founda- The Michael White Archive is located at Dul-
tion seeks to respond to racism, Islamophobia, wich Centre. This archive includes Michael’s
sexism, and homophobia. unpublished papers and video recordings of his
Since 1999, Dulwich Centre has hosted Inter- teachings and selected therapy sessions. Two
national Narrative Therapy and Community Work books, Narrative Practice: Continuing the Con-
Conferences in Adelaide (Australia), Atlanta versations and Narrative Therapy Classics,
(USA), Liverpool (UK), Oaxaca (Mexico), Hong have already been published from archival
Kong (China), Kristiansand (Norway), and Salva- material. In the coming years, further material
dor (Brazil). These events seek: from the archive will be made available to prac-
titioners, students, and scholars.
• To provide high-quality presentations on the Finally, Dulwich Centre is also a continually
latest thinking and application of narrative evolving team and network of narrative thera-
ideas and to do so in ways that enable people pists, community workers, teachers, and
of differing experience to be both engaged and writers. The Dulwich Centre’s national and
challenged international faculty is diverse in terms of cul-
• To enable people of different cultures, coun- tures, locations, genders, sexual orientations,
tries, genders, ages, class backgrounds, physi- age, and class backgrounds. In recent years,
cal abilities, and sexual identities to come the Aboriginal Narrative Practice Teaching
together, enjoy each other’s company, and Team (led by Aunty Barbara Wingard and
have a sense that the conference program and Tileah Drahm-Butler) has begun to offer work-
processes include their perspectives, hopes, shops on narrative therapy through an Aborigi-
and ideas nal lens and on how narrative practices can be
• To use the conference as a chance to acknowl- used to decolonize identity stories. Dulwich
edge and come to terms with the history of the Centre is committed to and energized by collab-
land on which it is held orations across difference.
810 Duncan, Barry
Currently, he is the CEO of Better Outcomes

Duncan, Barry Now and the Director at The Heart and Soul of
Change Project. In this position, he has been able
Martha Hernández to continue his interest in research and training
Family Support Services at Ronald McDonald others use the PCOMS.
House at Stanford, Palo Alto, CA, USA
Name
Dr. Duncan has contributed in various ways
Barry L Duncan, Psy.D. and topics of interests in the field of psychology.
Dr. Duncan was the co-founder and the co-director
of The Institute for the Study of Therapeutic
Introduction Change, alongside colleagues Scott Miller and
Mark Hubble. During his time as the co-director,
Dr. Barry L. Duncan has been essential in the he was responsible for co-developing, with Miller,
development of client-centered measures specific the Outcome Rating Scale (ORS) and Session Rat-
to the therapeutic relationship, in an effort to ing Scale (SRS) family of measures. Each scale
improve the quality of treatment. In addition to includes four-items given to clients to complete.
his client-centered measures, his research has con- The ORS is given at the beginning of a session to
tributed to various areas including couple and assess client progress during treatment. While, the
family therapy, integrated behavioral health, phar- SRS is given at the end of sessions and aims at
maceuticals in pediatrics, and addiction. He has measuring the therapeutic relationship from the cli-
over one hundred publications in these areas of ent’s perspective.
specialty. After many years of research, Duncan and Sparks
(2002) jointly developed the Partners for Change
Outcome Management System (PCOMS), a clinical
Career system that includes administering both the ORS and
SRS for client-centered feedback regarding client
In 1984, Dr. Duncan obtained his Psy.D. from progress and therapeutic relationship. This now allo-
Wright State University, School of Professional wed the measures to inform the quality of care being
Psychology. In that same year, he began as provided to the client from the client’s perspective.
Clinical Faculty at Wright State University Duncan and Sparks, used the PCOMS to be able to
(1984–1994) and in 1985 as Clinical Assistant address the problem that many therapists struggle
Professor (1985–1992). As Director at The Day- with; being able to rate their own effectiveness with
ton Institute for Family Therapy, he developed a clients and treatment.
training and treatment center (1986–1994). As director of The Heart and Soul of Change
Since then Dr. Duncan has held various adjunct Project, he continues to research the clinical use of
professor positions at different universities. PCOMS. Dr. Duncan’s main focus has been the
More recently, he was the co-founder and client’s individual world views, as well as to utilize
co-director of The Institute of the Study of Ther- the client’s theory of change to improve outcomes.
apeutic Change (1997–2009), in which he Multiple studies have found that by just utilizing
co-developed the Outcome Rating Scale (ORS) PCOMS, client outcome increased and the thera-
and Session Rating Scale (SRS) family mea- peutic relationship improved. Since then, PCOMS
sures. He later utilized the ORS and SRS mea- has been recognized and listed on the SAMHSA’s
sures to create the Partners for Change Outcome National Registry of Evidenced-based Programs
Management System (PCOMS). and Practices.
Dyadic Adjustment Scale 811
Dr. Duncan continues to provide continuing

education training for those wanting to learn Dyadic Adjustment Scale
how to utilize PCOMS. PCOMS is easily acces-
sible and used in hundreds of organizations Adam R. Fisher1,2 and Alice F. Roberts3
1
throughout the United States and in countries The Family Institute at Northwestern University,
across the world. Dr. Duncan has increased acces- Evanston, IL, USA
2
sibility by creating Better Outcomes Now (BON), Brigham Young University, Provo, UT, USA
3
along with Bill Wiggins. BON is a web-based Bountiful, UT, USA
version of the PCOMS. It allows for therapists D
and supervisors to monitor clients’ perception
of progress and the therapeutic relationship, as Name and Type of Measure
well as the changes in scores for clients or the
therapist. More information on the PCOMS is The Dyadic Adjustment Scale* is a pen-and-paper
further discussed and included in Dr. Duncan’s measure of the quality of a marriage or similar
most recent book On Becoming a Better Thera- relationship.
pist: An Evidence-based Practice One Client at a
Time (2010).
Synonyms
DAS; DAS-7; RDAS

Cross-References
▶ Assessment in Couple and Family Therapy

Introduction
Therapy
Dyadic adjustment is one of the most common
constructs utilized for assessing marriages or
similar romantic relationships (Spanier 1976)
References
and has been used in relationship research for
Duncan, B. (2014). On becoming a better therapist:
over 50 years in thousands of studies (Graham
Evidence based practice one client at a time (2nd ed.). et al. 2006). These studies have involved adult
Washington, DC: American Psychological Association. relationships or marriages on a variety of topics
Duncan, B., & Sparks, J. (2002). Heroic clients, heroic such as stress, emotional health, relationship
agencies: Partners for change. Ft. Lauderdale, FL:
Nova Southeastern University.
problems, and outcome studies for psychother-
Duncan, B., & Sparks, J. A. (2016). Systematic feedback apy models. Definitions of dyadic adjustment
through the Partners for Change Outcome Management include how much accommodation each partner
System (PCOMS). In M. Cooper & W. Dryden (Eds.), gives the other or the degree to which a couple
Handbook of pluralistic counselling and psychother-
apy (pp. 55–67). London: Sage.
has established positive qualities in their
Duncan, B., Miller, S., Wampold, B., & Hubble, M. (Eds.). relationship – such as resolving disagreements.
(2010). The heart and soul of change: Delivering what Perhaps the most common definition conceptu-
works (2nd ed.). Washington, DC: American Psycho- alizes dyadic adjustment as the quality of a
logical Association.
Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does
romantic relationship involving two people
a continuous feedback model improve psychotherapy (Spanier 1976). This quality may also reflect
outcomes? Psychotherapy: Theory, Research, Prac- the degree a couple is able to reach consensus
tice, Training, 46, 418–431. on key issues, how much tension they experi-
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J.
(2015). Evaluating the efficacy of client feedback
ence due to their differences, and the general
in group psychotherapy. Group Dynamics: Theory, lack of distress in the relationship (Graham
Research, and Practice, 19, 122–136. et al. 2006).
812 Dyadic Adjustment Scale
Developers subscales are less reliable than the total score, with
the affective expression subscale being notably
The Dyadic Adjustment Scale (DAS) was devel- lower than the others (a = .73; Spanier 1976). Nota-
oped in 1976 by Graham B. Spanier at The bly, the RDAS removes affectional expression
Pennsylvania State University as a self-report entirely, and the DAS-7 includes only three items
measure of the quality of a marriage or similar assessing consensus, three for cohesion, and one for
relationship. satisfaction. The DAS-7 is a reliable and valid instru-
ment comparable to the DAS (Hunsley et al. 2001).
The DAS has also been evaluated for content
Description of Measure validity based on the relevancy of items to relation-
ships, consistency of definitions of satisfaction,
The DAS consists of 32 Likert-type items, which cohesion, consensus, and appropriateness of fixed-
were developed based on 300 items from existing choice responses (Spanier 1976). Concurrent valid-
measures, and is written at an 8th-grade reading ity has been demonstrated through a high positive
level. The DAS is administered separately to correlation with the Locke-Wallace Marital Adjust-
each partner. The DAS includes four subscales that ment Scale (Spanier 1976). Norms of the DAS are
can be separately measured: (1) dyadic satisfaction – based on a group of 218 married and 94 recently
the amount of tension and one’s commitment to divorced adults (Spanier 1989).
staying in the relationship (10 items); (2) dyadic
cohesion – shared behaviors and interests (five
items); (3) dyadic consensus – how much the couple Example of Application in Couple and
agrees on important issues (13 items); and (4) affec- Family Therapy
tional expression – satisfaction with sex and the
level of affection in the relationship (four items). The DAS can be applied in couple and family
Scoring of the DAS involves adding up the total therapy as a measure of marital or relationship qual-
score of each question – resulting in a range of 0 to ity of a couple at the time of the initial intake.
151 – with higher scores representing a higher qual- A couple therapist can compare each partner’s
ity of marriage or relationship. Each subscale can scores to the averages for people who are married
also be separately scored. Other shorter versions of (M = 114.8, SD = 17.8; Spanier 1976) or recently
the DAS have also been developed, including the divorced (M = 70.7, SD = 23.8), or to those who are
14-item Revised Dyadic Adjustment Scale (RDAS) in distress (<92) or who are “adjusted” or recovered
and a seven-item version (DAS-7). The DAS can be from distress (>107). Scores can be used to measure
administered by couple and family therapists, as the quality of the couple’s relationship pre- and
well as psychologists, counselors, social workers, posttreatment as a more objective measure of pro-
or other professionals with documented training, gress in couple therapy. A partner’s level of satis-
such as completion of university-level courses in faction in the relationship may change from day to
testing and assessment. day, but measuring adjustment through the DAS
may be seen as less susceptible to daily changes in
mood. Responses to specific items may also be used
Psychometrics to prompt discussion of treatment goals.
For example, Chris and Sarah presented to cou-
Reliability of the total DAS score is high (a = .96; ple therapy having been married for about two years.
Corcoran and Fischer 2013); the DAS is a reliable Their initial DAS scores prior to the intake strongly
measure of objective relationship characteristics. suggested some marital distress: Chris scored 96 and
Multiple studies have confirmed its high reliability Sarah 88. The therapist specifically looked at ques-
and have shown that it is not substantially affected by tion 32, which asks about level of commitment in the
sample participants’ marital status, ethnicity, sexual marriage. Sarah scored a 3 out of 5 and Chris a 4 out
orientation, or gender (Graham et al. 2006). The four of 5 on this question, agreeing with the statements,
Dyadic Coping Inventory 813
respectively – “I want very much for my relationship References

to succeed, and will do my fair share to see that it
does,” and, “I want very much for my relationship to Corcoran, K., & Fischer, J. (2013). Measures for clinical
practice and research: A sourcebook: volume 1: Cou-
succeed, and will do all I can to see that it does.” The
ples, families, and children (5th ed.). New York:
therapist addressed this with the couple near the end Oxford University Press.
of the intake, noting that both partners were very Graham, J. M., Liu, Y. J., & Jerziorski, J. L. (2006). The
committed to making changes in the marriage. Scor- Dyadic Adjustment Scale: A reliability generalization
meta-analysis. Journal of Marriage and Family, 68,
ing lower on this question may be cause for concern
regarding beginning couple therapy and may sug-
701–717. https://doi.org/10.1111/j.1741-3737.2006. D
00284.x.
gest the need for a more appropriate approach such Hunsley, J., Best, M., Lefebvre, M., & Vito, D. (2001). The
as discernment counseling. seven-item short form of the Dyadic Adjustment Scale:
Further evidence for construct validity. American
The therapist then readministered the DAS
Journal of Family Therapy, 29, 325–335. https://doi.
about once every five sessions or so to check in org/10.1080/01926180152588734.
on progress, as well as specific areas that were Kurdeck, L. A. (1992). Dimensionality of the Dyadic
initial concerns during the intake, including dem- Adjustment Scale: Evidence from heterosexual and
homosexual couples. Journal of Family Psychology,
onstrations of affection, household tasks, and the
6(22), 22–35.
frequency of arguments. The therapist presented South, S. C., Krueger, R. F., & Iacono, W. G. (2009).
the data to the couple each time along with a Factorial invariance of the Dyadic Adjustment Scale
graph displaying their scores. At the end of across gender. Psychological Assessment, 21, 622–628.
https://doi.org/10.1037/a0017572.
therapy – which lasted 15 sessions – Sarah’s DAS
Spanier, G. B. (1976). Measuring dyadic adjustment: New
had increased to 97, out of the “distressed” range, scales for assessing the quality of marriage and similar
and Chris scored a 112, close to the average score dyads. Journal of Marriage and Family, 38, 15–28.
for a married adult. The therapist and the couple Spanier, G. B. (1989). DAS: Dyadic Adjustment Scale.
Retrieved from http://downloads.mhs.com/das/das.pdf
discussed the meaning of these scores, what
Spanier, G. B., & Filsinger, E. E. (1983). Clinical use of
amounts of change are clinically significant the Dyadic Adjustment Scale. In E. E. Filsinger
(11 points or more), and where the couple felt like (Ed.), Marriage and family assessment:
they were still vulnerable or concerned in their A sourcebook for family therapy (pp. 156–168). Bev-
erly Hills: Sage.
marriage. They each reported feeling much more
stable in their marriage after the sessions, but noted
some continued areas of concern, and the therapist
provided them with referrals for after their upcom-
ing move for work. Both partners were also appre- Dyadic Coping Inventory
ciative to see the data from the DAS; it provided
them with both confidence and clarity in the Guy Bodenmann1, Laura Jimenez Arista2,
process. Kelsey J. Walsh3 and Ashley K. Randall4
1
Department of Psychology, University of Zurich,
Binzmuehlestrasse, Zurich, Switzerland
2
Cross-References Arizona State University, Phoenix, AZ, USA
3
Arizona State University, Tempe, AZ, USA
▶ Assessment in Couple and Family Therapy 4
Counseling and Counseling Psychology,
▶ Classification in Couples and Families Arizona State University, Tempe, AZ, USA
▶ Couple Distress in Couple and Family Therapy
▶ Discernment Counseling in Couple and Family
Therapy Name and Type of Measure
▶ Marital Satisfaction Inventory: Revised
▶ Norms in Couples and Families The Dyadic Coping Inventory is a self-report
▶ Spanier, Graham questionnaire that measures stress management
▶ Locke-Wallace Marital Adjustment Test in couples.
814 Dyadic Coping Inventory
Synonyms disinterest), ambivalent (providing support to

the partner but in an unwilling and unmotivated
DCI way, making the partner feel that provision of
support is not appreciated), and superficial (the
partner provides support but with no motiva-
Introduction tion, no authentic empathy, and no real under-
standing). The STM provides a strong
The Dyadic Coping Inventory (DCI*) is a widely theoretical framework for empirical studies on
used (Falconier et al. 2016) self-report question- examining associations between stress and cop-
naire developed by Bodenmann (2008) to assess ing on relationship quality, stability, and well-
partners’ stress expression and dyadic coping being than other dyadic coping approaches
behaviors as conceptualized in the Systemic- (Bodenmann et al. 2011).
Transactional Model (STM; Bodenmann 1995,
2005). According to the STM, dyadic coping is
viewed as a stress management process within Developer
the couple, which goes above and beyond social
support received from others, where the commu- The developer of the scale is Dr. Guy Bodenmann,
nication of one partner’s stress, supportive dyadic who published the German version of the DCI
coping, delegated dyadic coping, negative dyadic in 2008.
coping, and common or joint dyadic coping are
differentiated.
Supportive dyadic coping includes behaviors Description of the Measure
such as showing empathy and understanding,
showing solidarity with the partner, helping The DCI is a 37-item self-report assessment
the partner to reframe the situation, helping the that measures partners’ stress communication
partner to calm down, helping the partner to and dyadic coping behaviors (35 items). Two
believe in himself/herself, physical tenderness additional items assess the satisfaction and effi-
(neck massage, holding) or helping the partner cacy of the couples’ dyadic coping. Participants
to resolve a practical problem by assisting respond to the statements using a 5-point Likert
him/her, searching for practical solutions with scale (1 = never/very rarely, 5 = very often).
the partner, and giving the partner helpful The DCI yields information of the total dyadic
advice. Delegated dyadic coping means taking coping (sum or mean score), positive or nega-
over tasks and duties that normally the partner tive dyadic coping (positive dyadic coping is
does in order to reduce his/her burden. Com- typically built from the subscales supportive
mon/joint/communal dyadic coping includes dyadic coping, delegated dyadic coping, and
joint search for information, joint search for common/joint dyadic coping), and self-
solutions of the problem, mutual engagement perceived or partner-perceived dyadic coping.
in problem-solving, joint relaxation, joint soli- As mentioned above, indexes (i.e., of reciproc-
darity, joint reframing of the situation, joint ity, congruence, and equity) can also be used
spiritual coping, mutual self-disclosure and and reflect a more cognitive, appraisal-based
sharing negative emotions, and mutual tender- dimension of dyadic coping, while the subscales
ness (massages, physical contact). Negative represent perceived behaviors.
dyadic coping is differentiated as hostile As shown in Fig. 1, the DCI yields informa-
(expressing reluctance to help, blaming the part- tion on each partner’s perception of his/her own
ner for creating the stress, criticizing how the dyadic coping (self-perception) as well as of
partner has responded to the stress, minimizing the dyadic coping that is perceived from the
the partner’s stress, expression of disparage- partner (perception of the partner’s dyadic cop-
ment, distancing, mocking, sarcasm, open ing). As usually the DCI is completed by both
Dyadic Coping Partner A Partner B

Inventory,
Fig. 1 Structure of the Self-perception XXSB
XXSA reciprocity (o)
DCI (Bodenmann 2008)
congruence A
equity A
equity B
congruence B
Perception of D
XXPA reciprocity (p) XXPB
partner
partners, the DCI yields four direct behavior- (g) Partner’s delegated dyadic coping (items
oriented evaluations of dyadic coping and 12, 14)
three additional appraisal-oriented indexes, (h) Partner’s negative dyadic coping (items 7,
such as the reciprocity, the congruence, and the 10, 11, 15)
equity index. The reciprocity index reflects (i) Common or joint dyadic coping (items
one’s own and the partner’s own dyadic coping 31, 32, 33, 34, 35)
(reciprocity(own)) and the partner-perceived (j) Evaluation of couple’s dyadic coping
dyadic coping (reciprocity (partner)), i.e., how (items 36, 37)
much partner A’s and partner B’s dyadic coping
match in their self- and partner perception. The In different validation studies, however, this
congruence index refers to the overlap of per- factorial structure was not fully supported. In
ceived dyadic coping from partner A and B (i.e., the US validation study of the English DCI,
how much the self-perceived dyadic coping of items 2, 3, 9, 17, 18, and 24 were excluded due
partner A or B corresponds with the other’s to poor model fit (Randall et al. 2016). In the
perception of partner A’s or B’s dyadic coping). Latino validation study of the Spanish DCI in
The equity index depicts each partner’s evalua- the USA, items 2, 3, 15, 17, 18, 23, and 26 were
tion of how equal his/her and the partner’s con- excluded due to poor model fit (Falconier et al.
tributions to dyadic coping is. 2013). In the English validation study in
Canada, items 2, 3, 8, 17, 18, 23, and 25 were
excluded due to poor model fit (Levesque et al.
Subscales of the DCI 2014). In the French validation study, items
The following subscales were factor analytically 2 and 3 were excluded due to poor model fit
reported in the original German version of the (Ledermann et al. 2010). In the Chinese valida-
DCI (Bodenmann 2008): tion study of the DCI with a sample of mainland
Chinese couples, items 2, 3, 17, and 18 were
(a) One’s own stress communication (items 1, 2, excluded due to poor model fit (Xu et al. 2016).
3, and 4) In the Romanian validation study of the DCI,
(b) One’s own supportive dyadic coping (items items 2, 3, 17, and 18 were excluded due to poor
20, 21, 23, 24, 29) model fit (Rusu et al. 2016). However, in the
(c) One’s own delegated dyadic coping (items Italian (Donato et al. 2009), the Portuguese
28, 30) (Vedes et al. 2013), and the Hungarian (Martos
(d) One’s own negative dyadic coping (items et al. 2012) validation studies, all items were
22, 25, 26, 27) included as presented in the German version
(e) Partner’s stress communication (items (Bodenmann 2008). In sum, it seems that items
16, 17, 18, 19) 2, 3, 17, and 18 do not fit in different cultures.
(f) Partner’s supportive dyadic coping (items 5, Therefore, it is recommended to use the vali-
6, 8, 9, 13) dated versions of the specific country where the
study is conducted or to run a factor analysis Ruffieux et al. 2014). The scale has been used in
with one’s own data to replicate the factorial couples and family research, clinical studies, as
structure (see Nussbeck and Jackson 2016 in well as health studies (e.g., Rottmann et al. 2015).
Falconier et al. 2016).
The DCI is used in research as well as in
clinical practice. Subjects need 10–15 min to com-
Example of Application in Couple
plete the DCI. Its evaluation is easy, but requires a Therapy
template for practitioners. Norms and cut-off
The DCI is administered to each partner at the
scores according to gender and five age groups
(30, 31–40, 41–50, >50) are available for the beginning of therapy, in conjunction with an ini-
tial set of questionnaires measuring relationship
German DCI. The scale can be used with hetero-
quality and satisfaction, couple communication,
sexual couples as well as with same-sex couples
(Meuwly et al. 2013; Randall et al. 2017). couple’s expectations, areas of problems, and
sexuality. By having each partner’s separate
The DCI has been translated into 25 languages:
assessments, the therapist can then compare each
Arabic, Chinese, Danish, Dutch, French, German,
Greek, English, Indonesian, Italian, Japanese, partner’s scores within the couple (e.g., ones’ own
views of dyadic coping provided by oneself and
Hebrew, Hindi, Hungarian, Norwegian, Persian,
the partner compared to the views of the partner’s
Polish, Portuguese, Romanian, Russian, Korean,
Spanish, Thai, Turkish, and Urdu (Falconier sights) and between couples, classifying the cou-
ple within the norms of nonclinical reference pop-
et al. 2016). The questionnaire can be used for free
ulation. Typically, the therapist will discuss the
in the different languages, except for the German
version, where the publisher Hogrefe Tests requires results of the DCI with the couple early in the
process of the couple therapy (usually during the
a fee.
treatment-goal-setting process), pointing out
strengths and weaknesses in couple’s dyadic cop-
Psychometrics ing. This is done based on a graphical illustration
of both partners findings, matched in one figure.
The reliability of the original DCI (Bodenmann The therapist specifically focuses on (1) aspects of
2008) was tested in a validation sample of 2,499 dyadic coping that could be improved in each
subjects and has been replicated since then in partner and (2) congruences or discrepancies
multiple studies all over the world. The question- between partners (e.g., one provides a great deal
naire has a four- or five-factorial structure of supportive dyadic coping, the other not). The
according to the samples. The five-factorial struc- DCI mostly commonly serves as a subjective out-
ture differentiates problem-focused and emotion- come measure for the effectiveness of couple
focused common/joint dyadic coping, while the therapy, as it is applied pre- and posttreatment
four-factorial structure just considers common/ (i.e., 2 weeks and 6 months post-termination).
joint dyadic coping as one subscale. However, in some cases, the DCI can be utilized
Internal consistencies of the different subscales during treatment (e.g., after each fifth session).
of the DCI vary between a = 0.71 and 0.92. Take the examine of Thomas and Barbara who
Cronbach’s alpha of the total scale is a = 0.90. enter therapy with several marital problems.
The validity of the DCI has been supported on Thomas and Barbara have been married for
concurrent validity (i.e., relationship satisfaction, 20 years. Although they have been committed
dyadic communication; e.g., Falconier et al. for a long time, since the birth of their third
2015), criterion validity (i.e., well-being, depres- child, their relationship quality has consistently
sion, and anxiety; e.g., Bodenmann et al. 2011), decreased. Compounding this issue, Thomas has
divergent validity (i.e., individual coping; e.g., recently lost his job, which has caused distress for
Herzberg 2013; Papp and Witt 2010), as well as the couple. Barbara complains about Thomas’
prognostic validity (Bodenmann and Cina 2006; lack of emotional support and thinks that Thomas
could also help her more around the house (e.g., References
delegated dyadic coping), given that he is not
currently working. Thomas, on the other hand, Bodenmann, G. (1995). A systemic-transactional view of
stress and coping in couples. Swiss Journal of Psychol-
reports that he does not feel understood and is
ogy, 54, 34–49.
constantly criticized, which are all characteristics Bodenmann, G. (2005). Dyadic coping and its significance
of negative dyadic coping. He feels like a loser. for marital functioning. In T. Revenson, K. Kayser, & G.
In working with Thomas and Barbara, after Bodenmann (eds.), Couples coping with stress: Emerg-
ing perspectives on dyadic coping (pp. 33–50). Wash-
administering the DCI to both of them, the therapist
discusses the results with them as a couple. Specif-
ington, DC: American Psychological Association. D
Bodenmann, G. (2008). Dyadisches Coping Inventar:
ically, the therapist points out strong deficiencies in Testmanual. [Dyadic coping inventory]. Bern: Huber.
stress communication in both partners, low levels of Bodenmann, G., & Cina, A. (2006). Stress and coping
among stable-satisfied, stable-distressed and sepa-
supportive dyadic coping, and extreme low scores in
rated/divorced Swiss couples: A 5-year prospective
common dyadic coping. Not surprisingly, Thomas longitudinal study. Journal of Divorce and
reports high levels of negative dyadic coping from Remarriage, 44, 71–89.
Barbara. Scores are above the norms of the reference Bodenmann, G., Meuwly, N., & Kayser, K. (2011). Two
conceptualizations of dyadic coping and their potential
sample (between couple comparison), and within
for predicting relationship quality and individual well-
the couple there is a high congruence in a regret of being. European Psychologist, 16, 255–266.
insufficient dyadic coping. Donato, S., Iafrate, R., Barni, D., Bertoni, A.,
Based on these results and observing the couple, Bodenmann, G., & Gagliardi, S. (2009). Measuring
dyadic coping: The factorial structure of Bodenmann’s
the therapist defines goals regarding dyadic coping
“Dyadic Coping Questionnaire” in an Italian sample.
and explains how the couples’ current situation (i.e., TPM-Testing, Psychometrics, Methodology in Applied
high level of family strain and current unemploy- Psychology, 16, 25–47.
ment of Thomas) may impact their general life, as Falconier, M. K., Nussbeck, F., & Bodenmann, G. (2013).
Dyadic coping in Latino couples: Validity of the
well as dyadic coping. The therapist further explains
Spanish version of the dyadic coping inventory. Anxi-
the importance of dyadic coping as an important ety, Stress and Coping, 26, 447–466.
resource of mutual support. The therapist also illus- Falconier, M. K., Jackson, J., Hilpert, J., &
trates how Thomas and Barbara can join together to Bodenmann, G. (2015). Dyadic coping and relation-
ship satisfaction: A meta-analysis. Clinical Psychology
cope with their stresses and how they can improve
Review, 42, 28–46.
on their techniques. In several sessions, the therapist Falconier, M., Randall, A., & Bodenmann, G. (2016).
works with the couple by means of the three-phase Couples coping with stress – A cultural perspective.
method on their mutual stress communication, lis- New York: Routledge.
Herzberg, P. Y. (2013). Coping in relationships: The interplay
tening to each other’s stress-related self-disclosure
between individual and dyadic coping. Axiety, Stress, &
and provision of dyadic coping, matching the Coping: An International Journal, 26, 136–153.
other’s needs. Ledermann, T., Bodenmann, G., Gagliardi, S., Charvoz, L.,
At the end of the therapy, the therapist Verardi, S., Rossier, J., Bertni, A., & Iafrate, R. (2010).
Psychometrics of the dyadic coping inventory in
readministers the DCI. In the posttreatment, all
three language groups. Swiss Journal of Psychology, 69,
scores of the DCI reached the average scores of 201–212.
non-distressed couples and stayed stable over the Levesque, C., Lafontaine, M.-F., Caron, A., &
follow-up period. Fitzpatrick, J. (2014). Validation of the English version
of the dyadic coping inventory. Measurement and Eval-
uation in Counseling and Development, 47, 215–225.
Martos, T., Sallay, V., Nistor, M., & Jozsa, P. (2012).
Cross-References Dyadic coping and well-being – the Hungarian version
of the dyadic coping inventory. Psychiatria Hungarica:
▶ Coping-Oriented Couple Therapy A Magyar Pszichiatriai Tarsasag Tudomanyos
▶ Couples Coping Enhancement Training Folyoirata, 27(6), 446–458.
Meuwly, N., Feinstein, B. A., Davila, J., Nunez, D. G., &
Enrichment Program
Bodenmann, G. (2013). Relationship quality among
▶ Systemic-Transactional Model of Dyadic Swiss women in opposite-sex versus same-sex romantic
Coping relationships. Swiss Journal of Psychology, 72, 229–234.
Nussbeck, F. N. & Jackson, J. B. (2016). Measuring Health Psychology., 34, 486. https://doi.org/10.1037/
Dyadic Coping Across Cultures. In M. K. Falconier, hea0000218
A. K. Randall, & G. Bodenmann (eds.), Couples Cop- Ruffieux, M., Nussbeck, F. N., & Bodenmann, G. (2014).
ing with Stress. A Cross-cultural Perspective (pp. Long-term prediction of relationship satisfaction and
36–53). New York: Routledge. stability by stress, coping, communication, and well-
Papp, L. M., & Witt, N. L. (2010). Romantic partners’ being. Journal of Divorce & Remarriage, 55, 485–501.
individual coping strategies and dyadic coping: Impli- Rusu, P., Hilpert, P., & Bodenmann, G. (2016). Dyadic
cations for relationship functioning. Journal of Family coping in an eastern European context: Validity and
Psychology, 24, 551–559. measurement invariance of the Romanian version of
Randall, A. K., Hilpert, P., Jimenez-Arista, L. E., dyadic coping inventory. Measurement and Evaluation
Walsh, K. J., & Bodenmann, G. (2016). Dyadic coping in Counseling and Development., 1–12. https://doi.org/
in the U.S.: Psychometric properties and validity for 10.1177/0748175616664009
use of the English version of the dyadic coping inven- Vedes, A., Nussbeck, F. W., Bodenmann, G., Lind, W., &
tory. Current Psychology, 35, 570–582. Ferreira, A. (2013). Psychometric properties and valid-
Randall, A. K., Totenhagen, C. J., Walsh, K. J., ity of the dyadic coping inventory in Portuguese. Swiss
Adams, C. B., & Tao, C. (2017). Coping with work- Journal of Psychology, 72(3), 149–157.
place minority stress: Associations between dyadic Xu, F., Hilpert, P., Randall, A. K., Li, Q., &
coping and anxiety among women in same-sex rela- Bodenmann, G. (2016). Validation of the dyadic coping
tionships. Journal of Lesbian Studies, 21, 70–87. inventory with Chinese couples: Factorial structure,
Rottmann, N., Hansen, D. G., Larsen, P. V., Nicolaisen, A., measurement invariance, and construct validity. Psy-
Flyger, H., Johansen, C., & Hagedoorn, M. (2015). chological Assessment. Advanced online publication,
Dyadic coping within couples dealing with breast 28, e127. https://doi.org/10.1037/pas0000329
cancer: A longitudinal, population-based study.
E
Eastern Philosophy in Couple Description

and Family Therapy
Eastern thought was first formally introduced to
Wai Yung Lee1,2 and Viviana Cheng1 Western philosophy and psychology when British
1
Asian Academy of Family Therapy, scholars began to translate Indian spiritual texts
Hong Kong, China such as Bhagarard Gita in the 1700s (Germer
2
Aitia Family Institute, Shanghai, China et al. 2013, p. 11). Western philosophy is broadly
defined as striving to find and prove the “truth,”
while Eastern philosophy accepts the truth as
Name of Theory given and is more interested in the state of
“being.” The term, “Eastern philosophy” covers
Eastern Philosophy in Couple and Family Theory a broad spectrum of concepts, thoughts, and phi-
losophies from various regions including India,
China, Korea, and Japan. At times, the term
Introduction includes Persian, Arabic, Babylonian, and Jewish
philosophies from across the Middle East. Since
Psychotherapy is often regarded as the connecting the 1700s, ideas from Eastern philosophy have
point between the East and West. Many of the core become widespread in psychotherapy literature.
concepts in psychotherapy can be traced back to Despite its Western origins, the art of psychother-
the key elements within the three main Eastern apy often involves addressing elements of the
philosophical schools of thought – Buddhism, body, mind, and soul, which challenges the logical
Taoism, and Confucianism. In particular, the thinking or “established truth” that Western phi-
global movement of mindfulness, which stems losophy is known to embrace. Thus, it could be
from Buddhist thinking, has influenced the devel- argued that psychotherapy is a field where East
opment of couple and family therapy in the and West are bound to intertwine.
twenty-first century. Some aspects of Eastern philosophy are found
in the theories and practices of almost all of the
founders and prominent figures in the family ther-
Prominent Key Figures apy field. Many of the core concepts of family
therapy, such as holism, interdependence, circu-
Gautama Siddhartha, Laozi, Zhuangzi, Liezi, larity, and homeostasis, are conspicuously similar
Confucius, Jay Haley, Milton Erickson, Gregory to the essence of the Eastern worldview, where
Bateson both call for awareness of the unity and mutual
https://doi.org/10.1007/978-3-319-49425-8
820 Eastern Philosophy in Couple and Family Therapy
interrelation of all things that are inseparable parts Around 100 CE, Buddhism split into two main
of a cosmic whole (Capra 2010). Although these schools: Theravada, the classic Buddhist teach-
three mainstream Eastern philosophical schools of ings as mentioned above, and Mahayana, which
thought are quite different from one another, their focuses on the notion of “emptiness.” The view of
distinctions are often blurred when applied to Mahayana is that all reality is devoid of any dis-
clinical discussion. For the sake of clarity, a brief cernable content or description. The Mahayana
description of each is outlined below: Heart Sutra maintains that everything about our
identities and the ordinary world we reside in is
Buddhism empty and has no true content. It proclaims that
Buddhism was founded between 563 BC and even the four noble truths are empty. The Heart
483 BC by an Indian prince named Gautama Sutra questions the basic Theravada teachings that
Siddhartha, later known as Buddha. He lived in distinguish between the ordinary realm of life,
the comfort of his palace until the age of 29 years, death, and suffering and the realm of Nirvana, in
when he first had a chance to catch a glimpse of which suffering is extinguished. It suggests that
the outside world. On the four occasions that the two realms are actually the same. Not only is
Buddha left his palace, all he witnessed was the ordinary realm of life and death empty of
human misery, including giving birth, aging, fall- descriptive content, even Nirvana, the very solu-
ing ill, and dying. These experiences of human tion to our misery, has no descriptive content.
suffering had such a profound impact on him that To further grasp the notion of emptiness, Zen
he decided to become a monk and devote his life Buddhism was founded in China in around the
to the pursuit of enlightenment. fifth century. It is renowned for its paradoxical,
Buddhism draws heavily from Hindu philoso- meditative puzzles. It focuses on experience,
phy, such as the belief in reincarnation and the resists verbal coaching, and has no creed. In
search for ways to achieve salvation. Buddha Zen, enlightenment cannot be attained through
himself wrote nothing. After his passing, his rational discourse and doctrine. The experience
immediate disciples began to preserve his teach- of enlightenment is transmitted from the mind of
ings through enforced memorization and oral rec- a seasoned teacher to the student in training. Zen
itations. The Pali Canon is a result of such process can be regarded as the most mesmerizing aspect in
that took four centuries, from fifth century BCE to Buddhism that has captured the fascination of
the first century BCE, before it became a complete intellects and psychotherapists worldwide.
written version.
Buddhism focuses on the quest to enlighten- Taoism
ment, which involves four noble truths. The first Taoism emerged in the fourth century BCE, dur-
truth is that life contains inevitable suffering, ing China’s Warring States period. In Taoism, the
from birth to aging to death. The second truth is way to end social chaos was to return to nature or
that suffering is caused by desire and the craving to the time before the appearance of the feudal
for its gratification. The third truth is the elimi- system in China. Taoism is taught through three
nation of suffering by extinguishing the three important texts. The first one is the Tao Te Ching
fires of greed, delusion, and hatred. This then or Book of the Way, believed to be written by
leads to the fourth truth – the path to the cessation Laozi around 450 BCE. Tao Te Ching is an anthol-
of suffering, a state in which “no passion ogy of sayings, specifying a “hands-off” policy. It
remains,” and attainment of Nirvana. Buddha was compiled to instruct kings on government.
believed that people are in a state of endless The second one is Zhuangzi, written by Zhuangzi
suffering and the only way to extinguish suffer- around 369–286 BCE. Zhuangzi contains vivid
ing is to eliminate desires and achieve a state of stories and parables that are intended for the gen-
“no-self.” By rejecting the common notion of the eral public.
self, one could be free from the suffering associ- The third book is the Classic of Complete
ated with it. Emptiness, written by Liezi around 300 CE.
Eastern Philosophy in Couple and Family Therapy 821
Contrary to the Taoist rejection of desire, Liezi The principle record of Confucius’ teaching
proposed a more carefree attitude, claiming that was The Analects, written as clusters of conver-
desires for beautiful things, good food, music, and sations between the Master and his students. It
sex are simply human nature. There is no need to emphasizes the importance of virtuous conduct,
suppress them. addressed in four specific themes: ritual conduct,
The central concept in Taoism is the notion of humanity, filial obedience, and good
the Tao, which means “way” or “path.” It refers to government.
the fundamental ordering principle behind nature, Unlike Buddhism and Taoism, which focus
society, and individual people, as described in Tao more on the attainment of self-actualization,
Te Ching: Confucianism is the major school that empha-
E
sizes social, political, and family systems. In
The Tao that can be named is not the eternal and
unchanging Tao. The name that can be spoken is not contrast to the naturalistic characteristics of Tao-
the eternal and unchanging name. The nameless is ism, Confucius recommended a strong infra-
the source of heaven and earth. The named is the structure with a clear set of rules and doctrines,
mother of all things. Always be without desires and governing all aspects of social life in the govern-
you will see mystery. Always be with desire, and
you will see only its effects. They are both a mys-
ment and family systems. Confucius maintained
tery, and where mystery is the deepest we find the that good government begins at home and
gate of all that is subtle and wonderful (Tao Te believed that there is a proper way of behaving
Ching). for virtually every activity. Rituals and traditions
were regarded as the observable glue that binds
Tao is seen as an indescribable source of all
society together. The family unit is seen as the
existence that can only be grasped by mystically
primary social unit, and family members are
experiencing its subtlety. It emphasizes the
expected to actively participate in the learning
notion of non-action (wu wei), which proposes
of ritual conducts, which are seen to refine and
that things should flow simply, with spontaneity,
elevate the quality of lives and serve as a tool for
and without being contrived. The notion of non-
moral instruction.
action goes hand in hand with that of non-mind
Filial obedience (hsiao) is the area in which
(wu-hsin). Taoism rejects traditional methods of
Confucius’ teaching had the most influence in
education, such as learning from a teacher.
shaping government and family structure. He
Accumulated knowledge is seen as hindering
held that there are five relationships (wulun) that
creativity and causing one to become inflexible
underlie the order of society: father-son, elder
or subject to a false sense of security.
brother-younger brother, husband-wife, elder
Taoism shares many ideas with Buddhism,
friend-junior friend, and ruler-subject. Within
particularly in the notion of emptiness and the
these relationships, the subordinate person is
rejection of desires. Its naturalistic attitude is
duty bound to show obedience, while the superior
often in contrast to Confucianism, which contains
person is expected to show kindness. Under this
doctrines and rules of governance.
notion, the husband is expected to be more dom-
inant and the wife more obedient in the husband-
Confucianism wife subsystem, much against gender-equality
Confucius (551–479 CE) was a teacher and phi- values in modern society.
losopher who offered his solutions to end the Despite that, Confucianism did offer a more
social chaos during the Warring States period in pragmatic approach with clear doctrines to guide
China. He traveled to the various states in China interpersonal conducts at all levels of government
to give advice on good governance for 13 years. and social structure. These structures are still
It is believed that his disciples recorded his heavily referenced in discussions on Asian fami-
teachings in four major Confucius texts after lies today.
his death. These texts have had a profound influ- Viewed separately, these three major schools
ence in East Asia for almost 3000 years. of thoughts are very different and sometimes
contradictory. Collectively, they form crucial The attitude toward mindfulness between the
parts of both historic and current Eastern East and the West has been described as being
philosophy. fundamentally different. In the East, meditation is
viewed as a lifelong practice within a rich spiritual
The Mindfulness Movement context. In the West, it is considered a short-term
The Buddhist term “mindfulness” originated from intervention to achieve clear goals (Wylie 2015).
the Pali word sati. It refers to psychological states However, this does not stop the mindfulness move-
of awareness through meditation, a discipline ment from gaining popularity among contemporary
whereby one pays attention to thoughts, feelings, couple and family therapists. Many therapists con-
and body sensations in the present moment, with- sider the core elements of awareness, acceptance,
out having to be altered or avoided (Bishop et al. and staying in the present in mindfulness psychol-
2004). In 1930, Freud believed that the mind and ogy to be powerful concepts when used in conjunc-
body sensations in the present moment are to be tion with traditional clinical processes (Germer et al.
essentially regressive. The fact that the University 2013). In addition, it is generally agreed that mind-
of Massachusetts mindfulness-based stress reduc- fulness has had a positive effect on relationship
tion program (Kabat-Zinn 2013) would turn into a satisfaction, empathy development, and skillful
big enterprise 35 years later was unimaginable communication (Gambrel and Keeling 2010).
in 1979. Numerous studies note the benefits of mindfulness
Mindfulness training and other forms of med- practice on various aspects of a couple’s relation-
itation have since been recommended for a wide ship, including an increase of intimate relationship
range of medical conditions. As many as 20 mil- satisfaction and a more secure attachment (Wachs
lion people were reported to be using meditation and Cordova 2007). It has also been suggested that
for health purposes in the 2007 census report on Buddhist practices of accommodation to suffering,
adults seeking complementary or alternative med- in particular, could shift the traditional focus in
icines in the United States. The mindfulness- therapy from change to acceptance, within the con-
based relationship enhancement (MBRE) pro- texts of couple and family therapy (Gehart and
gram for couples (Carson et al. 2004) is one clin- Collum 2007).
ical example, which introduced a range of
mindfulness exercises to couples, including part-
ner yoga, loving-kindness meditation, and mind- Relevance to Couple and Family
ful touch, over the course of 8 weeks.
Mindfulness research soared in the 2000s Various aspects of Buddhism, Confucianism, and
following Harvard Professor Herbert Benson’s Taoism have had an impact on the development of
studies of the physiological responses of the different approaches within the field of family
Tibetan monks during meditation in the 1980s. therapy. However, when Zen Buddhism ideas
Studies have been conducted on almost every entered the clinical field in the 1950s, the psycho-
topic that has a remote connection to mindful- dynamic ideology contained premises so opposite
ness and most of them claimed to have high from Zen that it was impossible for the two
success rates in using mindfulness as a remedy approaches to connect. The focus on insight in
for treatment. However, in a massive meta- psychotherapy was in sharp contrast to the absur-
analysis of meditation programs conducted at dity in Zen, such as its infamous riddle, “What is
John Hopkins University, it has been found the sound of one hand clapping?”, which seems to
that mindfulness meditation had only a “small defy any logical responses. Milton Erickson, who
yet consistent benefit in relieving anxiety, also spoke in riddles and paradoxes, was possibly
depression, and pain.” Depressive symptoms the only therapist whose approach was different
have been found to have improved by roughly from psychodynamic theory at the time. In this
10–20%, which is similar to the effect of anti- regard, he may be considered the first Buddhist
depressants (Goyal et al. 2014). therapist in the West. Following that, family
Eastern Philosophy in Couple and Family Therapy 823
therapists began to develop an interest in the abandon words altogether, focusing on experi-
notion of paradox in Zen. The use of rephrasing, ence, keeping a “non-mind” and “non-self”
an attempt to challenge the meaning of reality, was stance.
a popular technique used by early pioneers such as Aspects of Taoism resemble the cybernetics con-
Carl Whitaker and members of the MRI group. In cept, whereby all systems have their own way to
the family therapy development that followed, its self-regulate and a “don’t touch” approach is highly
systemic perspective fit well with the Eastern phi- preferable. Gregory Bateson’s (1972, 1979) theory
losophy that all things exist as inseparable and of the pattern that connects suggests that every
contradictory opposites. The symbol of Yin and family member is connected to everyone else.
Yang, the masculine and feminine sides of human A change in one person’s behavior leads to a change
E
relationship, has become universal in addressing in all family members. Therapists might use obser-
any dyadic relationship within the family system. vation and interviewing processes to understand this
The influence of Zen Buddhism can be seen in pattern and describe their insights to family mem-
the work of Haley, who considered the ideas behind bers. However, any attempt to change this pattern
Western psychopathology matched the basic pre- through the unilateral exercise of power may lead to
mise of Zen – humans are seen as trapped in the unintended consequences, threatening the integrity
wheel of life and keep repeating distressing behav- of the system. Bateson felt strongly that this pattern
ior. The more a person attempts to escape from this of organization must be respected. This position
destiny, the more they are caught up in it (Haley clearly matches the “non-action” philosophy that is
2013). Haley held that once problem-maintaining prominent in Taoism. Later social-constructionist
patterns have been understood, they may be altered therapists, such as Andersen, Cecchin, Boscolo,
through carefully designed direct or paradoxical and Hoffman, also adopted this position.
interventions. He believed that like Zen masters, Confucius teachings, which place great attention
therapists must be experts at bypassing resistance. on family structure with clear prescriptions of rules
The paradoxical nature of Zen can be found to have and boundaries among each of the subsystems, may
strongly influenced his strategic and directive West- be closer to Ludwig von Bertalanffy’s general sys-
ern therapy in promoting change. tems theory, in which interrelationships between
The continuous questioning of the perception elements altogether form the whole and hierarchy
of reality in Zen Buddhism that attracted early and boundaries are considered essential elements in
family therapy founders was also addressed in the production of new patterns. Confucius teaching
the Constructivism movement that followed. is generally considered to be the backbone to under-
Eastern philosophy perceived the entirety of real- standing families of the East and has been
ity as one empty thing that is incapable of distinc- referenced in almost all of the literature on Asian
tion or descriptive content. This is similar to the families. At the same time, his ideas on family and
Constructivist view, seeing everything as filtered organizational structure share some similarities with
through the mind of the observer. Constructivists those in Salvador Minuchin’s Structural Family
believe that the world can only be experienced Therapy, which also focus on family structure,
subjectively, through the observer’s own unique boundaries, and hierarchy, particularly in working
constructs of the environment. Constructivism with children and adolescent delinquent problems.
emphasizes cognitive meaning and personal inter- Confucius ideas on gender role distribution are cer-
pretation rather than action. Under this model, tainly dated and feminist critiques may even find
therapists don’t assume that they know how fam- them offensive. Yet, his ideas on the importance of
ilies should change but would explore the family rituals can be observed in the work of con-
assumptions people have about their problems. temporary therapists such as Evan Imber-
However, this seemed to be where the East and Black (1993).
the West diverge. Constructivist therapists use It should be noted that couple-hood is not
words or conversations to change narratives and addressed specifically in any of the three major
reconstruct a new reality. Eastern philosophers Eastern schools, other than an emphasis on
achieving balance between Yin and Yang. Ironi- but I don’t need to get rid of them. They are there,
cally, mindfulness in Buddhism practice, which sup- but they cannot overwhelm me!”
posedly addresses one’s inner-balance, is widely Following the same process, the therapist also
used by modern therapists as a way to prepare guided Sam to acknowledge his intense feeling of
individuals in couple therapy. Despite their different guilt and remorse, as well as his inability to
worldviews and diverse ways of manifestation, the respond to Emma in facing her rage and blame.
East and the West are constantly in the process of Realizing that these emotions had been blocking
mutual exchange and interactions. It is expected that him from getting closer to his wife, he began to
the different cultures and philosophical ideas will face Emma’s pain and accusation instead of run-
continue to mix and match in various forms, giving ning away from her as he previously did.
new shape to couple and family therapy interven- Throughout the couple session, the therapist
tions worldwide. was very mindful in bringing the couple’s attention
to the here-and-now moment. After engaging the
couple to concentrate on their own emotional reac-
Clinical Example of Application of tions, the therapist began to encourage them to
Theory in Couple and Family Therapy relate to each other in a more satisfactory manner,
now that their own emotions did not stand in their
Emma and Sam are a middle-class couple in their way of communication. As a result, the couple was
mid-thirties. They have two young children and able to deal with the hurt and sense of abandonment
have been living relatively settled lives until that they both experienced and work through their
2 months ago, when Emma found out that Sam interpersonal conflict. Ultimately, Sam begged for
has had an extramarital affair. When she forgiveness from Emma, who was finally ready to
confronted him angrily, he dismissed the affair forgive him. The therapist has helped the couple
and said that it was “just a fling.” The conflict reestablish intimacy and survive the damage of a
between the couple escalated and they came for nasty extramarital affair.
couple therapy to deal with their dilemma. This is one example of how a therapist adopted a
To break the stalemate, the therapist helped mindfulness framework to couple therapy. She
them stay in touch with their conflict and learn worked alternatively between the partner’s internal
to live with it by realizing how their circle of and interpersonal processes until the couple was
reactivity is causing them to be trapped in the able to establish intimate conversation and connec-
entanglement. As a first step, she suggested that tion. Mindfulness exercises, including meditation
they delay their reactions toward each other while and yoga, were used to assist estranged couples to
paying attention to their own emotional process. rediscover one another.
Through meditation and concentrating on their
own emotions, the therapist guided Emma to get
in touch with her feelings of hurt and betrayal Cross-References
from her husband’s extramarital affair. In doing
so, her feelings of hurt and anger became more ▶ Boundary Making in Couple and Family
intense, and she began to cry aloud. The therapist Therapy
then guided her to be aware of the existence of ▶ Family Structure
these negative feelings and not to ignore them ▶ First Order Cybernetics
while helping her separate herself from these feel- ▶ Second-Order Cybernetics in Family Systems
ings so that they would not affect her as much in Theory
her reactions to Sam. Through a guided imagery ▶ Strategic Family Therapy
exercise, the therapist guided Emma with, “I ▶ Structural Family Therapy
know these feelings are there. I don’t like them, ▶ Meditation in Couple and Family Therapy
Eclecticism in Couple and Family Therapy 825
References Wachs, K., & Cordova, J. V. (2007). Mindful relating:

Exploring mindfulness and emotion repertoires in inti-
Bateson, G. (2000 reprint. First published 1972). Steps to mate relationships. Journal of Marital and Family
an ecology of mind: Collected essays in anthropology, Therapy, 33, 464–481. https://doi.org/10.1111/
psychiatry, evolution, and epistemology. Chicago: Uni- j.1752–0606.2007.00032.x.
versity of Chicago Press. ISBN 0-226-03905-6. Wylie, M. S. (2015). The mindfulness explosion. Psycho-
Retrieved July 29, 2016. therapy networker. Retrieved from https://www.
Bateson, G. (1979). Mind and nature: A necessary unity, psychotherapynetworker.org/magazine/article/66/the-
Advances in systems theory, complexity, and the human mindfulness-explosion
sciences. Cresskill: Hampton Press.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson,
N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M.,
Velting, D., & Devins, G. (2004). Mindfulness:
E
A proposed operational definition. Clinical Psychology
Science and Practice, 11(3), 230–241. https://doi.org/ Eclecticism in Couple
10.1093/clipsy.bph077. and Family Therapy
Capra, F. (2010). The Tao of physics: An exploration of the
physics between modern physics and Eastern Terence Patterson
mysticisim. Boston: Shambhala Publications, Inc.
Carr, A. (2012). Family therapy: Concepts, process and University of San Francisco, San Francisco,
practice (3rd ed.). Manchester: Wiley. CA, USA
Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. H.
(2004). Mindfulness-based relationship enhancement.
Behavior Therapy, 35, 471–494.
Gambrel, L. E., & Keeling, M. L., (2010). Relational aspects Synonyms
of mindfulness: Implications for the practice of marriage
and family therapy. Contemporary Family Therapy, 32, Assimilative integration; Eclecticism; Heteroge-
412–426. https://doi.org/10.1007/s10591-010-9129-z neity; Synthesis; Theoretical integration
Gehart, D., & Collum, E. E. (2007). Engaging suffering:
Towards a mindful re-visioning of family therapy practice.
Journal of Marital and Family Therapy, 33(2), 214–226.
https://doi.org/10.1111/j.1752-0606.2007.00017.x.
Germer, C. K., Siegel, R. D., & Fulton, P. R. (2013). Introduction
Mindfulness and psychotherapy. New York: The
Guilford Press.
Goyal, M., Singh, S., Sibinga, E. M. S., Gould, N. F., The term eclectic has been both widely used and
Rowland-Seymour, A., Sharma, R., Berger, Z., Sleicher, misunderstood in the field of psychotherapy.
D., Maron, D. D., Shihib, H. M., Ranasinghe, P. P. P. D., Recently it has come into some disrepute and
Linn, S., Saha, S., Bass, E. B., & Haythornthwaite, J. A.
(2014). Meditation programs for psychological stress and developed the connotation of indiscriminately
well-being: A systematic review and meta-analysis. drawing from various theories and techniques
JAMA Internal Medicine, 174(3), 357–368. https://doi. without a core foundation. Eclecticism has
org/10.1001/jamainternmed.2013.13018. emerged in couple and family therapy (CFT) in
Greenan, D. (2015). Resiliency-focused couple therapy:
A multidisciplinary model. AEDP Transformance Jour- particular due to the multiple approaches that do
nal, 5(1). https://www.aedpinstitute.org/transformance/ not clearly fit traditional theoretical models and
resiliency-focused-couple-therapy/. Accessed 3 Septem- techniques and are not anchored in a compre-
ber 2016. hensive conceptual base. The term systemic has
Haley, J. (2013). Jay Haley on Milton J. Erickson.
New York: Routledge. also been appropriated by some as a defining
Imber-Black, E. (1993). Secrets in families and family aspect of CFT, while many others consider sys-
therapy. New York: Norton. tems to be core to the entire field of. The wider
Kabat-Zinn, J. (2013). Full catastrophe living. New York: realm of psychotherapy has delineated models
Random House LLC.
Langer, E. J. (2000). The construct of mindfulness. Journal that distinguish eclecticism from other models
of Social Issues, 56, 1–9. https://doi.org/10.1111/0022- such as spiritual orientation, which can be
4537.00148. viewed as an aspect of diversity.
826 Eclecticism in Couple and Family Therapy
Prominent Associated Figures eschews personality-based or technique-driven

approaches. Snyder and Balderrama-Durbin
Arnold Lazarus, John Norcross, Marvin (2012) propose an integrationist model specifi-
Goldfried, Larry Beutler, and Ray DiGiuseppe cally for couple therapy. Lebow (1997), a seminal
thinker who suggests that it is time to end delin-
eating approaches based on theoretical orienta-
Description tion, has described the evolution of integration in
CFT as a revolution that is here to stay.
Eclecticism in CFT has emerged in the effort to The term technical eclecticism* has been widely
avoid rigid, dogmatic positions and from the gen- promoted by Lazarus and Beutler (1993) and forms
eral view that no single theoretical orientation or the basis of multimodal therapy. This approach is
approach is universally applicable to all disorders, anchored in a theoretical model that asserts that
settings, or populations. While this may be con- techniques from other models can be applied coher-
sidered an advancement from the early domina- ently within its framework. Patterson (1997)
tion that psychodynamic therapy, for instance, has described a similar model in which diverse tech-
had on the field, many clinicians have adopted a niques (rather than theories) can be coherently inte-
mixture of concepts and methods that do not log- grated into a major comprehensive model.
ically or pragmatically fit together. Such a mixed, Assimilative integration* combines models
indiscriminate stance contradicts standards of that may be seemingly disparate into an amalgam
competence that involve the need for a compre- that involves components of other systems, but is
hensive approach to assessment, case conceptual- mostly characteristic of a singular approach such
ization, treatment formulation, and evaluation that as psychodynamic (Striker and Gold 2005).
is considered essential for effective treatment. Castonguay et al. (2005) describe a CBT model
Benchmarks such as common factors and in which the practitioner is competent in both the
evidence-based treatments have been dissemi- theories and methods involved.
nated to establish an epistemological basis for Another interesting paradigm is described by
categorizing psychotherapy models, and concepts DiGiuseppe and Wilner (1980) who discuss the
such as technical eclecticism*, theoretical integra- indications and contraindications for CFT within
tion*, assimilative integration*, and pluralism* certain contexts and recommend that other modal-
have emerged as alternatives to eclecticism. ities and formats such as individual child therapy
Theoretical integration* was first formally might be used collaterally or alternatively.
explored in 1983 by the Society for Psychotherapy The term pluralism* is a generic term used to
Integration (SEPI), prominently by Goldfried refer to the heterogeneity* of the models
et al. (2005). It is the most developed and anchored discussed here, while the term informed plural-
model in that it is theory based and presumes that ism* is used to describe concepts that organize
practitioners are competent in each approach. Tech- theories and techniques contextually from widely
nical applications are less stressed, although clinical diverse approaches (Safran and Messer 1997). In
theoretical grounding generally involves a solid everyday practice, the overlapping and ambigu-
awareness of pragmatic aspects. Theoretical integra- ous nature of the terms defined in this section is
tion involves a synthesis of compatible theories into often used haphazardly to accommodate various
a blend that is different from its constituent parts; a approaches whose basic tenets defy assimilation
new approach emerges that fits the style and purpose into a common framework.
of the clinician and the client and is therefore dis-
tinctive in its application.
Beutler et al. (2001) focus on the integration Relevance to Couple and Family Therapy
of a distinct model, cognitive-behavioral
therapy (CBT). With an emphasis on empiricism Theories and techniques in CFT have evolved
and common factors, theoretical integration from a combination of rejection of earlier models
Eclecticism in Couple and Family Therapy 827
of psychotherapy, personality-based practices school on Basil that indicated rumination

based on distinctive pioneers, and an expansion about being attacked and his drawings depicted
of traditional individual models of psychotherapy violent scenes.
(psychodynamic, humanistic, behavioral) to Assessment formulations include the follow-
include systemic and contextual factors. Some ing: a dysfunctional marital relationship,
CFT models are comprehensive in that they spec- chronic trauma secondary to violence in their
ify methods for assessment, treatment formula- home countries, and an anxiety and depressive
tion, and appraisal, and others involve only disorder in Basil. The parents’ priority was to
philosophical concepts or dramatic techniques. stabilize Basil’s school situation rather than to
Due to the competence essential for the effective work on their marriage. Rather than follow a
E
practice of CFT and the complexity involved in psychodynamic model with individual therapy
highly contextual formulations and interventions, to explore earlier experiences in depth, a family
it is vital for clinicians to have a solid grounding in therapy model with a CBT orientation was
both theories and methods. employed in order to respect their preferences,
limited availability, and cultural understanding.
From this foundation three individual sessions
Clinical Example of Application of Topic were held with Malik and Genna, one with
in Couples and Families Basil, and two with the entire family. Basil’s
teacher and counselor were consulted for addi-
Malik and Genna are a mid-forties couple who tional information, and recommendations were
have been married for 10 years and have two made for assisting him in school, and the parents
children, Basil, 8, and Malia, 6. Basil’s school were referred for financial and vocational
has contacted them saying he appears restless counseling through a religious organization.
and is not concentrating on his work and is not Person-centered and trauma-informed tech-
getting along with his schoolmates. They have niques were effective in eliciting responses
both emigrated from politically unstable coun- from the parents about their earlier experiences,
tries, where their parents and extended family and they indicated feeling relief. They were also
still reside. Their marriage is satisfactory – 5.5/10 coached to respond to Basil’s anxiety with
on the Beavers-Timberlawn Family Evaluation understanding and reassurance and to steer
Scale (Lewis et al. 1976), which indicates some away from reinforcing it in any way.
mild depression, distancing, and mild dissatisfac- The model employed with this family can be
tion with the marriage and the potential for described as technically eclectic* with a (CBT)
anxiety-related disturbances in the children. foundation guiding the treatment. With family
Malik and Genna also have chronic anxiety due therapy as the primary modality, formats for
to traumatic experiences in their countries of ori- sessions were flexible, and collateral contacts
gin, as well as work-related and economic were made on behalf of family members. The
problems. understanding of trauma is viewed as topic spe-
Assessment did not indicate the need for cific; accurate empathy and collaboration is
individual treatment of the parents, partially based on Rogerian techniques and multicultural
because culturally they feared the stigma it competence; the coaching regarding Basil fol-
would involve, though the suggestion to treat lows a parent-child consultation model; and the
the family as a whole appealed to their more contacts with allied professionals are
collectivist worldview. Individual sessions eco-systemic. None of these methods deviates
with the couple were held initially to determine from the basic CBT model as the techniques
their priorities, availability, and commitment used were congruent with the objective of
and to remove some of the obstacles that were behavioral change. It is also consistent with
creating distance and dissatisfaction between the paradigm proposed by DiGiuseppe and
them. Test data was then collected from the Wilner (1980) above.
828 Ecosystem in Family Systems Theory
Cross-References
Ecosystem in Family Systems
▶ Assimilation in Integrative Couple and Family Theory
Therapy
▶ Common Factors in Couple and Family Christie Eppler
Therapy Seattle University, Seattle, WA, USA
▶ Eclecticism in Couple and Family Therapy
▶ Integration in Couple and Family Therapy
Name of Concept
References Ecosystem in Family Systems Theory
Beutler, L. E., Harwood, T. M., & Caldwell, R. (2001).

Cognitive-behavioral therapy and psychotherapy inte-
gration. In K. S. Dobson & K. S. Dobson (Eds.), Hand-
Synonyms
book of cognitive-behavioral therapies (2nd ed.,
pp. 138–170). New York: Guilford Press. Context/contextual; Human ecology; Systems/
Castonguay, L. G., Newman, M. G., Borkovec, T. D., systemic
Holtforth, M. G., & Maramba, G. G. (2005).
Cognitive-behavioral assimilative integration. In
J. C. Norcross, M. R. Goldfried, J. C. Norcross, &
M. R. Goldfried (Eds.), Handbook of psychotherapy Introduction
integration (2nd ed., pp. 241–260). New York: Oxford
University Press.
In family systems therapy, ecosystems are broadly
DiGiuseppe, R., & Wilner, R. S. (1980). An eclectic view
of family therapy: When is family therapy the treatment defined as interconnected contextual* variables
of choice? When is it not? Journal of Clinical Child and patterns of functioning. Ecosystems can be a
Psychology, 9(1), 70–72. place, culture, or norm that influences clients
Goldfried, M. R., Pachankis, J. E., & Bell, A. C. (2005).
(e.g., social locations, boundaries, rules, etc.).
A history of psychotherapy integration. In
J. C. Norcross, M. R. Goldfried, J. C. Norcross, & Considering the ecosystem in therapy changes
M. R. Goldfried (Eds.), Handbook of psychotherapy the perspective from treating individuals and
integration (2nd ed., pp. 24–60). New York: Oxford their symptoms to conceptualizing clients and
University Press.
their presenting problems as the interactions of
Lazarus, A. A., & Beutler, L. E. (1993). On technical
eclecticism. Journal of Counseling & Development, relationships, environments, and larger systems*
71(4), 381–385. https://doi.org/10.1002/j.1556- in symbiotic processes.
6676.1993.tb02652.x.
Lebow, J. (1997). The integrative revolution in couple and
family therapy. Family Process, 36(1), 1–17. https://
doi.org/10.1111/j.1545-5300.1997.00001.x. Theoretical Context for Concept
Lewis, J. M., Beavers, W. R., Gossett, J. T., & Phillips, V. A.
(1976). No single thread. New York: Brunner/Mazel. Although Eastern spiritualities, African traditions,
Patterson, T. (1997). Theoretical unity and technical eclec-
and Indigenous cultures have long considered
ticism: Pathways to coherence in family therapy. Amer-
ican Journal of Family Therapy, 25(2), 97–109. https:// interconnections and collectivist ways of relating,
doi.org/10.1080/01926189708251059. it was not until the 1950s that Western mental
Safran, J. D., & Messer, S. B. (1997). Psychotherapy health professionals used an ecosystemic ap-
integration: A postmodern critique. Clinical Psychol-
proach to inform family treatment. Multiple eco-
ogy: Science and Practice, 4, 140–152.
Snyder, D. K., & Balderrama-Durbin, C. (2012). Integra- logical perspectives were delineated, an antithesis
tive approaches to couple therapy: Implications for to the medical model that dominated the field
clinical practice and research. Behavior Therapy, of early psychotherapy. Germinal theorists of
43(1), 13–24.
ecosystem thinking in systems therapy include
Striker, G., & Gold, J. (2005). Assimilative psychodynamic
therapy. In Handbook of psychotherapy integration Bateson (1979), Bronfenbrenner (1979), and
(pp. 221–240). New York: Oxford University Press. Bubolz and Sontag (1993). Compared to their
Ecosystem in Family Systems Theory 829
predecessors, who sought to explore humans In a later model, Bubolz and Sontag (1993)
intrapsychically, ecosystemic-focused family the- introduced the natural and human built worlds as
orists employed concepts from the natural sci- particularly salient factors that affect human func-
ences, anthropology, and communication theory tioning. Their framework considers the natural
to understand people and their relationships. world or environment such as sunny or cloudy
Bateson (1979), an anthropologist, social scien- regions, human built structures such as apartments
tist, and biologist, applied physical world phenom- with or without lead-based paint, and social or
ena, such as feedback loops and entropy, to human cultural norms such as egalitarian or hierarchical
interactions. This approach focused on the meta, or relationship rules. Each system* reciprocally
how human systems learn and reflect on their expe- affects the others. Clients who live in brisk and
E
riences, believing that it is not what one thinks, but rainy climates may spend most of their time
rather how one thinks. Bateson and his research indoors, which can influence how land and energy
group explored cybernetics (i.e., how systems regu- resources are consumed. A linear view suggests
late using structures, constraints, and possibilities). that lack of sun increases the risk of seasonal affect
They defined the double-bind hypothesis as unclear disorder (SAD). An ecological model hypothe-
communication that fosters mental disorders sizes not only how sunlight affects mental health,
(Bateson et al. 1956). Their classic study hypothe- but also how families with individuals who have
sized that if a mother’s verbal message did not mental health diagnoses impact their natural and
match her nonverbal stance, her child was at created worlds.
increased risk for a diagnosis of schizophrenia. More recent theorists have used an eco-
Bronfenbrenner’s (1979) ecological human systemic perspective to explore particular con-
development model examined how growth and structs. Walsh (2006) employed an ecosystem
development happen in proximal processes, recip- approach in her model of family resiliency. Post-
rocal interactions that occur over extended periods modern models, such as liberation psychology
of time. Developmental growth systems are in family therapy (Hernández 2002); transforma-
interlocking layers with networking parts. The tive family therapy (Almeida et al. 2008); and
microsystem, the most immediate level and the Falicov’s (2014) multidimensional ecosystemic
one with which the client system has direct inter- family therapy, expanded earlier paradigms to
action, may include family, school, work, and consider the intersections of social locations
places of worship, etc. The mesosystem includes (age, gender, sexual identity, immigrant status,
the interactions between and among micro- etc.), empowerment, and advocacy in systemic*
systems; for example, the quality of interaction practice.
between a family and the child’s school. Exo-
systems influence the microsystem, but without
direct interaction. Examples of exosystems Description
include the courts, government, and health care
companies, all of which affect client functioning, Family therapy and mental health counseling
but clients may not be active participants within have many similarities (e.g., treating clients, doc-
these systems*. The chronosystem considers the umenting treatment plans, and writing case notes).
influence of time: family stories, familial lifecycle The crux of their opposing epistemologies lies
stages, and cultural narratives of historical trauma. in the focus on the individual versus an ecological
For example, a family (microsystem) that finds or human ecology* paradigm. Couples and family
connection and support (mesosystem) from a therapy is rooted in systems thinking* and human
place of worship (microsystem) may have strong ecology* theory (Wetchler and Hecker 2014).
ties to each other over time (chronosystem). The Individuals themselves are considered as sys-
family may use resources from their insurance tems* embedded in larger interconnected sys-
company, an exosystem, to secure therapy in tems* (Bronfenbrenner 1979). Psychiatry and
order to mediate problems that arise. mental health counseling examine intrapersonal
830 Ecosystem in Family Systems Theory
dynamics. Providers consider the cause and effect ecology-informed therapist holds regard for
of cognitions, affects, and behaviors. This linear second-order processes, or the underlying struc-
process in thinking is reductionist where symp- tures that maintain a symptom. For example, the
toms are classified within clusters to form a given family’s lifecycle stage is a developmental? pro-
diagnosis. cess that influences both family functioning and
The ecosystem or human ecology* in sys- the presenting problem. The therapist inquires
temic* therapy is built on an alternative paradigm. about what it must be like for this family to
The focus shifts from the individual to relation- encounter transitions as their child moves from
ships, the space between family members and adolescence to adulthood; how the process of
larger environmental systems*. The system* is decision-making differs from an earlier stage of
defined as more than the sum of the parts. The their child’s development. These questions assist
holistic practice of family therapy focuses on pro- the therapist in remaining inquisitive about multi-
cesses instead of content. The individual is not the generational and isomorphic processes such as
sole focus of treatment even when the individual is how previous generations dealt with transitions;
the only person present in treatment. Treatment what cultural shifts impacted the family lifecycle;
explores the meaning behind behaviors instead of the ways in which the family rules and boundaries
the actions themselves. Rather than hypothesizing may have changed over time; the role of social-
about what is happening and why, an ecologically- political factors in creating and maintaining the
oriented clinician examines a presenting prob- family’s presenting problems; and the way in
lem’s manifestation and maintenance from multi- which each member of the family has contributed
dimensional, relational perspectives. Systemic* to changing the cultural narrative regarding care-
therapists look for reciprocal causality, circularity, taking and adolescence.
patterns, and meanings. A couple may have a Treatment at the ecosystem level is not an
reciprocal effect on one another’s behavior, independent treatment modality. Therapists
although this does not exonerate an individual of synthesize ecosystemic factors with family ther-
responsibility (e.g., offender of intimate partner apy theories (e.g., structural family theory, nar-
violence). Behaviors are understood in context. rative family therapy). Consideration of
For example, a child who defecates on the walls ecological factors starts before the first session.
in the school’s bathroom may be sent to a therapist The therapist invites the entire family, rather
to address the child’s negative behavior. When a than each individual member, into the session.
systemic therapist learns that this child was Anyone who has significant influence on the
harassed on multiple occasions when he went to relationship is invited to attend therapy. During
the bathroom alone, the child’s symptom connotes the clinical intake process, the therapist gathers
a different, protective meaning rather than being information related to the client system’s eco-
perceived as naughty behavior. systems. Assessments include genograms,
which are utilized to find patterns in the family
ecosystem, and ecomaps, which explore com-
Application of Concept in Couple and munity resources and limitations. All parts of
Family Therapy the ecosystem affect each other (e.g., the care-
giver’s narrative of what it was like for her to be
Most problems that clients bring to therapy may an adolescent affects her parenting style and
be seen as first-order problems, or symptoms. An how her child may perceive her). The clinician
example of a first-order symptom is when care- avoids overemphasizing one piece of the sys-
givers of an adolescent complain about their tem. For example, the therapist would not
child’s missed curfew. Although such a complaint ascribe blame to an individual (e.g., the adoles-
may appear to be the caregivers’ pressing pre- cent is acting out). Assessing and intervening on
senting issue, after careful observation of the the ecosystemic level continues throughout
processes associated with these symptoms, the each phase of the treatment.
Ecosystem in Family Systems Theory 831
Clinical Example about their meta-level beliefs in order to explore

the meaning of the couple’s time together as well
Opal and Luke presented for couples therapy out as being apart.
of concern for a breakdown in their communica- Although the therapist treated the couple
tion. Opal, a 32-year-old biracial female, has a from a narrative family therapy framework, the
college degree and works as a home health aide focus of the clinical work was attuned to sys-
for elderly patients. Her mother immigrated to the temic* processes. For Opal and Luke, their first-
US from Ecuador as an adolescent and her father order symptom was their communication skills.
is African-American. Opal expressed frustration The process, or the second-order structure that
over Luke’s passivity, which Opal defines as his maintained the symptom of ineffective commu-
E
disconnection from his feelings, her feelings, and nication, was to achieve a mutually agreeable
their disagreements. Luke, a 33-year-old Cauca- balance between cohesion and individuality.
sian male who identifies as a Midwesterner, works This balance was influenced by the couple’s
as a physical therapist. He stated Opal spends too interactions among larger systems (e.g., time
much time with her mother, asks too many ques- spent with kin, at work, with one another). The
tions, and reminds him of tasks incessantly. therapist and clients dialogued about ways in
In the early phase of treatment, the family which external connections affected the rela-
therapist asked Opal and Luke to talk about what tionship’s cohesion (how the couple felt
brought the couple together, ways in which each connected); flexibility (static or dynamic nature
partner feels connected to the other, and how of time spent together or alone); adaptability
they would like the relationship to be different (how the amount of time together has changed
at the end of therapy. The therapist drew a geno- since they met). The therapist assisted Opal and
gram and an ecomap. The integrated data gathered Luke to explore what it is like to partner with
by the therapist revealed strengths such as similar someone from a different cultural background.
vocations and differences regarding the couple’s In each session, the process, identified as themes
families-of-origins expectations of the amount of and patterns derived from the couple’s
time families spent with one another and in the responses to the therapist’s inquiries, is linked
larger community. Luke’s family of origin valued back to the content, or the presenting problem.
independence and self-reliance; they had fewer Luke and Opal decided to end their treatment
connections to social networks, local places, when they were able to understand their commu-
and friends. Conversely, Opal hailed from a nication patterns at a deeper level. The improve-
bi-cultural family with many links to larger sys- ment in their communication was measured
tems (e.g., political groups, art school, neighbors, through the number of times they identify feeling
and Opal’s mother’s connection with the immi- heard and supported by one another. Each partner
grant community from Ecuador). These differ- was able to validate the other’s perspective
ences sparked verbal fights, thus leading the regarding emotions and experiences, even if she
couple to a perception of having compromised or he disagreed with their partner’s perceptions.
communication.
The therapist used circular questioning to
understand how each member of the couple per- Cross-References
ceived one another. Did Opal think that Luke’s
perceived passivity was aloofness or the need for ▶ Circular Causality in Family Systems Theory
solitude? What were Luke’s ideas about being in a ▶ Double Bind Theory of Family System
community – that was unhealthily enmeshed or ▶ First-Order Change in Family Systems Theory
lovingly bonded? The therapist inquired about ▶ First Order Cybernetics
how Opal’s answers compared with how Luke ▶ Narrative Couple Therapy
described his own experiences and vice versa. ▶ Postmodern Approaches in the Use of
The therapist and clients created a dialogue Genograms
832 Ecosystemic Structural Family Therapy
▶ Second-Order Change in Couple and Family ESFT trains family therapists to go against the
Therapy cultural grain by empowering caregivers and nur-
▶ Second-Order Cybernetics in Family Systems turing resilient patterns of family and community
Theory connection.
Family therapists face three key clinical chal-
lenges when they are working to strengthen trans-
References actional patterns that weaken a family’s ability to
nurture its children. These challenges are: (1) to
Almeida, R., Dolan-Del Vecchio, K., & Parker, L. (2008). see the family as ensnared in a set of negative
Transformative family therapy: Just families in a just
interactional patterns fueled by avoidance and
society. New York: Pearson/Allyn & Bacon.
Bateson, G. (1979). Mind and nature: A necessary unity abdication; (2) to understand the therapist’s role
(1st ed.). New York: Dutton. to help caregivers envision new transactional pat-
Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956). terns; (3) to respond to the family through a
Toward a theory of schizophrenia. Behavioral Science,
collaborative partnership with the caregivers and
1, 251–264.
Bronfenbrenner, U. (1979). The ecology of human devel- the at-risk child.
opment: Experiments by nature and design. Cam-
Bubolz, M. M., & Sontag, M. S. (1993). Human ecology
theory. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R.
Schumm, & S. K. Steinmetz (Eds.), Sourcebook of
family theories and methods: A contextual approach The development of ESFT was influenced by Sal-
(pp. 419–450). New York: Plenum Press. vador Minuchin (SFT 1974), John Bowlby
Falicov, C. J. (2014). Latino families in therapy (2nd ed.).
(Attachment 1983, 1988), and Bessel van der
Hernández, P. (2002). Resilience in families and commu- Kolk (Trauma 1997).
nities: Latin American contributions from the psychol-
ogy of liberation. The Family Journal, 10, 334–343.
https://doi.org/10.1177/10680702010003011.
Wetchler, J. L., & Hecker, L. L. (2014). An introduction to
marriage and family therapy (2nd ed.). New York:
Routledge. ESFT therapists believe that children thrive when
Walsh, F. (2006). Strengthening family resilience (2nd ed.). the key caregiver relationships in their lives rest
solidly on four pillars: a secure caregiver- child
attachment, a healthy alliance between and among
their caregivers, a predictable and balanced
Ecosystemic Structural Family approach to caregiver executive functioning, and
Therapy the strengthening of each family member’s ability
to increase distress tolerance and emotion rela-
Marion Lindblad-Goldberg and Edward A. Igle tion. A breakdown in one or more of these pillars
Philadelphia Child and Family Therapy Training sustains a child’s troubles. ESFT teaches thera-
Center, Philadelphia, PA, USA pists how to: (1) discern and target the cyclical
patterns of interaction that sustain the breakdown
of key relationship and (2) work collaboratively
Introduction with the child’s ecosystem to develop new
growth-promoting relational patterns.
Ecosystemic Structural Family Therapy (ESFT) is The ESFT model provides a map of these four
an empirically supported treatment/supervision/ stages of treatment:
training model developed by Marion Lindblad-
Goldberg in the 1970s and further elaborated at 1. Constructing a therapeutic system. In this
Philadelphia Child and Family Therapy Training stage of treatment, the therapist is challenged
Center. to determine who constitutes the family and
Ecosystemic Structural Family Therapy 833
must look within and around the household 3. Creating key growth-promoting interper-
for members of the child’s ecosystem with a sonal experiences. In this stage of treatment,
view toward recruiting relevant family mem- the family therapist and the family members
bers, informal support persons, and formal join together to create in-session scenarios
community partners into a therapeutic alli- that activate the members of the family to
ance. The therapist then convenes and col- experiment with obscured or untapped
laboratively joins with each participant – resources. This is done through directed
including the symptom bearer – and proposes enactments that restructure the transactions
the structure and purpose of family therapy in maintaining the presenting problem and
a way that differentiates it from other formats replace them with transactions that
E
of care. The therapist notes the transactional confront and defeat the family’s CNIP.
patterns that sustain the child’s symptoms, These transactional experiments may be
such as problems with conversational bound- aimed at promoting healthy exchanges in
aries, failing attempts at executive functioning or the care-giver alliance, strengthening parent
emotion regulation, conflicts over caregiving, or executive skills, increasing distress toler-
weaknesses in attachment bonds. ance and emotion regulation, and/or creating
2. Establishing a meaningful therapeutic focus. age-appropriate parent-child attachment. In
In this stage of treatment, the goal is to use this way, ESFT addresses child or family
therapeutic alliances to place the presenting trauma, the legacies of family losses, the
problem in a relational frame. A relational cultural marginalization of the family, the
frame is a summary statement that directly transgenerational effects of poverty, and
links the presenting symptoms to specific many other relationally disruptive
changes in key family relationships listed factors in the “here and now.” The emphasis
above. It orients family members toward an is not on living in the past but on living with
inter-personal outcome that is within their the past as a strong and resilient family
power to control and galvanizes them to take system.
action. ESFT equips the therapist with assess- 4. Solidifying change and discharge planning.
ment tools that focus on the relational stories of In ESFT, the experiments of change
family members such as genograms, relational that restructure family transactions during
timelines, and eco-maps. the third stage of treatment are expanded
In ESFT, assessment is both a process and and extended into the ecology of the
a product. The process reveals family struc- family’s complex relationships to the agen-
ture: the invisible set of functional demands cies, institutions and resources that orbit
that regulates how each family member par- the family. Recognizing that so many fam-
ticipates in the family system. The product is ilies have endured chaotic, unplanned, and
a systemic hypothesis: a recursive explana- unexplained relational endings, ESFT
tion that identifies the core negative inter- therapists carefully plan termination of
actional pattern (CNIP) that sustains the family therapy in such a way as to (1) pro-
presenting problem. The hypothesis will cess the loss of the therapeutic relationship
drive all the family therapy interventions in as an opportunity to use new relational
the next stage of treatment, so it is essential patterns to tackle future relational chal-
that the therapist and the family collaborate lenges, and (2) anchor the family in healthy
on its meaning and the language. The thera- alignments with supportive resources in its
pist actively helps the family to see and community environment. Toward these
understand how the CNIP is sustaining the ends, ESFT therapists often help families
family’s pain and to respond to the CNIP by develop closing rituals that reinforce
joining with the therapist to reduce its control feelings of personal agency and family
over the family. strength.
834 Ecosystemic Structural Family Therapy
Populations in Focus are keeping the family in misery, and dilute the
power of the CNIP by practicing healthier trans-
ESFT is designed to treat families in outpatient, actional patterns. The development of a relational
inpatient, and in-home settings. Its design is also frame is viewed as a collaborative effort: once the
applicable to families that are seeking to reinte- therapist and the family come to a meeting of the
grate a child from residential treatment, as well as minds on which family struggles to target for
families that are accepting a traumatized child into change, the focus of clinical attention moves
a foster care or adoption arrangement. ESFT has toward designing and experimenting with new
been applied to a wide variety of internalizing and relational patterns through enactment.
externalizing disorders, including problems with Enactment refers to any therapist-initiated
attention and concentration, insecure or anxious activity in which family members are challenged
attachment, self-injury and depression, disorders to engage directly with one another about an issue,
in eating, co-occurring disorders, behavioral prob- a conflict, or a task. ESFT uses enactments,
lems, addictions, and traumas (physical abuse, attended by boundary-making, circular
sexual abuse, and more). questioning, tracking, and crisis induction, to pro-
ESFT is able to engage and help families voke the occurrence of the CNIP and to give
resolve these problems because of its trauma- family members concrete experiences of triumph
informed perspective of child and adolescent over it. Enactments provide the therapist with
mental health. This means that the model itself opportunities to punctuate the strengths of family
generates a treatment plan for every client family members and give family members new informa-
as though at the heart of the problem there is an tion about their own resilience and their ability to
attachment-related developmental disruption offset the legacies of avoidance and abdication
associated with the child and/or caregiver’s expe- that previously controlled them.
rience of unresolved trauma.
Research About the Model

Strategies and Techniques Used in the
Model The empirical support for the ESFT model
targeted over 4000 families in 39 different sites,
The assessment phase of ESFT organizes the fam- having youth with severe emotional and behav-
ily therapist to see, understand, and respond to the ioral disturbance who were either at risk of out-of-
family’s struggle around four important areas of home placement or who had already spent time in
family functioning: the co-caregiver alliance, the an inpatient or residential setting. The families of
security of attachment, executive functioning, and these youth tended to be compromised by trauma-
emotion regulation/distress tolerance. However, it induced parental substance abuse, conflictual rela-
is not enough for the therapist to have ideas about tionships, emotional disturbance, and the absence
what to do about these areas of struggle; somehow of emotional or concrete support (Lindblad-
the therapist has to language the problem concep- Goldberg et al. 1998; Lindblad-Goldberg and
tualization in such a way as to help the family see Northey 2013; Lindblad-Goldberg and Igle
relational change as the key to its resolution of the 2015).
presenting problem. This is done by reframing,
that is, placing the presenting problem and the
core negative interactional pattern that sustains it Case Study
in a relational frame.
Reframing the presenting problem in relational Betsy, a Caucasian ESFT therapist in outpatient
terms empowers family members to see the pre- practice, received a call from Sharita, an African
senting problem as something under their control, American divorced mother of two in late October.
to understand how habitual patterns of behavior Sharita explained that her son, Rainier, age
Ecosystemic Structural Family Therapy 835
11, was about to be expelled from a charter school change his relationship to school, the conversa-
because he continually talked back to his teachers, tion gets lost in a tangle of post-divorce resent-
disrupted class with crude remarks, and got in ments and disappointments?
fights with peers. Because he was so bright, the Betsy found the use of particular assessment
school had given him many “second chances,” tools helpful in both generating a working hypoth-
provided in-school counseling, and even esis and in creating a relational frame. She
reworking his schedule so that he would not be constructed the genogram in such a way as to
instructed by particular teachers who, he claimed, give Rainier the opportunity, not just to identify
did not like him. Sadly, Sharita went on to say, assorted relatives but also to specify the over-all
nothing worked, and Rainier would be expelled quality of these relationships. In a similar way,
E
unless his family could find “outside help” to Betsy used the relational time line to help all three
settle him down. Sharita added that because she family members agree on the key events that
had to be called to the school so often, she had brought their relationships into the space wherein
missed so many days of work that she was at risk family therapy was necessary. The family’s eco-
of losing her job as a department manager at a big map was also served as a valuable instrument in
box store. helping both Betsy and the family assess how this
Betsy scheduled an appointment time that allo- family was managing its connections to the vari-
wed Sharita not to miss more work. She explained ous resources in its social environment. And
to Sharita that in order to fully understand what throughout the assessment period, an observable,
was going on with Rainier, Betsy wanted to predictable interaction would show itself: talk
include everyone who lived at home with him in would come dangerously close to discussion of
the first interview. Sharita did not think that Rain- the parents’ divorce, and then talk would be
ier’s sister, Ivana, age 13, should have to attend focused on Rainier’s troubles in school.
the session because she was an exceptionally Betsy’s hypothesis was that there was a link
cooperative child. Betsy explained to mother that between the family’s navigation of divorce and
it would be helpful for her to observe Rainer’s Rainier’s navigation of school. The challenge for
relationship with his sister. Betsy also shared with Betsy was how to language this connection in
mother that siblings often have ideas about what such a way as to capture the family’s imagination
needs to change in a setting that has become in a reframe that would empower the family to
problematic. work toward change so that Rainier could master
Betsy met with Sharita, Rainier, and Ivana for the emotional and behavioral struggles associated
the first interview. She joined with Sharita first, with his parents’ divorce. Betsy met this challenge
remarking on how respectful both children were with a powerful relational reframe: “Rainier is
as she and their mother conversed and attributing acting out in school because he has convinced
that respectfulness to Sharita’s guidance and lead- himself that it is his job to regulate his family’s
ership. Joining with Ivana proceeded in a similar shock and grief over its post-divorce
way. However, when it was time to join with reconfiguration; he will do better in school when
Rainier, the façade of civility between Ivana and the family resolves the hurts caused by the
Rainier crumbled. Betsy observed that Ivana con- divorce.”
tinually challenged the truthfulness of Rainier’s Betsy’s hypothesis made sense to the family
responses, persisting in this behavior even when and allowed them to move into the stage of the
Sharita redirected her, even to the point where ESFT model when family therapy sessions are
Ivana accused Rainier of “being a liar just like devoted to experiments in relational change that
Daddy.” This transactional pattern gave Betsy her confront and dissolve the power of the core neg-
first important clue about a core negative interac- ative interactional pattern over family transac-
tional pattern that might be sustaining Rainier’s tions. Betsy helped the family accomplish this
troubles in school. Could it be, Betsy thought, by directing the enactment participants to persist
that, when this family attempts to help Rainier while discussing difficult material despite their
836 Eisler, Ivan
urge to run away from it. She also helped enact- Lindblad-Goldberg, M., & Northey, W. (2013).
ment participants to set and keep boundaries Ecosystemic structural family therapy: Theoretical
and clinical foundations. In Contempory family therapy
around their dialogues so that conversations that (Vol. 35, pp. 147–160). New York: Springer.
started between two family members could stay Lindblad-Goldberg, M., & Igle, E. (2015). Grandparents
between them until both family members could raising grandchildren: An ecosystemic structural fam-
feel heard and understood. These enactments ily therapy (ESFT) treatment approach. In S. Browning
& K. Pasley (Eds.), Contemporary families: Translat-
supported Sharita’s competence as the family’s ing research into practice (pp. 248–266). New York:
leader in guiding her children in discussing of Routledge.
difficult material and empowered Sharita to Minuchin, S. (1974). Families and family therapy. Cam-
reach out to the father, Roman, to join her in bridge, MA: Harvard University Press.
Van der Kolk, B. A. (1997). The psychobiology of post-
meeting with school officials to discuss Rainier’s traumatic stress disorder. Journal of Clinical Psychia-
progress. try, 58, 16–24. Memphis: Physicians Postgraduate
Toward the end of family therapy, when it Press.
became clear that the members of the family
could talk plainly and openly about their shared
story of family disruption and when Rainier was
no longer dragging disruption around with him
Eisler, Ivan
whenever he entered the school building, Betsy
asked whether the family was interested in sharing
Judith Lask and Liz Dodge
its progress with Roman. Sharita led Ivana and
London, UK
Rainier in a discussion of the risks and benefits of
this idea, and the family decided that it was a good
idea. The purpose of the sharing would be to make
Name
it clear that this is a family wherein there is no
more need to hide from the truth of its own story
Professor Ivan Eisler Ph.D., OBE
as a family. The meeting with Roman turned out to
be the first of several meetings that proved helpful
to Rainier in anchoring the changes he was mak-
ing in school to important relational changes in his Introduction
family.
Eisler has made a unique, international contribu-
tion to the field of family therapy and family
psychology, and specifically to the field of eating
References
disorders. His contribution covers extensive and
Bowlby, J. (1983). Attachment and loss (Vol. 1, 2nd ed.). highly valued research, training, service develop-
New York: Basic Books. ment, and national policy formulation and imple-
Bowlby, J. (1988). A secure base: Parent-child attachment mentation. He has been a major influence on the
and healthy human development. New York: Basic
creation of effective, evidence-based eating disor-
Books.
Lindblad-Goldberg, M. (2011). Ecosystemic structural ders services in the UK and internationally. In
family therapy treatment manual. Philadelphia: Phila- addition, his focus on evidence-based interven-
delphia Child and Family Therapy Training Center. tions and his collaborative approach to therapy,
Lindblad-Goldberg, M., Dore, M., & Stern, L. (1998).
focusing on the way the family organize them-
Creating competence from chaos: A comprehensive
guide to home-based services. New York: Norton. selves around the problem, and avoiding family
Lindblad-Goldberg, M., & Dore, M. (2004). Effective blame, has been an important influence on the
family-based mental health services for youth with field of family therapy. His research has ensured
serious emotional disturbance in Pennsylvania. The
that family therapy and other systemic approaches
ecosystemic structural family therapy model. Philadel-
phia: Philadelphia Child and Family Therapy Training are accepted as key interventions in the treatment
Center. of eating disorders.
Eisler, Ivan 837
Career Early in his career he became involved in fam-

ily therapy training, running MSc programs in
Eisler was born and grew up in Prague. He studied London at the Institute of Family Therapy,
psychology and philosophy at Oxford University, London and later at the Institute of Psychiatry.
England, returning to Prague where he gained his Many students have benefited from his research
Diploma in Psychology. He worked as a clinical teaching and his pragmatic and collaborative
psychologist in Prague until he moved to London, approach to working with families in extremely
England, taking up a research post at the Institute difficult circumstances. He has influenced training
of Psychiatry in London and completing his Ph.D. standards and curriculum in the UK and Europe
He joined a team, led by Professor Gerald Russell, through his involvement with the Association for
E
which was pioneering research in family treat- Family Therapy (UK), United Kingdom Council
ments for eating disorders. This research was to for Psychotherapy, and the European Family
influence both the treatment of eating disorders Therapy Association.
and family therapy in general. He progressed his In addition, Ivan Eisler has had a significant
career at the internationally renowned South involvement with prominent journals in the fields
London and Maudsley Foundation Trust and the of family therapy and eating disorders including
Institute of Psychiatry, Psychology and Neuro- editorship of the “Journal of Family Therapy”
science (Kings College London). He has had a from 2002 to 2008 and membership of several
distinguished academic career. In 1995, he was advisory boards, including “Family Process.”
appointed assistant head of clinical psychology Eisler has advocated therapeutic interventions
and in 2009 “Professor of Family Therapy and built on an evidence base. He has spent a large
Family Psychology”; the first UK professor part of his career gathering that evidence and
appointed with this title. He has lectured and adapting his thinking in response to the results of
presented around the world and received a number research, as well as encouraging younger col-
of awards for his contribution including the Acad- leagues, some of whom might be lacking in confi-
emy for Eating Disorders “Outstanding Clinician dence, or suspicious of research. The strength of his
Award” (2009), a Lifetime Achievement Award research credentials has made him an essential
from “Beating Eating Disorders” (2012) and an member of committees, advising government on
award from the American Family Therapy Acad- policy development and implementation, especially
emy for “Distinguished Contribution to Family in relation to eating disorders. In the last decade, has
Systems Research”(2014). been invited by NHS England to take a key role in
His UK contribution to the field was recog- the development of curricula for systemic family
nized nationally when he was awarded an practice and eating disorders as part of a major
O.B.E. (Order of the British Empire) in 2016. policy initiative (Children and Young Person’s
Increased Access to Psychological Therapies).
This has also included a significant input into the
Contribution to the Profession development of a whole service approach and a
well-trained workforce. His development of multi-
Since his first publication in 1985, Eisler has family approaches and training courses based on
published more than 100 peer reviewed academic this intervention has had a major impact on the
papers and contributed to numerous books. field. Not only has this impacted on the eating
He has administered numerous research grants disorders field, but his approach has influenced fam-
and carried out highly evaluated research, includ- ily therapy training and practice in general. His
ing randomized control trials, service appraisals, emphasis on the importance of good quality broad-
and economic evaluation of services. This work based training where family therapists develop a
was mainly in relation to eating disorders but he range of approaches and skills, which can be
has also had an interest in depression and sub- adapted to suit clinical need, has influenced family
stance abuse. therapy training across the UK and beyond.
838 Elderly in Couple and Family Therapy
The bringing together of research on treatment Introduction

and service development is demonstrated in ser-
vices such as the one developed at the South The elderly of today differ in many significant
London and Maudsley Trust. This is clearly ways from those of previous generations. As the
described in a readily available service manual baby-boomers, those born between 1946 and
by Ivan Eisler and colleagues. Here the multi- 1964, moved into the categories of middle and
disciplinary team has a primary focus on family old age, they brought with them new ways of
involvement utilizing both single and multifamily thinking about and behaving relative to aging.
therapy in addition to incorporating other inter- Retirement no longer necessarily indicates the
ventions, as and when clinically appropriate. end to productivity and involvement in the outside
world but now often signals the beginning of a
meaningful second half of life. Rather than
Cross-References
consigning themselves to rocking chairs and a
slowing down of their faculties and activities,
▶ Family Meals
retirees tend to see themselves as younger longer,
▶ Maudsley Family Therapy for Eating Disorders
confident, engaged, and active, as well as excited
▶ Multifamily Group Therapy
about what lies ahead.
The context within which this shift has
occurred is that of our aging* society. That is,
References
between 2003 and 2013, the 65+ population
Eisler, I., Simic, M., Blessitt, E., Dodge, L., & Team. increased from 35.9 million to 44.7 million, a
(2016). Maudsley service manual for child and adoles- 24% increase. By 2060, this number is expected
cent eating disorders (Revised). London: Child to reach 98 million, or to double. In 2013, the 85+
and Adolescent Eating Disorders Service, South population was 6 million. By 2040, this popula-
London and Maudsley NHS Foundation Trust. Avail-
able at: http://www.national.slam.nhs.uk/services/ tion is predicted to be 14.6 million, or to triple
camhs/camhs-eatingdisorders/resources. (Administration on Aging 2015). In the following
Eisler, I. (2005). The empirical and theoretical base of family sections, the impact on the elderly of the changes
therapy and multiple family day therapy for adolescent just noted, including descriptions of important
anorexia nervosa. Journal of Family Therapy, 27,
104–131. concepts, relevant research, and special consider-
Eisler, I., Szmukler, G. I., & Dare, C. (1985). Systematic ations for marriage and family therapy, are all
observation and clinical insight – are they compatible? addressed.
An experiment in recognizing family interactions. Psy-
chological Medicine, 15, 173–188.
Russell, G. F. M., Szmukler, G. I., Dare, C., &
Eisler, I. (1987). An evaluation of family therapy in Descriptions
anorexia nervosa. Archives of General Psychiatry,
44, 1047–1056. In the traditional framework according to which
families have long been understood, elderly adults
are described in terms of two stages of develop-
Elderly in Couple and Family ment, each with its particular tasks and challenges
Therapy (Becvar and Becvar 2013). According to this
framework, the emotional issue for middle age
Dorothy Becvar adults involves letting go of children and, as a
Saint Louis University, Saint Louis, MO, USA couple, facing each other again. Their stage criti-
cal tasks include rebuilding their marriage, wel-
coming the spouses of their children and
Synonyms grandchildren into the family, and dealing with
their aging* parents. In the final stage, that of the
Aging; Later Life retired adult, the emotional issue is accepting
Elderly in Couple and Family Therapy 839
retirement and old age. Stage critical tasks include likely to be female. This situation is the case given
maintaining individual and couple functioning, that women have a greater life expectancy, women
supporting the middle generation, coping with tend to outlive their generally older spouses, and
the death of parents and spouse, and closing or women in any age group tend to be more comfort-
adapting the family home. able with the idea of therapy. For elderly women,
While the above framework probably was particularly those who are widows, an important
never completely accurate, it provided a useful issue is the loss of financial security and social
set of guidelines to consider. What is more, some network that may occur following the death of a
aspects may continue to be relevant to a portion of spouse. Further, regardless of gender, facilitating
today’s elderly individuals and families. How- connections with a meaningful support system
E
ever, for the most part new descriptions, espe- may be important as the loss of friends and family
cially relative to timing, are in order given the members becomes ever more common the older
demographic and behavioral changes noted in one gets.
the introduction. For example, rather than an
empty nest, middle age parents often find them-
selves in a new stage that might be called, “when Relevant Research About the Elderly
the kids come back home.” That is, after initially
leaving home, perhaps graduating from college Over the years, the topic of aging* and its related
and/or for economic reasons, many young adults concerns have been the focus of a very small
return to the family home in order to get their feet percentage of the family therapy literature. The
on the ground financially. In addition, many area that has received the most attention within
young adults are choosing to build a career before this realm is that of the role of the family care-
marrying or having children. For the middle age giver. From this body of research we are reminded
adults a focus on the spousal relationship that assuming the role of family caregiver to a
thus may be postponed along with the process of physically or emotionally compromised older per-
welcoming their children’s spouses and son represents a major life transition that may
grandchildren into the family. Meanwhile, having have far-reaching consequences for the care-
retired earlier than in a manner consistent with the giver’s physical, mental, and social well-being
previous norm, they may be looking forward to (Ziemba and Lynch-Sauer 2005. Further, emo-
what they perceive to be an exciting next chapter. tional closeness as well as similarity of gender
Indeed, older adults generally are staying and attitudes may be strongly associated with
healthier and living longer than in previous gen- which children mothers identify as probable care-
erations. Further, given the lengthened lifespan, givers. Another study revealed that female care-
adults may be older as they are called upon to givers often feel unprepared for the role and
support their aging* parents, who also are older. experience emotional distress related to both the
They also may be less available for the caretaking loss of a parent and the loss of their youth. Addi-
of grandchildren as they continue to explore new tionally, it has been found that the quality of the
opportunities and interests of their own. However, caregiver’s marital relationship influences the
while the timing may be different, the elderly still psychological effects of becoming a caregiver
may continue to face issues around maintaining for a biological parent or spouse (Choi and
the functioning of older individuals and couples. Marks 2006). It also has been found that humor
The oldest old may continue to be called upon to used to communicate information about socially
support the middle generation. Dealing with taboo or sensitive topics (e.g., bowel movements,
dying, death, and bereavement issues also is inev- loneliness, personal safety, and intimate care)
itable as is the need to alter living arrangements often masks problems and concerns (Bethea
when appropriate. et al. 2000).
In addition, although slowly changing, the fact Regarding the implications for future research
remains that a large segment of elderly clients are related to the elderly, it has been suggested that
840 Elderly in Couple and Family Therapy
studies are needed on the topics of roles and important information, and/or to have more than
responsibilities and parent–child interactions one complaint. They also need both to understand
including patterns of contact, required assistance, that health issues and/or medications may have an
and support. Additional research would also do adverse effect on behavior and to recognize the
well to focus on individual well-being, relation- influence of normal aging processes vs. disease
ship quality, and caregiving by adult children processes.
(Mancini and Bliesner 1989). In addition, therapists must be sensitive to their
own biases and preconceptions regarding the
elderly, possibly fearing the need for special skills
Special Considerations for Couple or fearing that older adults are fragile and thus not
and Family Therapy to be confronted (Davey et al. 2000). They also
may have unresolved issues with their own par-
Until recently, the elderly have often been reluc- ents and grandparents that are in need of attention.
tant to avail themselves of therapy, and therapists Their assumptions about sexual activity among
often have had little experience dealing with the elderly may be inaccurate and thus need to
elderly individuals and their families. However, be checked out. That is, sexual intimacy does not
given the many changes noted above, it is highly necessarily end at a particular age and may remain
likely that therapists will need to educate them- a constant throughout life. In addition, therapists
selves about this growing cohort of clients. may need to overcome their own fears about
Elderly family members may bring themselves dying, death, and bereavement, a crucial topic of
to therapy or younger individuals may seek help consideration for the elderly and their families.
regarding elderly family issues. Therapists, there- Early models of bereavement proposed that
fore, will need to have knowledge about the entire the grief process occurs in three stages: 2 weeks
life cycle as well as an ability to work with family of intense grief, followed by 2 years in which the
members of all ages. They also will need knowl- survivor was to disconnect from the one who
edge about medical issues and how to work with died, and a return to normal thereafter. Failure
other health care providers. to follow this agenda was considered to connote
Involving as many family members as possible pathological grieving. More recent models of
may aid the therapy process, particularly when grieving, however, suggest that the grieving pro-
role transitions are the focus. Regardless of the cess may have no fixed endpoint and may even
presenting issue, the use of a genogram may allow last a lifetime. Further, complete detachment
the elderly to tell their stories and engage in a kind from the deceased is recognized as neither pos-
of life review that increases their comfort level. sible nor desirable. Rather, bereaved persons
Indeed, it may be important to support and may remain involved and connected to the per-
validate elderly individuals, acknowledging son who has died, often constructing an inner
efforts already made to solve problems as well as representation of the deceased. Further, bereave-
feelings of being stuck they may be experiencing. ment may take many forms, and the degree to
Clients also may be commended for coming to which grief is or is not maladaptive must be
therapy given the courage this may have required. decided on an individual basis. In therapy, the
Indeed, although their feelings may change, goal is to help family members to resolve rather
elderly clients may feel shame or worry that their than work through the loss. This may involve
reputation will be tarnished by engaging in ther- helping them to acknowledge and learn to accept
apy. Therefore, it may be appropriate to normal- and live with grief while at the same time being
ize, emphasizing to clients that they are not crazy, successful in reclaiming joy as an equally valid
and responding first to questions and concerns. part of life; recognizing each experience of loss
Therapists also need to understand the tendency as unique; allowing the bereaved to tell their
of older adults to be vague in their descriptions of stories as often as need be; and understanding
problems and concerns, to gloss over potentially that grief may never end, and that this does not
Elderly in Couple and Family Therapy 841
necessarily indicate pathology or preclude the be open to new ideas. Healthy aging behaviors
possibility of reclaiming joy. include caring about others, accepting the past
In addition, at any age two important aspects of and taking sustenance from previous accom-
the therapy process may include facilitating resil- plishments, and cheerfully accepting the “indig-
ience and supporting healthy aging. With the goal nities of old age.” Also important is being
of resilience in mind, the focus is on strengths graceful about dependency issues, taking care
rather than deficits with the assumption that fam- of self, and, when ill, becoming a good patient
ilies have the ability not only to survive difficult (Vaillant 2002).
times but also to eventually thrive as they emerge Working with later life* families involves dis-
from those experiences. For the elderly this may tinctive issues and challenges (Shields
E
involve encouraging celebrating and having fun, et al. 1995). At the same time, with an approach
taking advantage of opportunities to experience that is sensitive to the specific needs and concerns
spontaneity and a sense of humor. Therapists also of middle-aged and elderly families and their
may suggest the creation of rituals that might fill a members, the therapist may experience unique
void, or the recreation of traditions that no longer opportunities to assist clients in achieving their
fit as individuals grow older and families mature. goals. They thus may succeed in contributing to
Also appropriate may be conversations around the enhancement of the quality of life during what
goals and values and understanding the impor- is often one of its most stressful phases.
tance of a sense of meaning and purpose in life,
particularly when dealing with end-of-life issues
and challenges. It also may be appropriate to
References
consider the role of religion and/or spirituality in
clients’ lives, recognizing that this area may be an Administration on Aging. (2015). A profile of older Amer-
important source of coping for older adults. Ther- icans, 2014. http://www.aoa.acl.gov/Aging_Statistics/
apists therefore might include questions about Profile/2014/docs/2014-Profile.pdf. Accessed 6 July
2015.
religion/spirituality in initial assessments, be curi-
Becvar, D. S., & Becvar, R. J. (2013). Family therapy:
ous about various orientations, and access A systemic integration. Boston: Allyn & Bacon.
resources from the religious/spiritual realm as Bethea, L. S., Travis, S. S., & Pecchioni, L. (2000). Family
appropriate. caregivers’ use of humor in conveying information
about caring for dependent older adults. Health Com-
Encouraging a focus on ways to create an older
munication, 12(4), 361–376.
age that is as enjoyable as possible may involve Choi, J., & Marks, N. (2006). Transition to caregiving,
helping clients revise their self-talk about what marital disagreement, and psychological well-being.
lies ahead. Therapists also may provide sugges- Journal of Family Issues, 27(12), 1701–1722.
Davey, A., Murphy, M. J., & Price, S. J. (2000). Againg
tions derived from recent research on aging, help-
and the family: Dynamics and therapeutic interven-
ing them to plan to live a very long life – perhaps tions. In W. C. Nichols, M. A. Pace-Nichols,
80 or 90 years – and taking steps to guarantee the D. S. Becvar, & A. Y. Napier (Eds.), Handbook of
intellectual and social stimulation that is desirable family development and intervention (pp. 235–252).
New York: Wiley.
in later years (Dychtwald 2000).
Dychtwald, K. (2000). Age power: How the 21st century
It may be important to help clients avoid will be ruled by the new old. New York: Jeremy
getting trapped in yesterday’s linear model of P. Tarcher/Putnam.
aging. This effort may include adjusting their Mancini, J. A., & Bliesner, R. (1989). Aging parents and
adult children: Themes in relationships between older
psychological, social, and financial expecta- parents and their adult children. Journal of Marriage
tions to support a life plan that is periodically and the Family, 51, 275–290.
revised to envision new career goals and chal- Shields, C. G., King, D., & Wynne, L. C. (1995). Interven-
lenges. Intellectual flexibility and the ability to tions with later life families. In R. H. Mikesell,
D. D. Lusterman, & S. H. McDaniel (Eds.), Integrating
learn new skills and technologies are likely to be
family therapy: Handbook of family psychology and
significant in this process. It is important that the systems theory (pp. 141–158). Washington, DC: Amer-
elderly maintain or find social connections and ican Psychological Association.
842 Elementary Pragmatic Model
Vaillant, G. E. (2002). Aging well. Boston: Little, Brown Theoretical Framework (Including Core
and Company. Concepts of Model, Theory of Change,
Ziemba, R. A., & Lynch-Sauer, J. M. (2005). Preparedness
for taking care of elderly parents: “First, you get ready and Rationale for the Model)
to cry”. Journal of Women and Aging, 17(1/2), 2005.
Rooted in work by Gregory Bateson, EPM
explores how the world is perceived and
Elementary Pragmatic Model exchanged in interpersonal relationships. EPM is
based of ideas related to interactions of the mind
Piero De Giacomo1 and Jessica L. Chou2 between two individuals (De Giacomo 1992).
1 These exchanges produce four outcome modali-
University of Bari Aldo Moro, Bari, Italy
2 ties of interactions: (1) acceptance of other’s
world, (2) acceptance of one’s own world,
(3) acceptance of what is shared, and (4) accep-
Name of Model tance of what is outside the world of the two
interacting persons. From these interactions
Elementary pragmatic model ensued the development of 16 functions and also
coined as interactions and relational styles. The
Introduction interactions between the 16 relationship styles
give rise to 256 possibilities of interactions
The elementary pragmatic model (EPM) was devel- (De Giacomo 1992). EPM also draws from a
oped in the 1960s in order to expand on family structural approach to therapy in that the model
systems theory and further explore interpersonal focuses on subsystems within the family unit and
relationships. The theory focuses on a “pragmatic” communication styles among dyads.
approach by examining communication of behav- In addition to the family therapy field, there has
iors between two individuals and an “elementary” to be mention of the important development in the
approach for classifying communicative interac- field of problem-solving creativity. Problem-
tions (De Giacomo 1992; De Giacomo et al. 2013). solving creativity has extended into the general
field of psychotherapy (De Giacomo et al. 1990)
as well as in the field of informatics (De Giacomo
Prominent Associated Figures 1999). The latest development of EPM to include
creativity explores metacognition (i.e., thinking
The theory defined as EPM was born in Bari, Italy, about the mind) and how to think differently.
from the meeting of Piero De Giacomo, Professor Further information can be located in the book
of Psychiatry at University of Bari, and Alberto titled Creativity Mind (De Giacomo and Fiorini
Silvestri, Professor of Numerical Calculations and 2015).
President of Economy Faculty at Trento Univer-
sity. This meeting was a result of De Giacomo’s
interest in general systems theory, which at the Populations in Focus
time was an emerging theory. De Giacomo sought
to meet an expert in mathematics, physics, and In the field of family therapy, the original EPM
computer science and explore the possibilty of the interventions were developed for persons diag-
integration of these fields with general systems nosed with anorexia nervosa and schizophrenia.
theory. From this meeting, EPM was created. As the model evolved, it has since been
Luciano L’Abate from Georgia University also expanded and can be used for a myriad of rela-
contributed greatly to EPM and coauthored a tional dyads, including those with and without
book with De Giacomo titled Intimate Relation- clinical diagnoses. EPM has been utilized as
ships and How to Improve Them (L’Abate and De short- and long-term therapeutic model
Giacomo 2003). (De Giacomo et al. 2012).
Elementary Pragmatic Model 843
Strategies and Techniques Used begun skipping meals. Though Aida had partici-
in Model pated in various sports during high school, she
had recently quit her teams and told her parents
The model implements techniques and strategies she did not want to play sports so she could shift
considered straightforward and direct while also her focus to counting calories.
focusing on paradoxical interventions (De At the start of therapy, the therapist arranged
Giacomo et al. 1997b). One technique used in the family members according to a structural
EPM is called the empty box. The empty box approach. The therapist sat behind the desk,
intervention can be used when a family is deemed and Mia and Russel sat laterally in front of the
“uncooperative” by the therapist. This interven- desk with the two chairs facing each other. Aida
E
tion mobilizes the families’ capacity to change. was placed in a second line in front of the ther-
The therapist tells the family he knows the solu- apist. The therapist established friendly contact
tion to the problem, however, believes they are not with all family members, showing interest in
yet ready to hear the solution. Another example of each person’s world, starting with Mia and
an EPM technique explores using common Russel and then Aida. After joining with the
logic. If a therapist is working with a client who family, the therapist inquired about the problem.
is dissociative and displaying incoherent speech, In response, Mia took the lead in explaining
the therapist will meet the client where he/she is Aida’s problems. She reported that Aida was
by also using incoherent speech in order to assist not eating and was irritable and emotional. The
the client in developing a cooperative relational therapist utilized a direct and paradoxical
style (De Giacomo 1992). approach, saying that in fact there was reason
to be seriously concerned because when some-
one exhibits symptoms of anorexia nervosa the
Research About the Model danger of death is real. The therapist also
reported that he was not sure the problem
EPM has 40 years of experimentation with normal could be overcome. The family became more
and pathological subjects that have yielded signif- anxious and asked what could be done.
icant results. De Giacomo et al. (1997) studied The therapist asked if the family was willing
EPM in a sample of families in which one person to do everything possible to solve the problem
was diagnosed with schizophrenia. The research (this is first asked collectively to the whole fam-
showed efficacy for EPM when used in conjunction ily and then to each separate member). Every-
with medication compared to a medication-only body answered in the affirmative. The therapist
population. Specifically, those who participated in asked the father and Aida to follow him into the
EPM and received medication had reduced psychi- consultation room next door while the mother
atric symptoms and increased social improvement remained in the original room. In the consulta-
compared to those who had medication only. tion room, the therapist asked the daughter to
step on the scale and the father to check her
weight. The situation seemed ridden with anxi-
Case Example ety. Russel had increased concern upon seeing
his daughter’s weight, and Aida was also visibly
EPM can be conceptualized through an adapted uneasy. The therapist, the father, and the daugh-
case study published in Finite Systems and Infinite ter then came back into the therapy room. Mia
Interactions (De Giacomo 1993). was moved to Aida’s chair, and Aida was moved
Mia and Russel brought their daughter, Aida, to her mother’s seat.
to therapy because they were concerned about The therapist asked Russel to inquire about
Aida’s recent eating habits and weight loss that the eating behavior of his daughter: what food
developed over the past 6 months. Aida restricted she prefers and which she hates, if she vomits or
her calories at all meals and, additionally, had takes laxatives, etc. Then he asked Aida what
844 Elementary Pragmatic Model
menu she would accept for breakfast, lunch, and agreement when they give it. The therapist
dinner. As Aida responded, Russel was warmly said goodbye to the family and invited
instructed to write the information down. The them to contact again in 6 months.
therapist asked again if the family was willing
to do everything necessary to solve the prob-
lem, reporting that what he was going to ask
Cross-References
was something that was very difficult to
carry out.
▶ Family Therapy
The family answered affirmatively in great
▶ First Order Cybernetics
earnest. The following prescription was given:
▶ Paradoxical Directive in Couple and Family
Russel and Aida were instructed to travel
Therapy
together, by themselves, to a place of their
▶ Second-Order Cybernetics in Family Systems
choice where they have no friends or relatives.
Theory
They were instructed to spend a month there
(sometimes 3 weeks) and be together at all
times. During this period, Russel was to try to
enter Aida’s world by finding out her thoughts,
References
wishes, and aspirations. Additionally, they were
instructed to phone home only once a day and De Giacomo, P. (1992). The elementary pragmatic model:
were told to not speak about food/eating during From theory to therapeutic practice. Annali Istituto
these conversations. Before the departure, Mia Superiore di Sanità, 28, 169–176.
De Giacomo, P. (1993). Finite systems and infinite inter-
was instructed to give Russel advice on how to
actions. Norfolk: Bramble Book.
behave toward Aida. At the end of the prescribed De Giacomo, P. (1999). Mente e Creatività. Milan: Franco
period, the first encounter with Mia was to be in the Angeli.
therapist’s office. The therapist acknowledged that De Giacomo, P., & Fiorini, R. (2015). Creativity mind.
Amazon Ebook Conversion by CICT CORE Group.
the greatest sacrifice is born by Mia, but that this
1st Digital Edition: August 2015.
sacrifice was necessary to rescue and protect her De Giacomo, P., Pierri, G., Lefons, E., & Mich, L. (1990).
daughter. This notion stems from the perspective A technique to simulate human interaction: Relational
that there are generally many interactions between styles leading to a schizophrenic communication pat-
terns and back to normal. Acta Psychiatrica
mother and daughter and a limited amount of inter-
Scandinavica, 82, 413–419.
actions between daughter and father. Building De Giacomo, P., Margari, F., & Santoni Rugiu, A. (1997a).
interactions between father and daughter assists in A successful one-session treatment of anorexia
generating new interaction patterns among the fam- nervosa: Report of fifteen case. International Journal
of Family Psychiatry, 2, 123–132.
ily, as a whole.
De Giacomo, P., Pierri, G., Santoni Rugiu, A., Buonsante,
The family met again for their second session M., Vadruccio, F., & Zavoianni, L. (1997b). Schizo-
after the month departure. The therapist, once phrenia: A study comparing a family therapy group
again, asked Russel to weigh Aida, at which following a paradoxical model plus drugs and a group
treated by the conventional clinical approach. Acta
time they found out her weight increased. The
Psychiatrica Scandinavica, 95, 183–188.
therapist complemented Russel, Aida, and Mia De Giacomo, P., L’Abate, L., Margari, F., Santamato, W.,
for their dedication to treatment. The therapist Belgiovine, M. T., Craig, F., & De Giacomo, A. (2012).
then spoke with the parents, giving the prescrip- The elementary pragmatic model: A new perspective in
psychotherapy. Estratto da Rivista di psichaitria, 47,
tion of four rules to follow moving forward:
1–8.
(1) from now on close their bedroom door, De Giacomo, P., L’Abate, L., Margari, F., Craig, F., & De
(2) go out alone three times a week for at least Giacomo, A. (2013). Diagnostic and therapeutic poten-
1 h, keeping what they do and where they go a tial of the elementary pragmatic model. Rivista di
Psichiatria, 48, 67–72.
secret from Aida, (3) demonstrate reciprocal
L’Abate, L., & De Giacomo, P. (2003). Intimate relation-
affection when they are in Aida’s presence, and ships and how to improve them. Westport: London
(4) assign Aida a small task demonstrating strong Praeger.
Elizur, Yoel 845
conditions. He was mentored in this work by

Elizur, Yoel Dr. Mordecai Kaffman, the medical director of
the Kibbutz Child and Family Clinics.
Jane Ariel
The Wright Institute, Berkeley, CA, USA
Contributions to the Profession
Introduction In 1995, Dr. Elizur joined the Hebrew University’s

psychology department where he initiated different
Yoel Elizur, Ph.D., associate professor, is the direc- consultation projects with senior administrators in
E
tor of the Clinical Child and Educational the Ministry of Social Affairs and Social Services.
Psychology Program at The Seymour Fox Following consultation with Israel’s Youth Protec-
School of Education at the Hebrew University of tion Authority, he formulated the Involvement-
Jerusalem, Israel (http://education.huji.ac.il/yoel- Collaboration-Empowerment (ICE) model for the
elizur). Dr. Elizur, a clinical, educational, and med- development of family-oriented care. Subsequently,
ical psychologist, is a leading expert in the design, Elizur developed innovative family-collaborative
implementation, and research of family-focused community and day residential care that is currently
care in public human services. Some of the specific provided to 17% of out-of-home Israeli children. He
areas he has contributed to include (a) the promotion also applied the ICE model to advance family-
of collaborative family-agency care for young chil- collaborative care in the IDF’s treatment center for
dren, adolescents, and young adults, (b) intervention combat-related stress disorders.
design and research with parents and teachers of Following the intensification of his scientific
young children with conduct problems, and work, Elizur accepted a full-time academic position
(c) work with stress-related issues of combat sol- in the Hebrew University’s School of Education.
diers in Israel. In 2010, he was appointed to a 3-year Subsequently, in collaboration with the Ministry of
term as chairperson of Israel’s Council of Psychol- Education’s Chief Psychologist, he designed and
ogists and the Minister of Health’s consultant on researched Hitkashrut, an early intervention program
policy and practice of psychology in Israel. that promotes attachment security, self-regulation,
and cooperation in preschoolers with conduct prob-
lems. Hitkashrut is a generic cost-efficient program
Career that has been culturally adapted to Israel’s diverse
populations. A randomized controlled trial of the
Dr. Elizur was born and raised in Israel and parent training component demonstrated clinical-
received his academic degrees from the Hebrew level success in real-world conditions and indicated
University of Jerusalem (Ph.D in 1981). In dual processes of change at the relational and early
1986–1987, he received a Post-Doctoral Fulbright personality development levels. Hitkashrut’s teacher
fellowship at New York University and training component is under study and preliminary
co-authored Institutionalizing Madness: Families, results indicate its effectiveness. These interventions
Therapy and Society with Salvador Minuchin. He are currently implemented and publically funded in
worked for 18 years in the Kibbutz Clinics in more than 30 municipalities throughout Israel.
Israel, during which time he headed the Hadera Hitkashrut’s success demonstrates how the develop-
and Yoav clinics and founded the Medical Psy- ment of an empirically based program together with
chology Center. Under his leadership, the Yoav systems consultation and research can change public
Clinic became an interdisciplinary mental health policy and create cost-effective services to children
center with 30 staff members. Based on his eco- and families.
systemic kibbutz work, he developed a life-span In 2010, Dr. Elizur was appointed by the Prime
family-systems developmental perspective that Minister and Minister of Health to head Israel’s
was applied to a variety of psychopathological Council of Psychologists. During his 3-year term,
846 Elkaïm, Mony
he chaired a group composed of 27 prominent Elizur, J., & Minuchin, S. (1989). Institutionalizing
Israeli psychologists who represented different madness: Families, therapy and society. New York:
Basic Books.
areas of practice and academic work. His Elizur, Y., & Perednik, R. S. (2003). Prevalence and
facilitation led to far-reaching change in the Psy- description of selective mutism in immigrant and native
chology Law, to a reform in the basic operating families: A controlled study. Journal of the American
procedures to enhance transparency and fair admin- Academy of Child and Adolescent Psychiatry, 42(12),
1451–1459.
istrative practices, and to a successful campaign for Elizur, Y., & Somech, L. Y. (2018). Callous-unemotional
the authorization of psychologists in ADHD diag- traits and effortful control mediate the effect of parent-
nosis and advanced ADHD-related training stan- ing intervention on preschool conduct problems.
dards. A further significant achievement was the Journal of Abnormal Child Psychology. https://doi.
org/10.1007/s10802-018-0412-z.
definition of a core academic curriculum for gradu- Somech, L. Y., & Elizur, Y. (2012). Promoting self-
ate professional psychology programs. These regulation and cooperation in pre-kindergarten children
reforms ended two decades of conflict over profes- with conduct problems: A randomized controlled
sional and science-based standards of training and trial. Journal of the American Academy of Child and
Adolescent Psychiatry, 51(4), 412–422.
academic freedom versus public regulation.
Besides Dr. Elizur’s numerous consultations to
public service and academic institutions, he has
received many research grants and a number of Elkaïm, Mony
awards, such as the Jerusalem Foundation’s Esther
Haar Award for an original contribution to social Michel Maestre
psychiatry in Israel (2005) and the Bahat and Haifa PSYCOM, Villeneuve d’Ascq, France
University Press Award for the best original nonfic-
tion manuscript of 2002: Holding their own: Self/
Mutual Help, Therapy, and Society. Dr. Elizur has Name
published four books, edited two others, and written
chapters in 12 publications. His more than 50 peer- Mony (Maïmonid) Elkaïm
reviewed articles cover such topics as treating famil-
ial and individual stress in different situations, the
integration of medical and clinical psychology,
supervision and training, and the collaboration of Introduction
organizational systems with therapeutic
interventions. Mony Elkaïm is one of the most important psy-
chotherapists to have contributed to the devel-
opment of family therapy in Europe, and
Cross-References
beyond. He is a neuropsychiatrist, Director of
the Institute for Family and Human Systems
▶ Minuchin, Salvador
Studies (Brussels) and Honorary Professor at
the Free University of Brussels. He is a consul-
tant and medical doctor of the consultation for
couples and families at the Department of Psy-
References
chiatry of the Erasmus University Hospital in
Elizur, Y. (1996). Involvement, collaboration, and empow- Brussels.
erment: A model for consultation with human-service He is the Founder of the European Family
agencies and the development of family-oriented care. Therapy Association (EFTA), which he presided
11 years, from 1990 until 2001. Since 2001, he is
Elizur, Y. (2012). Development and dissemination of collabo-
rative family-oriented services: The case of community/day the chairperson of the association’s Chamber of
residential care in Israel. Family Process, 51(1), 140–156. Training Institutes (EFTA-TIC).
Elkaïm, Mony 847
He was the President of the European Contributions to the Profession

Association for Psychotherapy (EAP) from
2007 to 2009, being Honorary President of this In the 1970s, Mony Elkaïm developed “Network
association. Practices” in the South-Bronx where he was
He is also an “Approved Supervisor under the directing a mental health center. From 1976 to
Founders Track” of the American Association for 1981, he coordinated the international network
Marriage and Family Therapy (AAMFT) and the “Alternatives to Psychiatry” with the support of
Director of the collection “Couleur Psy” at the Felix Guattari, Françoise and Robert Castel, Franco
Editions du Seuil in Paris. Basaglia, David Cooper, and Ronald Laing.
He has published several books and articles in In the 1980s, he enlarged the systemic
E
the field of psychotherapies. approach to better understand situations of change
by introducing the work of Ilya Prigogine (Nobel
Prize in Chemistry 1977) on systems far from
equilibrium and chance.
Career At the same time, Mony Elkaïm created a new
model for couple therapy insisting on reciprocal
After a fellowship at the Albert Einstein School double binds and on function of conflicts to main-
of Medicine in New York in the early 1970s, tain the homeostasis of the couple’s worldviews.
Dr. Elkaïm stayed in New York where he, cumu- He created the concept of “resonance” to
latively, practiced social and community psychia- provide a tool to psychotherapists who consider
try, founded a school to train family therapists, themselves part of the therapeutic system. The
and worked for 2 years as the Director of one of function of their feelings for the therapeutic sys-
the mental health centers of the Albert Einstein tem thus became an asset rather than a handicap.
School.
Since returning to Europe, Dr. Elkaïm has Cross-References
become a member of the Council of the Brussels
Doctors’ Order as well as of the Order of the ▶ Cahiers critiques de thérapie familiale et de
Departmental Council in Paris and a professor at pratiques de réseaux (Journal)
the Free University of Brussels (ULB). Trainer ▶ European Family Therapy Association
in family psychotherapy and the systemic ▶ Resonance in Couple and Family Therapy
approach in France and Switzerland since
1976, he has trained over 500 psychiatrists,
child psychiatrists, psychologists, and social References
workers in the framework of 4-years formation
cycles, both in private and public practice (as of Elkaïm, M. (1987). Les Pratiques de réseaux: santé
2016), in Paris and in Geneva. mentale et contexte social. Paris: ESF.
Elkaïm, M. (1989). Si tu m’aimes, ne m’aime pas.
On the strength of this experience, he
Approche systémique et psychothérapie. Paris: Le
decided, with the support of a number of col- Seuil.
leagues, his former students, to set up an orga- Elkaïm, M. (1994). La thérapie familiale en changement.
nization named “Elkaïm Formations,” aiming at Paris: Les Empêcheurs de Penser en Rond.
Elkaïm, M. (1995). Panorama des thérapies familiales.
the development of training courses in systemic
Paris: Le Seuil.
and family therapy. Elkaïm, M. (2017). Vivre en couple. Plaidoyer pour une
Since 1979, he has been also the Director of stratégie du pire (Coll. Philo. Gener.). Paris: Le Seuil.
the Journal Cahiers Critiques de Thérapie Elkaïm, M., & Glorion, C. (2006). Comment survivre à sa
propre famille? Paris: Le Seuil.
Familiale et de Pratiques de Réseaux, (Critical
Elkaïm, M., Cyrulnik, B., & Maestre, M. (2009). Entre
Reviews of Family Therapy and Network Prac- résilience et résonance. A l’écoute de nos émotions.
tices), De Boeck Editions. Paris: Fabert.
848 Emerging Technologies in Couple and Family Therapy
clinical professionals. The literature shows that

Emerging Technologies in telehealth first was used more broadly with phys-
Couple and Family Therapy ical health, but it took longer for behavioral health
to adopt it (Borcsa and Pomini 2017).
Viviana Ploper According to the 2017 OPEN MINDS Health
The Family Institute at Northwestern University, & Human Services Technology Survey, there has
Evanston, IL, USA been a substantial increase in the number of
behavioral health organizations using telehealth
technologies compared to the previous year, less
Name of Entry so for smaller practitioners who use technology to
support billing and documentation systems but
Emerging Technologies in Couple and Family have been slower to embrace the culture shift of
Therapy providing online therapies, which also involves
having the right technology in place. In the past
the use of telehealth was less common among
Synonyms marriage and family therapists, but there has
been a steady increase of cyber therapy use to
Computer therapy; Cyber therapy; E-therapy; treat individuals, couples, and families.
Information communication technologies (ICT); In couple and family therapy, information
Internet-based interactions; Internet-based inter- communication technologies (ICT) support
ventions; Mobile health; Telehealth; Tele- clinician-client communication (via texts, emails),
psychology and they can challenge clinicians to stay well-
informed and up to date about how to use these
for therapeutic purposes. Teletherapy can be done
Introduction both live (as in video conferencing) and be either
“synchronous” (both communicate in real time) or
The term “cyber therapy” came from Isaac Marks “asynchronous” such as when one person is
(Marks et al. 2007) and refers to the use of using a emailing or texting and the other person responds
computer to provide, enhance, or facilitate ther- with a later response.
apy. It can support therapy across the distance and These technologies also challenge state licen-
create virtual realities. sure boards and professional associations to mod-
Telehealth is defined as the use of electronic ify or maintain their regulations, standards, and
and communications technology to accomplish codes of ethics to align with the ongoing advances
health care over distance (Jerome and Zaylor of technology as well as the increasing develop-
2000), as the provision of health care by any ments of new apps.
telecommunication technology, to include tele- Technology has made it easier to reach more
phone, internet, email, video teleconferencing clients who otherwise may not be able to benefit
(VTC), smartphones, blogging, social media, from services. For young people, technology is
and others digital apps (Wrape and McGinn the way they communicate. In areas that lack
2018). Technology, which can be defined as the MFTs, individuals can now receive services
application of science and information to practical through video conferencing (VC); and families
areas, such as electronic or digital products and who may have a family member in another city
systems, is an ever-expanding part of the thera- can include that family member through VC in
peutic process and continues to change the way their family therapy sessions.
that both clients and MFTs approach treatment As mental health organizations discuss how to
(Pennington et al. 2017). Individuals can use improve individuals’ access and engagement in
their smartphone, computer, or tablet to visit services, telehealth has been mentioned as the
Emerging Technologies in Couple and Family Therapy 849
preferred solution to improving those issues. (CTiBS) was created as a nonprofit, with three
“Telemedicine” is now part of a much broader main priorities: the development of competencies
category of tech-enabled therapy services, for behavioral professionals using technologies;
referred as “virtual health” ranging from virtual the need to organize human, administrative, clin-
online provider networks and automated pro- ical, research, and other fields’ resources; and the
grams like e-CBT and mindfulness apps (Oss need to provide an interprofessional, international
2018). journal to support the scientific development of
Popular apps include mood trackers, online technology for psychiatry, psychology, social
journals, meditation tools, virtual coaching, edu- work, counseling, marriage and family therapy,
cation modules, and more. The Anxiety and addictions, and other professions. They publish
E
Depression Society of America has a large catalog the Journal of Technology in Behavioral Science
of available mental health applications, each with (JTiBS), which deals with the interface of tech-
ratings and reviews. There is an increasing nology, psychology, medicine, policy, health
amount of evidence indicating that virtual reality administration, and behavioral sciences.
(VR) technology can be effective in the treatment
for phobias, PTSD (Hughes 2017, May 8), and
other mental health conditions (Wolters Kluwer
publication of Harvard Review of Psychiatry, Challenges of Telehealth
May 2017).
Although technology use by marriage and fam- Technologies have raised some ongoing ethical,
ily therapists has been less studied, prior research risk management, and privacy issues raising ques-
indicates that clinicians communicate with clients tions related to informed consent; delivery of ser-
through email, texts, answering services, video vices; privacy, confidentiality, and privileged
conferencing, websites, and phones. Increasingly communication; documentation; and practi-
MFTs are using technology to support supervision tioners’ relationships with colleagues. States and
and for training. professional associations are developing new
The American Association for Marriage and standards of care that are being incorporated into
Family Therapy (AAMFT) added a standard licensing statutes and regulations, professional
about Technology-Assisted Professional Services, codes of ethics, and practice guidelines adopted
which addresses “the basic ethical requirements of by the professions of psychiatry, psychology,
offering therapy, supervision, and related profes- mental health counseling, marriage and family
sional services using electronic means” therapy, and clinical social work (Reamer 2018).
(American Association for Marriage and Family Other studies suggest concern in terms of best
Therapy (AAMFT) Code of Ethics 2015). And in practices in the areas of confidentiality, boundary
September of 2016, the Association of Marital issues, dual relationships, and crises situations.
and Family Therapy Regulatory Boards Furthermore, though individuals use the inter-
(AMFTRB) developed the Teletherapy Guide- net more frequently and regularly to communicate
lines, which are “to be used by Member Boards with social media and to research services, the
when regulating the practice of teletherapy by same is not as true for organizations, which appear
Licensed Marriage and Family Therapists to communicate infrequently, in one direction.
(LMFTs) across the country.” Several accredita- Emerging technology adoption poses new
tion and certification bodies now offer a tele- challenges and opportunities to clients, families,
psychology credential, to insure best practices in clinicians, and accreditation bodies. Research that
using computer-based therapies. explores clinicians’ understanding and use of
There is a lot of interest on the impact of information communication technologies is grow-
technology in psychotherapy. In 2014 the Coali- ing as evidence starts to show improved outcome
tion for Technology in Behavioral Science for accessing consumers.
850 Emery, Robert
From the standpoint of systemic therapists, there is Virtual Reality for Psychiatric Treatment? Research Shows
an implied relational level even in long-distance Promise for VR and Other Technologies in Mental
communication: written communication and a lim- Health Care, May 8, 2017. Retrieved from https://
ited number of characters do not transfer only data, wolterskluwer.com/company/newsroom/news/2017/
but also implicit emotional and relational elements. 05/virtual-reality-for-psychiatric-treatment-research-
Technology can be of great help to clinicians, but shows-promise-for-vr-and-other-technologies-in-men
therapists should employ with great care and aware- tal-health-care.html.
ness these new communicative devices, being Wrape, E. R., & McGinn, M. M. (2018). Clinical and
aware of risks which could compromise the setting ethical considerations for delivering couple and family
management and the therapeutic relationship. therapy via telehealth. Journal of Marital and Family
(Manfrida et al. 2018). Therapy Advance online publication. https://doi.org/
10.1111/jmft.12319.
Cross-References
▶ Couple and Family Therapy in the Digital Era Emery, Robert
Jenna Rowen
References The Family Institute at Northwestern University,
Evanston, IL, USA
Borcsa, M., & Pomini, V. (2017). Virtual relationships and
systemic practices in the digital era. Contemporary
Hughes, C. (2017, May 8). Virtual reality for psychiatric
Introduction
treatment? Research shows promise for VR and other
technologies in mental health care. Retrieved from Robert Emery has been one of the leading
https://wolterskluwer.com/company/newsroom/news/ researchers and authors in the areas of
2017/05/virtual-reality-for-psychiatric-treatment-rese
arch-shows-promise-for-vr-and-other-technologies-in-
interparental conflict, divorce, and
mental-health-care.html mediation for the past 30 years. He has spent
Jerome, L. W., & Zaylor, C. (2000). Cyberspace: Creating most of his professional career as a professor of
a therapeutic environment for telehealth applications. psychology at The University of Virginia, teaching,
Professional Psychology: Research and Practice,
31, 478–483.
conducting research, and leading a highly produc-
Manfrida, G., Albertini, V., & Eisenberg, E. (2018). Psy- tive lab of graduate students. He has authored over
chotherapy and technology: Relational strategies and 150 scientific publications, and several books,
techniques for online therapeutic activity. In R. Pereira including Marriage, Divorce, and Children’s
& J. L. Linares (Eds.), Clinical interventions in sys-
temic couple and family therapy (pp. 119–137). https://
Adjustment, Renegotiating Family Relationships:
doi.org/10.1007/978-3-319-78521-9_9. Divorce, Child Custody, and Mediation, and his
Marks, I. M., Cavanagh, K., & Gega, L. (2007). Computer guides for parents, The Truth about Children and
aided psychotherapy: Revolution or bubble? British Divorce: Dealing with the Emotions So You and
Journal of Psychiatry, 191, 471–473. https://doi.org/
10.1192/bjp.bp.107.041152.
Your Children Can Thrive & Two Homes, One
Oss, M. (2018, September). First telehealth – Now virtual Childhood: A parenting Plan to Last a Lifetime.
health. OPEN MINDS Daily Executive briefing. He is also the coauthor of Abnormal Psychology
Retrieved from https://mailchi.mp/openminds/first- with Dr. Thomas Oltmanns, a text widely used
telehealthnow-virtual-health?e=b92fedcb56
Pennington, M., Patton, R., Ray, A., & Katafiasz, H.
by undergraduate psychology departments.
(2017). A brief report on the ethical and legal guides Dr. Emery has lectured extensively on his research
for technology use in marriage and family therapy. across the United States and in numerous
Journal of Marital and Family Therapy, 43(4), countries throughout the world. In addition to his
733–742. https://doi.org/10.1111/jmft.12232.
Reamer, F. G. (2018). Evolving standards of care in the age
academic pursuits, Dr. Emery maintains a practice
of cybertechnology. Behavioral Sciences & the Law, as a couple and family therapist and divorce
36(2), 257–269. https://doi.org/10.1002/bsl2336. mediator.
Emery, Robert 851
Career the benefits of mediation over litigation in the

context of divorce.
Dr. Emery earned his B.A. from Brown Univer- Dr. Emery has published extensively on the
sity in 1974 and his M.A. in psychology SUNY at harmful effects of interparental conflict on chil-
Stony Brook in 1980. After completing a clinical dren and healthy ways that parents can navigate
internship at the Psychology Center at SUNY at the divorce process that is in the best interest of
Stony Brook, Dr. Emery earned his Ph.D. in clin- their children. His 1982 Psychological Bulletin
ical psychology from SUNY at Sony Brook in paper, Interparental conflict and the children of
1982. In 1981, Dr. Emery joined the psychology discord and divorce, was among the first
faculty at the University of Virginia as an Assis- published works that specifically examined the
E
tant Professor and was promoted to Associate relationship between marital discord and problem
Professor in 1986. From 1984 to 1987, behaviors in children using a systemic lens.
Dr. Emery served as the Coordinator of Research Dr. Emery’s 2016 book, Two Homes, One Child-
in Clinical Psychology within the Institute of hood: A parenting Plan to Last a Lifetime, is his
Clinical Psychology at the University of Virginia. most recent contribution to the literature, and it
At that time, he was also appointed an Associate provides empirically supported guidance for par-
Faculty position within the Institute of Law, Psy- ents to successfully create child-focused parenting
chiatry, and Public Policy within the Schools of plans.
Law and Medicine at the University of Virginia. As a practicing mediator himself, Dr. Emery
Since 1996, Dr. Emery has served as professor of has always been a champion of mediation in
psychology and director of the Center for Chil- juvenile and domestic disputes because of its
dren, Families, and the Law at the University of collaborative process and ability to preserve rela-
Virginia. He currently serves on or has served on tionships instead of creating adversaries.
the editorial board of 11 professional journals and Dr. Emery was able to convince judges in Vir-
has been an ad hoc reviewer for nine professional ginia to allow him to randomly assign separating
journals, the Judicial Council of California, the parents attempting to settle child custody dis-
National Science Foundation, and the NIHM putes to either litigation or mediation as the dis-
Grant Review Committee. He is also a beloved pute resolution method. In 1987, he published
advisor, teacher, mentor, and clinical supervisor the first study examining differences in the out-
and is known at the University of Virginia for comes, based on the assigned dispute resolutions
being an incredibly collaborative colleague and method. He found that disputes were settled
supremely supportive graduate advisor who main- much quicker and families did not end up having
tains professional relationships with students well to litigate child custody disputes. Dr. Emery
after completing their training. followed these 40 families for 12 years and
published a study in 2001 that examined the
long-term effects of mediation versus litigation.
Contributions to the Profession Dr. Emery found that family relationships were
significantly better preserved in the mediation
Over the past 30 years, Dr. Emery’s research has group; custody agreements tended to last longer
focused on family relationships and children’s and prove more effective, both parents saw their
mental health, and he has used important findings children more frequently, telephone contact
from this research to examine associated legal and between non-residential parents and children
policy issues. Dr. Emery’s most significant and was greater, and parents perceived one another
impactful contributions to the field have been his as more effective. This longitudinal examination
research on the impact of interparental conflict on of the positive impact of mediation is the only
children’s adjustment, research on best practices study of its kind and provides empirical support
in child custody, and his longitudinal research on for the benefits of mediation over litigation.
852 Emotion in Couple and Family Therapy
▶ Divorce in Couple and Family Therapy Our couple and family relationships are charac-
▶ Mediation in Couple and Family Therapy terized by emotional experiencing. When these
relationships are going well, we feel joy, interest,
and calm. Relationship distress, on the other
References hand, is characterized by intense negative emo-
tions such as anger and contempt. However,
Emery, R. E. (1982). Interparental conflict and the children emotional numbing and distancing and lack of
of discord and divorce. Psychological Bulletin, 92,
emotional responsiveness are even more corro-
310–330.
Emery, R.E. (2006). The truth about children and divorce: sive for relationships than chronic anger
Dealing with the emotions so you and your children can (Gottman et al. 1998). Traditional views of emo-
thrive. New York: Plume. (Paperback edition) tion in couple and family therapy, however, have
Emery, R.E. (2011). Renegotiating family relationships:
seen intense emotions as a destructive force
Divorce, child custody, and mediation (2nd ed.). New
York: Guilford. (Chinese translation forthcoming 2016). rather than a positive source of change; interven-
Emery, R. E. (2016). Two homes, one childhood: tions have sought to bypass or supplant them
A parenting plan to last a lifetime. New York: Avery. with new cognitions or communication skill
Emery, E. E., & Wyer, M. M. (1987). Child custody medi-
sequences. However, more recently in the field
ation and litigation: An experimental evaluation of the
experience of parents. Journal of Consulting and Clin- of couple and family therapy there has been
ical Psychology, 55, 179–186. movement toward acknowledging the impor-
Emery, R. E., Laumann-Billings, L., Waldron, M., Sbarra, tance of working with the emotion that arises
D. A., & Dillon, P. (2001). Child custody mediation and
within the context of couple and family relation-
litigation: Custody, contact, and co-parenting 12 years
after initial dispute resolution. Journal of Consulting ship patterns. Developments in the study of
and Clinical Psychology, 69, 323–332. attachment and neuroscience have pointed to
the centrality of relationships as a context for
emotion regulation. This has had a significant
role in shaping research and practice toward a
Emotion in Couple and Family focus on the transformative role of emotion in
Therapy couple and family relationships, that is the use of
corrective emotional experiences and interac-
Stephanie A. Wiebe1 and Sue M. Johnson2 tions to change negative interactional patterns.
1
The Ottawa Hospital, The University of Ottawa,
International Centre for Excellence in
Emotionally Focused Therapy, Ottawa, ON, Theoretical Context for Concept
Canada
2
The International Centre for Excellence in Evidence for the role of emotion in shaping pat-
Emotionally Focused Therapy, The University of terns in relationships has been studied extensively
Ottawa, Ottawa, ON, Canada in the context of attachment theory. From the
perspective of attachment theory, emotional
responsiveness in relationships fosters attachment
Name of Concept security, which sets up effective emotion regula-
tion experiences and interactions in relationships.
Emotion in couple and family therapy Bowlby (1969) was attentive to the central role of
affect in attachment relationships noting that
attachment-related affect is the means by which
Synonyms we evaluate the presence of threat, decide whether
proximity seeking is needed, and choose how to
Affect in couple and family therapy deal with our emotional life.
Emotion in Couple and Family Therapy 853
Insecure attachment – especially the avoidance Whether a source of soothing or stress, emo-
of attachment vulnerabilities and needs – involves tional signals organize interactions in love rela-
high levels of effortful control of attachment emo- tionships; they are the music of the interactional
tions such as anger, sadness, and anxiety. This dance. Given the centrality of emotion in organiz-
avoidance is associated with low levels of emo- ing relationship dynamics – through the lens of
tional experience, intensity, and attention to emo- attachment theory and neuroscience – working
tion in self and others. Insecure attachment in the with emotion appears to be necessary in order to
form of high attachment anxiety is associated with foster significant positive change for couples.
high attention to and easily triggered emotion, Therapeutic approaches for couples and families
greater emotional intensity, and high levels of that use the transformative power of emotions to
E
expressiveness. In contrast, secure comfort with shape interactions would need to be consistent
closeness is associated with less suppression, more with our current knowledge of emotion through
emotional balance, and lower emotional control of research in neuroscience and human develop-
anger, sadness, and anxiety. Secure attachment is ment, based on knowledge of how emotion is
generally related to high levels of expressiveness organized in the context of couple and family
and low levels of intensity and attention to affect, relationships, and organized by a unifying theory
such that those with a secure attachment style in that could provide a map for how to use emotion
relationships are better able to regulate and express to transform relationships in terms of cognitive,
emotions than those who are insecurely attached. behavioral, and interactional patterns.
Insecure attachment is associated with greater con-
trol, or down-regulation, of positive emotions as
well. Attachment is above all a transactional theory Description
of emotional development and regulation.
Neuroscience research has shown that even The dominant view in western thought is that
when emotions are controlled, they continue to emotion is to be distrusted in favor of cognition.
have a physiological impact. Suppression, for However, more recently, attention has been given
example, tends to increase arousal, and it is clear to the necessary and helpful functions of emotion
that even when emotions are bypassed and not in terms of communicating with others and mak-
addressed, they continue to have an effect. More- ing decisions. Therefore, it is no surprise that the
over, when emotions are addressed in the context field of couple and family therapy would have
of close relationships, they serve the function of initially focused primarily of restructuring the
helping both relationship partners regulate affect. system over exploring the emotional experiences
The interchange of affective information in rela- of individual family members. Indeed, every emo-
tionships allows us to respond emotionally to one tion is associated with a respective action ten-
another in a way that registers with each individual dency, as when anger triggers assertive approach
neurologically. The ability to read and coregulate in the service of need attainment.
emotions can have profound effects for individual Gottman and colleagues paved the way in giv-
affective functioning. Coan and colleagues (2011) ing attention to emotional experience in the context
developed social baseline theory based on their of couple relationships. Through observing couple
research showing that neurological signs of stress interactions they noticed that it was not the pres-
were greatly reduced when women in happy rela- ence of intense emotion that was most predictive of
tionships had their partner holding their hand, divorce, but rather lower levels of positive affect
whereas the absence of their partners increased and bids for attention that are not responded to by
the neurological signs of stress. Social baseline the other partner. This was the first time that emo-
theory is the idea that close relationships are neu- tion was viewed positively in couple relationships
rophysiologically necessary for effective affect reg- rather than as an instigating force of conflict to be
ulation and that the absence of or insecurity in close avoided. We now know that emotional accessibil-
relationships is inherently stressful. ity, responsiveness, and engagement are essential
components of a satisfying relationship. Indeed, dialogue characterized by emotional self-

close relationships characterized by emotional expression and engagement with one another,
accessibility, and mutual responsiveness foster would improve adaptive functioning in relation-
feelings of calm, joy and happiness, and relationships. Also developed around the same time is the
ships with these elements are more likely to be relationship enhancement (RE) psychoedu-
happy and lasting. Affect coregulation is under- cational model (Guerney 1977), which views cou-
stood to be a core aspect of close relationships ple distress as a lack of relationship skills, and
throughout the lifespan, first beginning with early focuses on training empathy and emotional
experiences between infants and their caregivers. responsiveness. In this model, empathy and emo-
When primary caregivers and infants are emotion- tional responsiveness are taught rather than
ally attuned to one another, this creates a state of actively worked with and shaped. Filial family
emotional balance in which the caregiver and therapy (FFT) is the family therapy version of
infant mutually regulate affect. This balance is RE, and teaches parents the relationship skills
upset when the caregiver does not engage in this necessary to be engaged and empathic with their
coregulation of emotion, which leads to high levels children. This approach is thought to help parents
of stress for infants, that is, until coregulation is foster in their children an orientation of accep-
reestablished. Therefore, emotional expression and tance and understanding of their emotional self-
responsiveness play a key role across couple and regulation. The RE model has accumulated a
family relationships, and ought to be at the center strong evidence base and has been applied across
of approaches to couple and family therapy. To a variety of populations. Filial family therapy has
repeat the metaphor stated above, changing the also demonstrated positive results in the research.
emotional music would seem to be a necessary The main current approach that focuses on
condition of changing the dance in family systems emotion and actively using emotion to shape
and changing this music potentially has the power change in couple and family therapy, emotionally
to reshape key interactional patterns. focused therapy or EFT (Johnson 2004) integrates
systemic and experiential perspectives with
attachment science and takes the view that emo-
Application of Concept in Couple and tional experiencing and signaling in relationships
Family Therapy is the main organizing factor of the family or
couple system and inseparable from it. Finding
Although, the understanding of couples and fam- new ways to help clients regulate emotion and
ilies as being emotionally bonded was present creating new kinds of corrective emotional expe-
from the first formulations of couple and family riences and emotional interactions are then con-
therapy, early approaches that acknowledged the sidered the primary route to change in this model.
emotional bond between family members tended The other contemporary approach to family
still to remain focused on the systemic context as therapy that explicitly acknowledges the role of
the focus of change, as evidenced in Minuchin’s emotions in change and shapes powerful emo-
(1974) structural approach and Watzlawick’s tional encounters that specifically promote
(1967) constructivist focus. Virginia Satir (1983) emotional bonding is dyadic developmental psy-
focused on the importance of valuing the unique chotherapy (DDP; Hughes 2007). The behavior-
experiential realities of each individual to produce ally based integrative behavioral couple therapy
encounters that foster emotional connection. She (IBCT; Jacobson and Christensen 1996) also
believed that individual family members would incorporates the naming and acceptance of emo-
flourish if given emotional responsiveness and tions rather than bypassing emotion as in original
genuine acceptance. At around the same time, versions of traditional behavioral couple therapy
couple and family therapists in the humanistic/ (TBCT). This more recent approach has demon-
existential tradition such as Kempler (1967) and strated superior results as compared to TBCT,
Whitaker (1977) theorized that new kinds of suggesting the benefits of addressing emotions in
couple therapy and the limitations of approaches are: (1) Cycle de-escalation; (2) Restructuring
that do not. attachment interactions, which involve both the
As emotionally focused couple and family re-engagement of withdrawn partners and the
therapy (EFT & EFFT) and dyadic developmental softening of more blaming partners; (3) Consoli-
psychotherapy (DDP) appear to be at the cutting dation and integration of change. Once the alli-
edge of the use of emotion to reshape couple and ance is established, in the first stage of therapy, the
family systems, and as they offer extensive and goal is to identify and de-escalate negative cycles,
explicit emotionally oriented interventions these and explore the underlying emotions that organize
models will be described in more detail. these cycles. At the end of this stage, the couple
has a meta-perspective on their interactions and
E
Emotionally Focused Therapy begins to see their negative cycle as the problem
Emotionally focused therapy (EFT) was devel- that maintains their insecurity and emotional dis-
oped by Sue Johnson to explicitly focus on emo- tress rather than blaming each other. The second
tions in couple and family relationships as the stage, restructuring interactions, involves the
locus of clinical change (Johnson 2004). In EFT, shaping of new emotional experiences and new
the therapist attends to and tracks patterns of emo- interactions so that more withdrawn partners
tional experiencing within the couple or family re-engage in the relationship and actively express
system. From an EFT perspective, emotional their needs, and more blaming partners can ask for
experiencing is a natural part of systems theory their attachment needs to be met in a softer man-
as it organizes the system within the couple or ner that primes the other’s emotional responsive-
family relationship. The EFT therapist acts as a ness. This latter event has been termed blamer
process consultant who empathically attunes to softening, and is associated with recovery from
and validates each partners’ emotional experienc- relationship distress in EFT, and a decrease in
ing, and creates a safe place to allow them to relationship-specific attachment anxiety (Burgess
become more engaged in the emotional Moser et al. in press). At the end of this stage,
experiencing of themselves and their partner. bonding events occur where each partner confides
Change is thought to occur in EFT through the in and seeks comfort from the other, becoming
formulation and sharing of emotional experience mutually accessible and emotionally responsive.
that transforms the system. EFT conceptualizes In this stage, the relationship is fundamentally
distressed relationships as an insecure attachment reorganized and redefined as a more secure
bond, and views the intense emotional experi- bond. The last stage of treatment, involves the
ences of partners in the context of attachment consolidation of new responses and cycles of
theory (Johnson 2004). That is, the couple and interaction and supporting the couple to solve
family system is organized by attachment related concrete problems that have been destructive to
emotions and needs – in distressed relationships, the relationship. These problems are more man-
attachment-related emotions arise as fears about ageable since they are no longer infused with
the lack of availability and responsiveness of negative affect or lacking in emotional respon-
loved ones. siveness (Johnson 2004).
The EFT therapist attunes to the “leading Emotionally focused family therapy (EFFT) is
edge” of partners’ emotional experience and uses analogous to EFT for couples. The goal of EFFT
the experiential interventions such as reflection, is to create a secure base for children to grow in
evocative questions, validation, heightening emo- and leave from (Johnson and Lee 2005). The more
tion, and empathic interpretation to explore and secure the parent-child relationship is, the more
deepen that experience (Johnson 2004). This tolerance there is of differences and the more
expanded emotional experiencing is then framed confident and autonomous the child and adoles-
within and drawn upon to create shifts in the cent can be. EFFT involves helping family mem-
system of interactions between partners and fam- bers explore emotional responses, particularly
ily members. The three stages of change in EFT attachment fears and unmet needs that underlie
the interactions between the child who is include supporting both partners to regulate emo-
experiencing problems and the parents (Johnson tion, and especially helping the blaming partner to
and Lee 2005). The family is seen together at the formulate and face underlying attachment fears.
beginning and end of therapy (10–12 sessions), The therapist strives to help both partners reach
but the rest of the therapy process most often and maintain a greater depth of emotional
involves triads or dyads, depending on the needs experiencing in these sessions so that the couple
of the family. Key change events might involve a can learn to be accessible and responsive to one
depressed adolescent first being able to confide another and coregulate attachment-related emo-
her fears of failure and how her father’s disap- tions into the future (Wiebe et al. 2017).
proval paralyses her and evokes the need to hide
and then, asking her father for his approval and Dyadic Developmental Psychotherapy
respect. Her father might then be able to confide Dyadic developmental psychotherapy developed
that he harangues her as a response to his own in the 1990s by Dan Hughes and his colleagues to
fears that he has failed as a parent and does not treat children in foster or adoptive homes who
belong in the family. In this encounter, new emo- have suffered abuse and neglect and manifested
tions are formulated and shared and rigid interac- severe psychological difficulties associated with
tions such as criticize/withdraw evolve into complex trauma and difficulties with attachment.
dialogues where both participants feel more It has since developed a broader focus, has grown
connected and reassured. The father is able, with into a comprehensive model of family therapy,
the support of the therapist using reflection and also referred to as attachment-focused family ther-
evocative questions, to express his “terror’ at his apy as it is based in attachment theory and affec-
sense of “incompetence’ when he realizes that he tive intersubjectivity (Hughes 2007). The therapy
does not “know how to be a good father.”. He can model focuses on the attachment bond as a way to
then tell his daughter, “I am trying to protect you; navigate complex emotions and behaviors in par-
but I don’t know how and that feels awful.” That ent/child relationships, and understands problem-
is, he is able to express his attachment needs and atic child behaviors in the context of the emotional
attachment-related emotions and be emotionally effects of past attachment traumas or injuries. The
engaged and responsive to the needs and emotions main components of the model include a strong
of his daughter. emphasis on the therapist’s use of self in the
EFT has accumulated a substantial amount of session and ability to strike a balance between
empirical support for the treatment of relationship following and guiding the child and family, a
distress (Wiebe and Johnson 2016). EFT has dem- focus on connection rather than compliance or
onstrated positive outcomes among a variety of problematic behaviors and the coregulation of
at-risk populations including couples facing ill- emotion and meaning making. Dyadic develop-
ness, depression, and posttraumatic stress. Nota- mental psychotherapy (DDP) for families has
ble, process research in EFT has identified two developed into a coherent and comprehensive
key elements of change: depth of emotional treatment modality for families. DDP is very sim-
experiencing and the gradual shaping of interac- ilar in terms of clinical process to EFFT, given
tions to help partners clearly express attachment- their joint focus on emotion and bonding interac-
related affect and to move toward affiliative tions and removing the blocks to those interac-
responding with one another. A key aspect of the tions. In DDP, children are guided to regulate and
therapeutic process in EFT, the blamer-softening express their emotions and send emotional mes-
event leads to successful outcomes and shifts in sages in ways that foster secure connection with a
negative interaction cycles and attachment change parent who is supported to respond positively and
(Burgess-Moser et al. in press). Therapeutic inter- empathically. DDP is different from EFFT in that
ventions in EFT, that foster a softening event it is often used with younger children and their
parents. The clinical use of EFFT has focused on you’re so afraid he won’t be able to
children over the age of 12, whereas DDP is used respond? Let him know just how scary this
with adolescents but also with children as young is and how he can be there for you right
as 4 or 5. now? (encouraging blamer reaching)
M: Alex, I’m so scared to tell you when I’m
feeling sad and alone. So, I just get mad and
Clinical Example yell and nag at you. I would do anything to
get you to pay attention to me, but being
The following clinical example demonstrates the vulnerable, showing you how sad I am? I am
process of emotionally focused couple therapy for too scared to do that. I’m scared you will just E
Alex and Mia in a blamer-softening session in turn away and ignore me. I want so much for
EFT. you to just look up from your game and listen
and tell me that you’re here with me.
M: He just curls up on the couch with his video Th: That was so wonderful Mia. You really
game, and that’s it! I might as well not even clearly told Alex just how you feel and
exist. I don’t matter. I might as well just pack what you need. How are you feeling inside,
my bags and leave!! (angry tone, tears) right now? (supporting blamer reaching)
Th: Mia, as you’re talking about how angry you M: I’m feeling shaky, kind of jittery, like
are with Alex, I see sadness and tears in I could get up and leave the room.
your eyes. You are so angry and also so sad Th: You just took a big risk here. This is really
as you talk about needing a response new, and you’re being so brave to stay here
from Alex. with Alex now that you have been so clear
M: I’m SO sad and SO alone. I need a response and so honest about your feelings and
from him. Anything! (tears, softer tone) needs. (supporting blamer). Alex, Mia just
Th: Have you ever told Alex this, just how sad turned to you and let you know how scared
you feel when you reach for him and he she is to show you her sadness, and that she
curls up with his video games without shows you her anger instead so often as a
turning to you or talking with you? Have way of protecting herself from being so
you shared this with him? vulnerable with you. What are you
M: No. All I can feel right then is angry. I yell feeling right now that you heard Mia take
at him. this big risk with you? (supporting engaged
Th: Right, you fight so hard to get his attention, withdrawer)
so you yell at him, and he doesn’t get to see A: I never really saw this side of you before,
how sad you are. It would be too hard to Mia. I didn’t know you felt scared. Partly
share your sadness, too scary? it’s hard to believe. When you get angry, it’s
M: Yes, too scary. He would just keep playing just so overwhelming for me, I don’t realize
his video game, so what’s the difference? that you are really feeling sad and scared.
Th: So, you don’t show him this part of you that I see it in your eyes now, though. I see the
is so sad and scared and alone? This part of sadness there. It makes sense, and I think
you comes up and says, “don’t trust him, he I understand you better.
won’t turn and respond to you, just keep the Th: So this is really new for you, it’s almost
sadness inside”. (supporting blamer, hard to believe because it’s such a new
preparing for reach) perspective on what is happening for Mia
M: *nods, tears continue to fall* when she is distressed. I also hear that
Th: Could you tell him that? Tell him that it’s so there’s another part of you that wants to
scary to show him your sadness because turn to her and say, “I understand now, I see
the sadness in your eyes and I want to be ▶ Hold Me Tight Enrichment Program
here for you”. Is that what is going on for ▶ Primary Adaptive Emotions in Emotion-
you, right now? (supporting engaged Focused Therapy
withdrawer) ▶ Primary Maladaptive Emotions in Emotion-
A: Yes, it’s like I understand now, I feel Focused Therapy
closer to her. I want to support her when
she feel sad and scared. I want to
hold her. References
Th: Alex, can you turn to Mia right now and tell
her, in your own words, how you Bowlby, J. (1969). Attachment and loss: Vol. I. attachment.
understand her experience, and how you Burgess Moser, M., Dalgleish, T. L., Johnson, S. M.,
want to hold her when she feels sad and Wiebe, S. A., & Tasca, G. (2017). The impact of
scared? (inviting engaged withdrawer to blamer-softening on romantic attachment in Emo-
respond) tionally Focused Couples Therapy. Journal of Marital
and Family Therapy. https://doi.org/10.1111/
A: I want to hold you, I want to be there for jmft.12284
you when you’re sad and scared. Coan, J. A., & Beckes, L. (2011). Our social baseline: The
M: I feel held by you. I feel supported. I feel role of social proximity in economy of action. Social
like I can take a deep breath *sighs* and Personality Psychology Compass, 12, 89–104.
Gottman, J. M., Coan, J., Carrere, S., & Swanson, C.
(1998). Predicting marital happiness and stability
from newlywed interactions. Journal of Marriage and
In this portion of an EFT session, the blamer- Family, 60(1), 5–22.
softening event, the therapist helps Mia explore Guerney, E. G., Jr. (1977). Relationship enhancement: Skill
training programs for therapy, problem, prevention,
and articulate her primary, attachment-related and enrichment. San Francisco: Jossey-Bass.
emotions and needs. She is then guided to share Hughes, D. A. (2007). Attachment focused family therapy.
these with her partner, Alex in a soft way that New York: Norton.
invites emotional connection and responsiveness. Jacobson, N. S., & Christensen, A. (1996). Integrative
couple therapy. New York: Norton.
The EFT therapist then supports the engaged Johnson, S. M. (2004). Creating connection: The practice
withdrawer to respond in an emotionally attuned of emotionally focused couple therapy (2nd ed.).
way to Mia. In this way, the EFT therapist helps to New York: Brunner/Routledge.
establish emotional attunement and responsive- Johnson, S. M., & Lee, A. (2005). Emotionally focused
family therapy: Restructuring attachment. In C. E. Bai-
ness between partner. In the end, Mia allows ley (Ed.), Children in therapy: Using the family as a
Alex to soothe her and help her regulate her resource (pp. 112–133). New York: Norton.
distressing affect. This opens up the possibility Kempler, W. (1967). The experiential therapeutic encounter.
that both partners will be able to turn to one Psychotherapy: Theory, Research and Practice, 4(4),
166–172.
another in times of stress and coregulate affect. Minuchin, S. (1974). Families and family therapy. Cam-
With their newly developing attachment security, bridge: Harvard University Press.
they should also be more open to experiences of Satir, V. (1983). Conjoint family therapy. Toronto: Hushion
joy, happiness, and playfulness as a couple. House.
Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D.
(1967). Pragmatics of human communication: A study
of interactional patterns, pathologies, and paradoxes.
Cross-References New York: Norton.
research in emotionally focused therapy for couples
▶ Emotional Cutoff in Bowen Family Systems
(EFT). Family Process, 55(3), 390–407. https://doi.
Theory org/10.1111/famp.12229.
▶ Emotion-Focused Family Therapy Wiebe, S. A., Johnson, S. M., Burgess Moser, M., Dalgleish,
▶ Emotion-Focused Therapy for Couples T. L., & Tasca, G. (2017). Predictors of follow-up out-
comes in Emotionally Focused Couple Therapy. Journal
of Marital and Family Therapy, 43(2), 213–226.
▶ Emotionally Focused Family Therapy Whitaker, C. A. (1977). Process techniques of family ther-
▶ Expressed Emotion in Families apy. Interactions, 1(1), 4–19.
Emotional Cutoff in Bowen Family Systems Theory 859
Emotional fusion describes a person’s reac-

Emotional Cutoff in Bowen tions within a relationship. People in a fused rela-
Family Systems Theory tionship react emotionally, being unable to think
through or talk about choices with the other per-
Judy Haefner son without reacting in a heightened emotional
University of Michigan Flint, Flint, MI, USA state. The level of anxiety a person experiences
is determined by external stress. Persons in a
highly fused relationship experience significant
Introduction anxiety due to fear that decisions or actions
could potentially cause emotional separateness.
E
How does it happen that family members can go A state of chronic anxiety exists if family mem-
years without any communication between them? bers do not have the capacity to think through
While an occasional holiday card might be their responses to relationship dilemmas and
exchanged, person-to-person contact does not bring about change but continue to react emotion-
occur. In many instances, all contact is lost not ally to them. Bowen (1978) believed a family that
only with extended family but nuclear family. In is unable to differentiate but remains fused will
family counseling persons will say, “I haven’t respond to a crisis in a “feeling process” and be
spoken to my father in 20 years. He remarried unable to respond intellectually. A common cop-
and moved to Colorado and started a new family.” ing mechanism is to emotionally separate or cut
Growing up, there was no contact with certain off from family because one is unable to self-
aunts or uncles. They were mysterious, never differentiate and adapt to changes of one’s envi-
spoken about, and somehow forbidden. ronment, and thereby experience less emotional
stress when interacting with family (Haefner
2014; Brown 1999; Bowen 1978).
Emotional cutoff is one concept in Bowen’s fam- Description of Concept

ily theory, which consists of a system of eight
interlocking states that describe the inevitable The concept of emotional cutoff describes people
chronic emotional anxiety present in family relation- managing their unresolved emotional issues with
ships and concludes that chronic anxiety is the parents, siblings, and other family members by
source of family dysfunction. The emotional dys- reducing or totally cutting off emotional contact
function of an individual disturbs all of that person’s with them. Emotional contact can be reduced by
relationship systems, especially the family system physically moving away from their families and
(Bowen 1978). Bowen’s family systems theory rarely going home, or it can be reduced by staying
model provides a framework to view the individual in physical contact with their families but avoiding
as part of the family. Key concepts of this theory are sensitive issues (Bowen 1978). Emotional cutoff is
differentiation of self and emotional fusion which understood as it relates to differentiation of self (the
refer to the ability of a person to distinguish ability to separate from the family of origin on a
him/herself from the family of origin on a personal personal and intellectual level), triangles (using a
and intellectual level (Bowen 1978). third person in a relationship for the purpose of
Differentiation of self is the ability of indi- decreasing anxiety between two people), and the
viduals to function autonomously by making family emotional system (how a family reacts to
self-directed choices yet remain emotionally stress is influenced by past generations’ reactions
connected to important relationships. “A poorly to stress, and a pattern will likely emerge and repli-
differentiated person is trapped within a feeling cate in future generations). Bowen did not develop
world. . . and has a lifelong effort to get the the concept of emotional cutoff until 1975, when he
emotional life into livable equilibrium” observed how one generation separated itself from
(Bowen 1976, p. 67). past generations (Harrison 2003).
860 Emotional Cutoff in Bowen Family Systems Theory
Family members unable to reduce or manage necessarily dysfunctional but became problematic
their unresolved emotional issues with parents or when the third person distracted the dyad from
other family members may totally cut off emo- resolving their tension (Bowen (1978).
tional contact by moving away geographically or Cutoff may not always be dysfunctional. It can
rarely going home. These unresolved emotional also be in response to child abuse, spousal abuse,
issues generally center on unresolved attachment and family members with addiction, chronic men-
and differentiation of self. Bowen (1978) asserts tal illness, or any other traumatic experience that
this running away does not indicate emotional occurred in the family setting. Bowen maintains,
independence but rather these persons tend to however, that this cutoff must be worked through
see the problems being with the parents rather because this behavior often becomes a coping
than with themselves. mechanism for all other stressful relationships.
Brown (1999) states Bowen distinguishes Bowen (1978) uses the phrase “generation gap”
between breaking away (emotional cutoff) and as a common theme in our society, where relation-
growing away (differentiation of self) The ships are emotionally distant, with brief superficial
unresolved family conflicts will resurface by visits to the family of origin out of a sense of duty.
way of emotional reactivity reflective of past Emotional distance or closeness to parental families
behaviors demonstrated in the nuclear family is determined by a combination of physical distance
communication pattern. Bowen (1978) points and quality of relationship. For example, (1) a per-
out that a person who runs away from his/her son feels he/she falls back into the child role when
family is as emotionally dependent as the person home and believes parents make decisions for
who cannot separate. Certain basic patterns him/her that the person prefers to make, or (2) a
between parent and child are replicas from the person feels his/her parents are pulling him/her back
past and will repeat in the next generations. Per- into a triangle and that he/she must again solve
sons who cutoff will likely cutoff again when parental or sibling conflicts or distresses, or (3) a
faced with anxiety provoking relationships. person believes his/her parents do not understand or
approve of him/her and feels angry about that lack
of respect (Bowen Center 2016). These individuals
Application of Concept in Couple and tend to see the problem as being that of his/her
Family Therapy parents or siblings, and running away becomes a
strategy for gaining independence from the parents
Bowen (1978) believed an ideal person-to-person or avoiding the siblings (Bowen 1978). Because of
relationship allows family members to dialogue poor and stilted communications, family members
freely about many personal situations. However, tend to keep secrets as an attempt to manage the
this requires significant differentiation of self and intense chronic and acute anxiety in the family
a mature respect for each other (Titelman 2003). system. Family members may see secrets as useful
When anxiety surfaces between two people, they initially because they ameliorate emotional intensi-
may be able to communicate for a few minutes but ties, but the secrets may actually increase emotional
as discomfort builds, the conversation will switch distance between family members.
to more trivial, superficial and safe topics, lead to Bowen (1978) asserts that although people are
silence, or they may bring in a third person to emotionally dependent and need emotional close-
relieve the tension, thus creating a triangle ness, they seem “allergic” to it (p. 85). Cutoff is a
(Bowen 1978). Triangulation occurs when anxi- reciprocal process. Relationships are mutually
ety and tension experienced between two persons reinforcing. Hoping things will be different this
is passed onto a third person in the family. The time, people often look forward to going home.
couple is able to communicate safely when they But old patterns of interactions generally surface
pull in the third person thereby shifting the anxiety with powerful emotional undercurrents or may
away from their relationship and onto the third even deteriorate and become hostile confrontations.
party. Bowen did not believe triangulation was Families become anxious and reactive and are
Emotional Cutoff in Bowen Family Systems Theory 861
relieved when the visit is over. Emotions may fur- to only a few days. Kate moved away from home
ther be escalated by siblings of the cutoff member at age 18 to a distant town and eventually to
blaming him/her for upsetting the parents (Bowens Minneapolis and then San Francisco, where she
Center 2016). lived for about 20 years. She reports a good rela-
The unresolved emotional differentiation can be tionship with her father but a confrontational rela-
emotional or physical. One can certainly physically tionship with her mother. She believes her mother
run away but one can also “runaway” by emotional disapproved of her lifestyle choices, her parenting
isolation while maintaining some degree of physical skills, and her choice for a husband. Her husband
interaction with their parents or siblings. Those who was convicted of a crime and served 15 years in
remain near the parental home and have emotional prison, triggering financial ruin for Kate and los-
E
cutoff by way of intrapsychic mechanisms tend to ing her home and custody of her older daughter to
develop more internalized symptoms when under foster care resulting from Kate’s alcoholism. She
stress, such as physical illness and depression. The was able to retain custody of her younger daugh-
one who runs away geographically is more inclined ter. Kate experienced significant hardship due to
to impulsive behavior (Bowen 1978). alcohol abuse, and her relationships with her
daughters deteriorated. Kate subsequently
moved to Louisiana about 5 years ago before
A Clinical Example moving to Houston.
Her older daughter was in foster care as a
Kate is a 69-year-old woman participating in teenager for 4 years but maintained contact with
group therapy as part of an alcohol rehabilitation extended family and her sister. Following a
program. She recently moved to Houston from a divorce 2 years ago, this daughter ended all con-
small town in Louisiana because she needed tact with her mother and extended family, hence
“access to big city transportation.” She does not perpetuating the pattern of emotional cutoff.
have any family or friends in the area or even Kate spoke of her upbringing stating there were
within several states. She is, however, vague regular family visits with extended family of her
about her decision to choose Houston. She has father but there were no family visits with mother’s
lived alone, away from family for the past family. Discussion of mother’s family or siblings
40 years. She has two daughters; one lives in was always shrouded in mystery. It is known that
Utah, and the other daughter and grandson live mother’s father deserted the family when she was a
in New York; Kate’s mother and sister live in young girl. After mother’s marriage in the late
Iowa. She has discontinued all contact with her 1940s, she did not have any contact with her own
older daughter (partly in response to her daugh- mother or siblings until shortly before her own
ter’s own emotional cutoff), and has very infre- mother’s death about 30 years later, when she visited
quent phone calls to her second daughter. She her mother and attended the subsequent funeral.
calls her mother primarily on “obligation days” This triggered a limited renewal of the relationship
such as Mother’s Day and Christmas. She reports of the mother with her sister.
these phone calls are generally filled with silence With Kate’s family, the generational pattern of
or “safe topics” such as discussion of the children emotional cutoff is seen in four generations:
or health matters. She visited her mother once mother’s father, mother’s siblings, Kate, and
several years ago for the first time in approxi- Kate’s older daughter.
mately 20 years. When discussing her family,
she laughs and says she visited her mother for a
week and, “I’m good for another 20 years.” In Bridging Cutoff
years past there were more frequent visits, primar-
ily centered on delivering or picking up her As a family therapist, it is crucial to look for
daughters following a lengthy visit with grandpar- family patterns such as divorce, intensity of rela-
ents. She reports these visits were usually limited tionships, and conflict resolution strategies or
862 Emotional Cutoff in Bowen Family Systems Theory
differences between generations. A major task of Emotional Cutoff Scale. The Emotional Cutoff
the therapist is to create a trusting, objective Scale (ECS) measures the sense of cognitive con-
environment in which the family members are nection to a person’s mother and father. Scores
comfortable exploring their own family emo- range on a continuum between 10 and 50. Lower
tional and relationship systems. Family systems scores mean a greater level of connection to par-
therapy begins with a family evaluation of their ents; higher scores mean a lesser level of connec-
emotional processes, closeness, distance, trian- tion or more emotional cutoff to parents. The
gles, and tensions that are still unresolved from internal consistency and reliability of the ECS is
the family of origin. The ideal method of work- high, with Cronbach’s alpha ranging from 0.82 to
ing with a family using Bowenian theory is to 0.90 (McCollum 1991).
have several generations participating. How- A clinician applying Bowen theory wants to
ever, a genogram that serves as a graphic repre- assess the nature of the cutoff – is it external with
sentation of family relationships, physical and little or no contact, or internal with little personal
mental health, and substance abuse can help interaction? One can simply ask, “How often do
identify patterns of interaction and promote you visit?” But don’t assume that because there is
insight about development of behaviors. Use geographical distance, it implies emotional cutoff.
of a family genogram will assist the therapist Conversely, an adult may never leave home yet
in maintaining a neutral stance while becoming have a poor relationship with other family mem-
aware of family triangles that identify who is bers. Assess for openness in personal relation-
outside of the family circle and possible reasons ships. Are they able to discuss personal and
why. Due to high levels of anxiety, it may be family concerns calmly and respectful of opin-
easier (and more beneficial) if the first contact to ions? Are there topics to avoid? Assess the rela-
bridge a cutoff is not with the cutoff member(s) tionship with the extended family. Do they
but with another family member who can pro- participate in important life events of extended
vide background and insight concerning the family? Births, weddings, funerals, anniversaries,
estrangement (Haefner 2014). and retirements? Assess for balance between fam-
Creating and referencing a genogram will also ily expectations and personal choice (Klever
help the client see the family as a system connected 2003). Is the expectation to attend all events at
together rather than as disconnected outliers – that the expense of individual choice and risk
the individual belongs to a system and all parties are increased family tensions?
interconnected. Because all parties are When working with others, it is beneficial if the
interconnected, it is profitable to consider the clinician has thought about his/her own emotional
whole system as opposed to parts of the system, as cutoff with family and friends. Understanding the
change in one party will affect the whole system. It patterns of interaction and attachment in oneself
is also helpful for the client to consider that change will widen the scope and understanding of work-
in one part of the system not only affects the whole ing with others. Experiencing the discomfort of
system but also impacts who he/she becomes in analyzing one’s own family can provide useful
terms of differentiation of self and level of emotional insight.
intelligence.
Bowen (1976) encourages practitioners to
throw out the “concept of normal . . . because it is
not possible to define normal. Think in terms of Cross-References
keeping “their relationships in balance” and there-
fore avoid “severe stress . . . and never develop ▶ Bowen, Murray
symptoms” (p. 66). ▶ Family Therapy
A useful evaluation tool to quantify emotional ▶ Family of Origin
cutoff was developed by McCollum (1991) The ▶ Genogram in Couple and Family Therapy
Emotional Reactivity in Emotion-Focused Couple Therapy 863
Bowen Center for the Study of the Family Georgetown Emotional reactivity can be defined as the strength
Family Center. (2016). Emotional cutoff. Retrieved
and duration of an affective response to a stimulus
from http://www.thebowencenter.org/theory/eight-
concepts/emotional-cutoff/. (Rothbart and Derryberry 1981; Shapero et al.
Bowen, M. (1976). Theory in the practice of psychother- 2016). In the context of couples, emotional reac-
apy. In P. J. Guerin (Ed.), Family therapy. New York: tivity can be defined as “the frequency with which
Gardner.
affect becomes dysregulated” in couple interac-
Bowen, M. (1978). Family therapy in clinical practice
(pp. 337–388). Northvale: Jason Aronson. tions (Greenberg and Goldman 2008, p. 58). Emo-
tional reactivity may occur in couple therapy
Brown, J. (1999). Bowen family systems theory and prac-
tice: Illustration and critique. Australian New Zealand
E
when a member of a couple expresses their feel-
Journal of Family Therapy, 20, 94–103. Retrieved
ings in a manner that is destructive to the relation-
from http://onlinelibrary.wiley.com/doi/10.1002/j.
1467-8438.1999.tb00363.x/pdf. ship, resulting in the escalation of affect and
Haefner, J. (2014). An application of Bowen family sys- negative interaction cycles. One goal of
tems theory. Issues in Mental Health Nursing, 35, emotion-focused couple therapy (EFT-C) is to
835–841.
move partners away from automatic emotional
Harrison, V. (2003). Reproduction and emotional cutoff. In
P. Titelman (Ed.), Emotional cutoff (pp. 245–269). reactivity and to the expression of more adaptive,
New York: The Haworth Press. regulated emotions that aid couple members in
Klever, P. (2003). Marital functioning and multi- meeting their needs (Goldman and Greenberg
generational fusion and cutoff. In P. Titelman (Ed.),
2007; Greenberg and Goldman 2008).
Emotional cutoff (pp. 219–243). New York: The Haw-
orth Press.
McCollum, E. E. (1991). A scale to measure Bowen’s con-
cept of emotional cutoff. Contemporary Family Therapy, Theoretical Context for Concept
13(3), 247–254. https://doi.org/10.1007/BF00891804.
Titelman, P. (2003). Emotional cutoff in Bowen family
systems theory: An overview. In P. Titelman (Ed.), Emo- Emotions may be adaptive or maladaptive,
tional cutoff (pp. 9–65). New York: The Haworth Press. depending in part on the degree of regulation or
dysregulation. Most individuals are motivated to
feel positive emotions and not experience negative
emotions and thus regulate their affect (Goldman
Emotional Reactivity in and Greenberg 2013; Greenberg and Goldman
Emotion-Focused Couple 2008). When individuals fail to regulate affect in
Therapy their relationships, emotional reactivity may result
in couple conflict (Goldman and Greenberg 2013).
Natasha Seiter1, Amy D. Smith1,2 and Theoretically, EFT-C recognizes three primary
Kelley Quirk2 motivational systems that drive emotions and
1
Marriage and Family Therapy/Applied interpersonal relationships: attachment, identity,
Developmental Science Program, Colorado State and attraction/liking (Goldman and Greenberg
University, Fort Collins, CO, USA 2013). Individuals are motivated to attach to
2
Marriage and Family Therapy Program, Human others and to achieve a positive sense of identity
Development and Family Studies, Colorado State to fulfill interpersonal needs and regulate affect
University, Fort Collins, CO, USA (Goldman and Greenberg 2013; Meneses and
Greenberg 2011). When the attachment or identity
systems are threatened, or related needs are
Name of Concept unmet, individuals may become activated
(Greenberg and Goldman 2008), and emotional
Emotional Reactivity in Emotion-Focused Couple reactivity may result if emotions are not suffi-
Therapy ciently modulated or responded to.
864 Emotional Reactivity in Emotion-Focused Couple Therapy
Description 2008). Partners in EFT-C are guided in trans-

forming their maladaptive emotional reactivity
Emotional reactivity involves the expression of to regulated emotional responses that are
dysregulated emotions (Goldman and Greenberg context-appropriate and less likely to lead to
2013; Greenberg and Goldman 2008). negative interaction cycles (Goldman and
Dysregulated emotions are not adaptive as they Greenberg 2007; Goldman and Greenberg
are often not context-appropriate (Elliot et al. 2013). This involves identifying the negative
2004; Goldman and Greenberg 2013) and thus interaction cycle and the roles each partner
not effective in helping an individual meet their plays in maintaining the cycle, as well as the
needs. For example, individuals may become underlying emotions driving their attachment
emotionally reactive when they perceive a threat and identity needs. By appropriately identifying
toward their attachment or identity systems, often these processes, the couple’s struggle is
leading to defensive or protective responses, even reframed toward expression of more vulnerable
if this threat is not consistent with the current underlying feelings regarding unmet attachment
context (Greenberg and Goldman 2008). In other and identity needs (Goldman and Greenberg
words, there may be times when partners respond 2007).
to one another in the moment based on past expe-
riences or emotional injuries.
Emotionally reactive maladaptive emotions are Clinical Example
likely to lead to negative interaction cycles in cou-
ple relationships (Goldman and Greenberg 2013; Alex and Mary sought emotion-focused couple
Goldman and Greenberg 2007). In an emotionally therapy to help resolve frequent conflict. In the
reactive state, couple members may shout at each session, Mary reveals that she feels Alex is
other and/or fail to listen to the others’ perspective controlling her free time and gets angry at her
(Goldman and Greenberg 2007). A common exam- when she expresses wanting to spend time with
ple of this is the demand/withdraw pattern, known her female friends. Alex responds with hostility,
to be destructive to relationship stability and satis- exclaiming that he doesn’t trust her to go out
faction (e.g., Eldridge and Christensen 2002). Ulti- without him. In response, Mary withdraws from
mately, emotional reactivity inhibits the connection Alex and he becomes even more hostile.
and safety that may be felt when more regulated, Their EFT-C therapist helps them to identify
adaptive emotions are expressed. their negative interaction cycle, a demand-
withdraw pattern that reinforces itself. She
helps them to recognize that when Alex
Application of Concept in Couple and becomes emotionally reactive, Mary becomes
Family Therapy overwhelmed and withdraws, and this makes
Alex feel abandoned and even more emotion-
Emotion-focused couple therapy aims to move ally reactive. The therapist also helps them to
clients away from harmful emotional reactivity identify the origin of Alex’s emotional reactiv-
to more effective emotion regulation (Goldman ity, his first wife’s affair. Alex recognizes that
and Greenberg 2007; Greenberg and Goldman when Mary wants to go to a dinner with her
2008). Therapists practicing EFT-C teach cli- female friends, he perceives a threat to their
ents to soothe their partners as well as to self- relationship and to his sense of identity as a
soothe, and these are seen as equally important husband. As his attachment and identity sys-
components of the therapeutic process. Such tems are activated, he may respond to his fear
self- and other soothing strategies are used to of betrayal with maladaptive emotion that is
enhance affect regulation, thus minimizing inappropriate for the context and does not help
emotional reactivity and stopping negative him meet his need for security. His failure to
interactional cycles (Greenberg and Goldman regulate his emotions may result in Mary feeling
Emotionally Focused Couple Therapy 865
attacked and becoming overwhelmed, leading

her to withdraw. The emotion-focused couple Emotionally Focused Couple
therapist teaches them to soothe themselves Therapy
and each other, enhancing their affect regulation
abilities during interactions. Emotional reactiv- Stephanie A. Wiebe1 and Sue M. Johnson2
1
ity is transformed to regulated emotional com- The Ottawa Hospital, The University of Ottawa,
munication, and Alex and Mary are able to International Centre for Excellence in
effectively listen and talk with one another. Emotionally Focused Therapy, Ottawa, ON,
Canada
2
The International Centre for Excellence in
E
Emotionally Focused Therapy, The University of
Cross-References
Ottawa, Ottawa, ON, Canada
▶ Emotion-Focused Therapy for Couples
▶ Goldman, Rhonda
Name of the Strategy
▶ Greenberg, Leslie
▶ Secondary Reactive Emotions in Emotion-
Emotionally focused couple therapy.
Focused Therapy
Synonyms
References
Eldridge, K. A., & Christensen, A. (2002). Demand-

EFT; Emotionally focused therapy
withdraw communication during couple conflict:
A review and analysis. In P. Noller & J. A. Feeney
(Eds.), Understanding marriage: Developments in the Introduction
study of couple interaction (pp. 289–322). Cambridge,
MA: Cambridge University Press.
Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, Emotionally focused couple therapy (EFT) is an
L. S. (2004). Learning emotion-focused therapy: The approach to couple therapy that helps create
process-experiential approach to change. Washington, attachment security in relationships by guiding
DC: American Psychological Association.
Goldman, R. N., & Greenberg, L. S. (2007). Integrating
partners to explore and share with one another
love and power in emotion-focused couple therapy. their core attachment-related emotions and
European Psychotherapy, 7(1), 117–135. needs. EFT conceptualizes the negative interac-
Goldman, R. N., & Greenberg, L. (2013). Working with tion patterns between partners in distressed couple
identity and self-soothing in emotion-focused therapy
for couples. Family Process, 52(1), 62–82.
relationships and the associated strong negative
Greenberg, L. S., & Goldman, R. N. (2008). Emotion- emotions as arising from emotional disconnection
focused couples therapy: The dynamics of emotion, and an insecure attachment bond. Core, primary
love, and power. Washington, DC: American Psycho- attachment-related emotions are often blocked
Meneses, C. W., & Greenberg, L. S. (2011). The construc-
from awareness and expression in distressed cou-
tion of a model of the process of couples’ forgiveness in ple relationships by protective reactions such as
emotion-focused therapy for couples. Journal of Mar- numbing due to the triggering of attachment-
ital and Family Therapy, 37(4), 491–502. related fears. In EFT, couples are encouraged to
Rothbart, M. K., & Derryberry, D. (1981). Development of
individual differences in temperament. In M. E. Lamb
explore core primary attachment-related emotions
& A. L. Brown (Eds.), Advances in developmental and needs as they arise in the therapy session and
psychology (Vol. 1). Hillsdale: Erlbaum. express these to their partner. Partners are then
Shapero, B. G., Abramson, L. Y., & Alloy, L. B. (2016). encouraged to tune into their partners’ emotions
Emotional reactivity and internalizing symptoms:
Moderating role of emotion regulation. Cognitive Ther-
and needs and respond. As partners tune into one
apy and Research, 40(3), 328–340. https://doi.org/ another’s now clarified and explicit emotional
10.1007/s10608-015-9722-4. realities, they are able to counter one another’s
866 Emotionally Focused Couple Therapy
attachment fears, establish emotional connection, activated in couple relationships map onto
and create a more secure bond. Since its develop- demand/withdraw pattern such that the pursuing
ment in the 1980–1990s, EFT has accumulated a partner typically expresses intense distress and
strong evidence base and is practiced by couple anger characterized by blame, criticism, and con-
therapists internationally. tempt and hyperactivates attachment signals to
protest the distance in the relationship. The with-
drawing partner downregulates affects and with-
Prominent Associated Figures draws emotionally, consistent with deactivating
strategies of affect regulation observed with
Sue Johnson developed EFT as she strove to attachment avoidance. Secure attachment rela-
understand and capture the complexity and inten- tionships, in contrast, involve mutual emotional
sity of her couples’ experiences in therapy, along- responsiveness, accessibility, and engagement
side Les Greenberg. In the first study of EFT, (Johnson 2004).
Johnson and Greenberg (1985a) discovered that In the EFT model, the intrapsychic focus of
focusing explicitly on and regulating emotions in experiential approaches is combined with the
couple therapy sessions was beneficial in alleviat- interpersonal perspective of systems theory to
ing relationship distress, and in fact superior to a slow down negative cycles of interaction, as
cognitive-behavioral problem-solving approach. well as increase emotional accessibility and
Sue Johnson and colleagues have further devel- responsiveness in the relationship. Change is
oped the model to include a primary emphasis on thought to occur through the creation of moments
attachment. Emotionally focused couple therapy of secure bonding as couples increasingly explore
developed by Johnson (2004) differs significantly and express underlying attachment needs and the
from emotion focused therapy for couples vulnerabilities that underlie secondary protective
(EFT-C; developed more recently by Greenberg emotional responses (Johnson 2004). As both
and Goldman 2008) in that it places emphasis on partners engage in this process of intrapsychic
the attachment relationship and views emotions exploration coupled with the direct expression of
that arise in the relationship as related to the here- attachment-related emotions and needs in the rela-
and-now attachment interactions between part- tionship, this interrupts the demand/withdraw pat-
ners. Greenberg and Goldman (2008), in contrast, tern seen in distressed relationships and allows
also place strong emphasis on identity, power, and couples to create new patterns of mutual respon-
individual emotional exploration and regulation. siveness and deeper levels of engagement
(Johnson 2004). Secure bonding potentiates effec-
tive caretaking and satisfying sexual connection.
EFT draws on humanistic and systemic principles Populations in Focus

within an attachment-based framework (Johnson
2004). In EFT, the negative, rigid interaction pat- Since attachment and associated emotions are uni-
terns and strong negative affect and lack of posi- versal in nature, a therapy that helps couples create
tive affect – noted by Gottman (1993) to be a more secure attachment, such as EFT, is a viable
central feature of distressed relationships – are approach across diverse populations of adult cou-
seen as constantly triggered attachment insecurity ples (Zuccarini and Karos 2011; Liu and
and a felt sense of isolation. Distressed relation- Wittenborn 2011). Liu and Wittenborn (2011) out-
ships are typically characterized by a demand/ line three principles for working with culturally
withdraw pattern of interaction in which one part- diverse couples in EFT: (1) give attention to mean-
ner pursues with criticisms and/or demands and ings and functions associated with emotional
the other partner withdraws (Gottman 1993). The expression and attachment behaviors; (2) seek
emotions that arise when the attachment system is understanding of the socially constructed meanings
of emotion; and (3) use words and metaphors to and reflect how this pattern of interaction takes
which clients can relate, especially clients’ own over the relationship and clarify each partner’s
words, and explore further to ascertain their core attachment fears, secondary emotions such
intended meaning. As the meanings underlying as chronic anger, and behavioral reactions, such as
attachment behaviors are investigated in session, turning against or away from the other and how
core attachment-related emotions and needs these impact each partner. The completion of
become apparent and are then open to exploration stage one is marked by the couple creating a
in a way that can be understood by both partners. meta-perspective and beginning to view their neg-
By remaining receptive to universal attachment ative cycle as the source of insecurity and distress
emotions, meanings, and functions underlying in the relationship as opposed to viewing their
E
behaviors – rather than taking responses at face partner as the problem. Stage 2 is restructuring
value – therapists can adapt EFT for diverse attachment interactions. This involves helping
populations of couples (Greenman et al. 2009). couples shape new positive interactional cycles
In terms of clinical presentations, EFT is par- where deeper primary emotions and attachment
ticularly relevant for couples with medical ill- needs can be shared in structured enactments.
nesses, depression, and posttraumatic stress. Partners are encouraged to provide emotionally
With the focus of EFT on building secure connec- attuned support to one another. When blocks to
tion, effective affect regulation, and creating sup- emotional attunement and engagement arise,
portive interactions with loved ones, it is not these are explored and understood in attachment
surprising that EFT has been found to be effective terms. Partners who previously withdrew in the
for these populations (Wiebe and Johnson 2016). relationship begin to express their fears of rejec-
EFT has also been tailored and tested for use with tion and failure and ask for their attachment needs
couples dealing with attachment injuries such as to be responded to, and become more responsive
affairs and other betrayals (Zuccarini et al. 2013). and engaged. In turn, partners who previously
Contraindications to EFT involve situations in were blaming and critical begin to clearly express
which it would not be safe for partners to become their attachment needs for comfort and reassur-
emotionally vulnerable with one another through ance in a way that invites the other partner to
the exploration and expression of core understand and respond. As the withdrawing part-
attachment-related emotions and needs. Unsafe ner reengages, and as the blaming partner softens
situations may include physical violence, sub- into vulnerable sharing, new positive interactional
stance abuse, or ongoing infidelity. responses are shaped in bonding moments. There
are two key change events that are understood to
occur in stage two of EFT: Withdrawer
Strategies and Techniques Used in reengagement and blamer-softening. Withdrawer
Model reengagement occurs when the partner who pre-
viously avoided open engagement with their part-
EFT draws on experiential and systemic interven- ner can express their attachment needs clearly and
tions including empathic reflection of emotions directly, and becomes more responsive to their
and interactive patterns, validation, evocative partner. Blamer-softening occurs when the partner
responding and questioning, heightening emo- who previously took a pursing stance in the rela-
tional engagement, empathic conjecture, and tionship, approaching their partner with blame
reframing and restructuring interactions within a and criticism, begins to express their more vulner-
process of three stages, as outlined by Johnson able primary emotions (hurt, sadness, fear, or
(2004). Stage 1 is cycle de-escalation. In this shame) in a soft but clear and direct way. Their
stage, EFT therapists help couples develop an partner is then encouraged to listen and respond in
understanding of their negative dance and the an emotionally attuned way. These events gener-
distance it creates as the source of distress in ate new, more constructive, cycles of contact and
their relationship. In this stage, therapists track caring, fostering secure attachment.
Stage 3 is consolidation. This stage involves resume the therapeutic process. Resolving the
integration of gains made during therapy into attachment injury was associated with significant
specific situations of conflict. During this stage, improvements in relationship satisfaction and for-
couples use their felt sense of more secure con- giveness. In a 3-year follow-up, couples who were
nection and increased trust to solve problems in able to resolve the injury continued to demon-
their relationship and everyday lives, creating a strate improved relationship satisfaction and for-
story of resilience and mastery in their relation- giveness (Halchuk et al. 2010). In a study of the
ship. In this way, new interactional patterns are process of healing attachment injuries in EFT,
consolidated and adaptive attachment behaviors Zuccarini et al. (2013) found that couples who
become increasingly frequent in the couple’s daily resolved their attachment injuries had demon-
interactions (Johnson 2004). strated greater depth of emotional engagement in
key sessions of therapy, a more reflective stance in
processing of emotions around the injury, and
Research about the Model greater levels of affiliative responding toward
their partner as compared to nonresolvers. In
Emotionally focused therapy has strong research terms of therapeutic interventions, resolved cou-
support in terms of both outcome and process of ples’ therapists tended to have increased levels of
change studies. Early EFT research established reflecting primary emotions, evocative questions,
the value of focusing on emotion in couple ther- and enactments in EFT sessions.
apy. In the first EFT studies, Johnson and Furthermore, EFT has been found to be effec-
Greenberg (1985a, b) discovered that exploring tive in reducing the neurological threat response
emotions and drawing on them to shape new to electric shock experienced by female partners
interactions resulted in significant improvements when their partner was present holding their hand
in relationship satisfaction for couples, and that (Johnson et al. 2013), suggesting that EFT may
these gains were more favorable as compared to a help couples coregulate threat, which may help
cognitive-behavioral problem-solving approach explain the effectiveness of EFT for highly
(PS). A meta-analysis by Johnson, Hunsley, stressed couples.
Greenberg, and Schindler (1999) found a recovery Process research has explored the ingredients
rate from relationship distress of 70–73% with a of change in EFT. The two main elements of the
Cohen’s d effect size of 1.31 using data from four therapeutic process in EFT that have been identi-
RCT studies of EFT. EFT has also been shown to fied as key ingredients of change are: depth of
be effective for couples facing depression, post- emotional experiencing and the process of shap-
traumatic stress, and chronic illness (Wiebe and ing interactions such that partners begin to clearly
Johnson 2016). express attachment needs and emotions and
The EFT literature has also outlined specific mutual affiliative responding (Greenman and
steps involved in working with couples facing Johnson 2013). In addition, the occurrence of a
relationship injuries such as affairs and other blamer-softening event – a key therapeutic event
betrayals in the attachment injury resolution characterized by high levels of emotional
model within EFT (AIRM; Makinen and Johnson experiencing and mutual affiliative responding –
2006; Halchuk et al. 2010). The AIRM model is associated with positive outcomes in EFT
states that it is necessary for the injured partner (Johnson and Greenberg 1988). Blamer-softening
to express and process feelings of anger, sadness, has been found to predict linear improvements in
and fear due to the attachment injury in order to relationship satisfaction across EFT sessions
create secure attachment and in order for forgive- (Dalgleish et al. 2015). Blamer-softening has
ness to be possible. In an investigation of this also been tied specifically to reductions in attach-
model, Makinen and Johnson (2006) found that ment anxiety across EFT sessions (Burgess Moser
63% of injured partners were able to successfully et al. 2017). Research has confirmed that attach-
resolve the injury, forgive their partner, and ment security improves across EFT sessions
(Burgess Moser et al. 2017) and during follow-up Th – So can you stay with that hurt and fear that
(Wiebe et al. 2016a), and that this change is pre- you are so bravely naming here – can you take
dictive of continued improvements in the first a breath and share that fear with Jack, right
2 years after completing EFT (Wiebe et al. here?
2016b). Marie: (She turns to Jack) It hurts so much to think
that maybe you don’t really desire me and then
you try to make love anyway, I can’t stand it!
Case Example Th: You really long to know that you are wanted
and desired by Jack, and it’s really hard to let
The following is a snapshot of the EFT therapeutic him hear these vulnerable feelings and what
E
process with Jack and Marie, illustrating a soften- ends up happening is you explode in anger, is
ing session within the context of forgiveness of an that what happened?.
attachment injury: Marie: Of course, I want to be the one you think
about, the one you turn to, but when you look
Th: How did you enjoy your vacation? at other women I just get scared and feel alone
Jack: It was good at first. Marie and I went out and rejected and so sad (She weeps).
dancing and we were having a good time. Then Th: Can you turn to Jack and tell him this is how
we got back to our hotel room and we started you feel? That you feel sad and scared and
kissing and then all of a sudden just like that alone in those moments?
she started yelling at me again about the affair Marie: Jack, when I’m reminded of the affair, I’m
and then got up and went to bed. The rest of our just overwhelmed with sadness and feeling
vacation was shot. She was just withdrawn and alone. I know I explode in anger, but it’s
sullen the whole time. because I just feel so vulnerable and hurt.
Th: Jack, it sounds like you were really enjoying Th: Jack – can you take that in? Can you help
being with Marie, and then something hap- Marie with these vulnerable feelings?
pened, and you want to try and understand. Jack: You just seemed so cold and distant all
Yes? night. Then when I went to kiss you, you
Jack: Yes, I want to hear it, whatever it is (he gazes exploded. I didn’t know you were hurting. If
at Marie intently). I could take back the affair I would, in a heart-
Marie: Don’t act so innocent. The whole night you beat. It hurts me to see you in pain like this.
were staring at that other woman, but I know I don’t want you to hurt anymore, Marie you
you don’t want me to talk about it so I held it in, know you are the only one I really want to
and then later when we were kissing I just felt be with.
like it wasn’t me you wanted to be with. I’m Marie: You know as I hear you say that it brings
never enough for you, just like the affair, I’m up a different sadness for me. What you did
never enough (Marie speaks angrily, but with caused me a lot of pain, but now it’s like you
tears filling her eyes) can feel that pain too and you understand what
Th: Marie, I hear your anger and frustration, and at it is like for me. I don’t want you to hurt
the same time I see your eyes well with tears. anymore either.
When you saw him glance at that other woman
you said to yourself ‘he doesn’t really want In this excerpt, the therapist helps Marie
me’, and it brought back all the pain of the stay with and articulate her softer, more vulner-
affair? And you held it in all night until you able attachment longings and fears underlying
were back at your hotel room and you were her angry responses to Jack. She is then
making love, then part of you said, ‘he doesn’t guided to turn to Jack with her core feelings of
really desire me’ – that terrible fear came up, pain and sadness around the attachment injury
and you felt all alone with it, is that it? in a way that pulls her partner closer. Jack is
Marie: Yes! So I just exploded, I let him have it. then able to turn to Marie and support her,
and express a deep empathy with her experi- Gottman, J. M. (1993). A theory of marital dissolution and
ence and regret for having hurt her. Marie can stability. Journal of Family Psychology, 7(1), 57–75.
https://doi.org/10.1037/0893-3200.7.1.57.
experience and take in a sense that Jack Greenberg, L. S., & Goldman, R. N. (2008). Emotion-
understands and feels her pain, and this allows focused couples therapy: The dynamics of emotion,
her to shift into a more loving and forgiving love, and power. Washington, DC: American Psycho-
response. logical Association.
Greenman, P., Young, M., & Johnson, S. M. (2009). Emo-
tionally focused therapy with intercultural couples. In
M. Rastogi & V. Thomas (Eds.), Multicultural couple
Cross-References therapy (pp. 143–166). Los Angeles: Sage.
Greenman, P. S., & Johnson, S. M. (2013). Process
research on emotionally focused therapy (EFT) for
▶ Attachment Injury Resolution Model in Emo- couples: Linking theory to practice. Family Process,
tionally Focused Therapy 52(1), 46–61. http://doi.org/10.1111/famp.12015.
▶ Attachment Theory Halchuk, R. E., Makinen, J. A., & Johnson, S. M. (2010).
Resolving attachment injuries in couples using emo-
▶ Circle of Security: “Understanding Attachment tionally focused therapy: A three-year follow-up.
in Couples and Families” Journal of Couple Relationship Therapy, pp. 31–47.
▶ Clarifying the Negative Cycle in Emotionally https://doi.org/10108015332690903473069, 9 SRC-G.
Focused Therapy Johnson, S. M. (2004). The practice of emotionally focused
couple therapy: Creating connection. New York:
▶ Deepening Emotional Experience and Brunner-Routledge.
Restructuring the Bond in Emotionally Johnson, S. M., & Greenberg, L. S. (1985a). Differential
Focused Couple Therapy effects of experiential and problem-solving interven-
▶ Emotion in Couple and Family Therapy tions in resolving marital conflict. Journal of Consult-
ing and Clinical Psychology, 53(2), 175–184.
▶ Emotionally Focused Couple Therapy and Johnson, S. M., & Greenberg, L. S. (1985b). Emotionally
Physical Health in Couples and Families focused couples therapy: An outcome study. Journal of
▶ Emotionally Focused Couple Therapy and Marital and Family Therapy, 11(3), 313–317.
Trauma Johnson, S. M., & Greenberg, L. S. (1988). Relating pro-
cess to outcome in marital therapy. Journal of Marital
▶ Emotionally Focused Family Therapy and Family Therapy, 14(2), 175–183. http://doi.org/
▶ Emotion-Focused Therapy for Couples 10.1111/j.1752-0606.1988.tb00733.x.
▶ Goldman, Rhonda Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler, D.
▶ Gottman, John (1999). Emotionally focused couples therapy: Status
and challenges. Clinical Psychology: Science and
▶ Greenberg, Leslie Practice, 6(1), 67–79.
▶ Hold Me Tight Enrichment Program Johnson, S. M., Moser, M. B., Beckes, L., Smith, A.,
▶ Hold Me Tight/Let Me Go Enrichment Pro- Dalgleish, T., Halchuk, R., & Coan, J. A. (2013).
gram for Families and Teens Soothing the threatened brain: Leveraging contact
comfort with emotionally focused therapy. PLoS
▶ Johnson, Susan ONE, 8(11), 1–10. http://doi.org/10.1371/journal.
▶ Training Emotionally Focused Couples pone.0079314.
Therapists Liu, T., & Wittenborn, A. (2011). Emotionally focused
therapy with culturally diverse couples. In J. L. Furrow,
S. M. Johnson, & B. A. Bradley (Eds.), The emotionally
focused casebook: New directions in treating couples
References (pp. 295–316). Rutledge: New York.
Makinen, J. A., & Johnson, S. M. (2006). Resolving attach-
Burgess Moser, M., Dalgleish, T. L., Johnson, S. M., ment injuries in couples using emotionally focused
Wiebe, S. A., & Tasca, G. (2017). The impact of therapy: Steps toward forgiveness and reconciliation.
blamer-softening on romantic attachment in Emotion- Journal of Consulting and Clinical Psychology, 74(6),
ally Focused Couples Therapy. Journal of Marital and 1055–64. http://doi.org/10.1037/0022-006X.74.6.1055.
Family Therapy. https://doi.org/10.1111/jmft.12284. Wiebe, S. A., & Johnson, S. M. (2016). A review of the
Dalgleish, T. L., Johnson, S. M., Burgess Moser, M., research in emotionally focused therapy for couples
Wiebe, S. A., & Tasca, G. A. (2015). Predicting key (EFT). Family Process, 55(3), 390–407.
change events in emotionally focused couple therapy. Wiebe, S. A., Johnson, S. M., Burgess Moser, M.,
Journal of Marital and Family Therapy, 41(3), Dalgleish, T. L., Lafontaine, M., & Tasca, G. (2016a).
260–275. Two-year follow-up outcomes in emotionally focused
Emotionally Focused Couple Therapy and Physical Health in Couples and Families 871
couple therapy. Journal of Marital and Family Ther- effective, empirically supported treatment for dis-
apy, 43(2), 227–244. tress in couple relationships (Wiebe and Johnson
Wiebe, S. A., Johnson, S. M., Burgess Moser, M.,
Dalgleish, T. L., & Tasca, G. (2016b). Predictors of 2016). There is also a body of process research on
follow-up outcomes in emotionally focused couple EFT, which informs clinicians about what to do in
therapy. Journal of Marital and Family Therapy, therapy with couples, when, and how (Greenman
43(2), 213–226. and Johnson 2013). The results of process
Zuccarini, D., & Karos, L. (2011). Emotionally focused
therapy for gay and lesbian couples: Strong identities, research also provide information on the type of
strong bonds. In J. L. Furrow, S. M. Johnson, & B. A. client experiences (e.g., emotional reactions,
Bradley (Eds.), The emotionally focused casebook: changes in relationship positions) that therapists
New directions in treating couples (pp. 317–342). need to foster in order to effect positive change.
New York: Routledge. E
Zuccarini, D. J., Johnson, S. M., Dalgleish, T. L., & Practitioners have recently begun conducting
Makinen, J. A. (2013). Forgiveness and reconciliation EFT outside of the traditional marriage-
in emotionally focused therapy for couples: The client counseling context. It has made its way into med-
change process and therapist interventions. Journal of ical settings and has been applied, for example, to
Marital & Family Therapy, 39(2), 148–162. https://doi.
org/10.1111/j.1752-0606.2012.00287.x. couples facing chronic illnesses such as cancer
(Naaman et al. 2011), heart disease (Greenman
and Johnson 2012), and diabetes (Greenman
et al. 2015). The rationale behind the integration
Emotionally Focused Couple of EFT into mainstream medical care is that
Therapy and Physical Health improvement in the quality of the couple relation-
in Couples and Families ship can play an important role in the effective
management of chronic disease.
Paul S. Greenman
Université du Québec en Outaouais, Gatineau,
QC, Canada Theoretical Context for Concept
Institut du Savior Montfort, Ottawa, ON, Canada
Ottawa Couple and Family Institute, Ottawa, ON, In contrast to “emotion-focused therapy”
Canada (Greenberg and Goldman 2008), emotionally
focused therapy is based heavily on attachment
theory and research, which stipulates that all peo-
Name of Concept ple have innate, wired-in needs for close emo-
tional connections to significant others (Bowlby
Emotionally Focused Couple Therapy and Phys- 1979; Zeifman and Hazan 2016). According to
ical Health attachment theory, these needs become particu-
larly salient in times of stress and when people
perceive threats to the presence or strength of their
Synonyms emotional ties to important figures in their lives.
For example, the diagnosis and management of a
Emotionally focused therapy for couples, EFT chronic illness such as diabetes would most likely
activate “attachment needs” for reassurance and
support in the patient, along with “attachment
Introduction fears” of losing the partner to illness in the
patient’s spouse.
Emotionally Focused Couple Therapy (EFT) is an From the EFT perspective, healthy couples are
experiential, systemic intervention designed to those who are able to send and respond to clear
improve relationship quality and satisfaction by signals of needs for connection and comfort. Ther-
creating a secure attachment bond between apy helps them learn how to do this effectively. It
partners (Johnson 2004). It is recognized as an is important to note that attachment is
872 Emotionally Focused Couple Therapy and Physical Health in Couples and Families
hierarchical; people tend to have stronger bonds to heightening of emotion and attachment needs is
certain beloved individuals, known as “attach- followed by enactments in which partners express
ment figures,” than to others (Castellano et al. their fears, longings, and needs directly to each
2014). Spouses or romantic relationship partners other, and in which they respond to clear signals
tend to be primary attachment figures for many of vulnerability in comforting ways. The repeated
people, which means that these relationships are expression of and response to emotional vulnera-
of paramount importance to them (Castellano bility in Stage II leads to a stronger, more secure
et al. 2014). bond in the couple. At this stage, couples who are
dealing with a chronic illness generally learn to
open up to each other about their stress around the
Description illness, the sense of loss it can bring into their
lives, their fears for the future, and their need for
EFT consists of three stages, divided into nine support and reassurance. They also learn to com-
empirically derived steps (Johnson 2004). In fort and reassure each other at this stage.
Stage I, therapists work to help partners identify Stage III of EFT involves helping the couple
their interaction cycle, which is construed as the solve practical problems now that they have a
true enemy of the relationship and usually secure attachment bond and consolidating the
involves one partner attempting to establish or gains that they have made in therapy. Couples
maintain emotional contact with the other, while coping with the challenges of a chronic illness
the other partner withdraws or disengages emo- are encouraged to engage in problem-solving
tionally. Both tendencies are framed in emotion- around the disease as a team. This might involve
ally focused therapy, but not always in emotion- learning to cook healthy meals or exercising
focused therapy, as attempts to manage the intense together for some couples. For others, the focus
emotions that arise out of perceived threats to the might be on adhering to a particular treatment
attachment bond. Once both partners understand regimen or medication.
and accept the cycle as their main problem and
they realize that they both play a role in creating
and maintaining it, they have achieved “de- Application of Concept in Couple and
escalation” and are ready to proceed to Stage II Family Therapy
of therapy.
Stage I work with couples facing a serious In the case of a couple facing chronic illness, the
illness such as heart disease, cancer, or diabetes partner who does not have the disease often tends
usually involves helping partners recognize how to carefully observe, track, and sometimes even
their questions, fears, and concerns related to the nag or control the partner who has the illness,
illness activate attachment needs and underlying usually out of fear for the sick partner’s well-
emotions such as fear or sadness. EFT therapists being. In EFT, this is seen as an attachment fear.
assist couples in the process of becoming more The partner with the chronic illness often tends to
aware of how their typical ways of managing minimize the concerns of his or her spouse,
these underlying emotions (e.g., emotional pursuit become defensive, or withdraw emotionally.
or emotional withdrawal) affect their interactions From an attachment perspective, this can lead to
and their relationship as a whole. feelings of loneliness that compound the stress of
In Stage II of EFT, therapists create change having a disease. The emotional withdrawal then
events by heightening and deepening primary, feeds into the partner’s fears, and the couple finds
vulnerable emotions that include fear and sadness, itself caught in a negative spiral. This is an exam-
which according to attachment theory are usually ple of the pursue-withdraw pattern that is typical
borne in distressed couples out of longing for in distressed relationships (Gottman 2011). The
emotional connection with the partner and an therapeutic work in Stage I with such a couple
inability to establish or maintain it. The would involve helping them recognize how they
Emotionally Focused Couple Therapy and Physical Health in Couples and Families 873
feel about the illness (e.g., afraid, depressed), marriage since the diagnosis, which she attributed
what they do when they feel that way (nag, to her husband Daniel’s excessive “nagging, con-
criticize – “You’re having ANOTHER beer?!” or trolling, and nastiness.” Upon hearing this, the
minimize – “It’s no big deal”), and how their nurse referred Jane and Daniel for couple therapy,
behavior affects their partner. The goal is for which is part of the gamut of outpatient services
them to identify this interaction pattern or cycle offered at the hospital. Daniel agreed to attend.
as their primary challenge and to unite against it.
Stage II with couples grappling with a physical Stage I
disease usually involves supporting the more Daniel and Jane met with a staff psychologist who
withdrawn partner to open up about his or her was an experienced EFT therapist. In the initial
E
anguish, stress, and sadness in the face of the sessions, the therapist established a strong alliance
disease and asking for emotional support rather with both partners, as this is essential to the suc-
than criticism. This is known as withdrawer cess of EFT. He also asked questions about how
reengagement. The Stage II process also involves Jane and Daniel had been feeling since Jane’s
helping the pursuing partner to soften by diabetes diagnosis. It became apparent that the
expressing his or her fears about the disease and main trigger of their negative interaction cycle
asking for the ill partner’s cooperation and under- was the diabetes and what Daniel perceived to
standing in managing it together. be Jane’s half-hearted attempts to maintain safe
Once the couple has developed a secure attach- blood-sugar levels. Daniel was the pursuing part-
ment bond in Stage II, exemplified by withdrawer ner and Jane the withdrawn partner in this case.
reengagement and pursuer softening, they move The therapist helped Daniel identify, experi-
on to Stage III of EFT. In medical settings this ence in-session, and talk about his fear of losing
generally entails supporting the couple to engage Jane, his sadness at the mere thought that she
in effective problem-solving around the disease. could become debilitatingly ill or die, and his
They might develop an exercise regimen together, sense of helplessness in this situation, despite all
devise a plan for continuing to administer and take of his medical knowledge. The EFT therapist
medications properly, and decide to share their reflected that these primary emotions and vulner-
experiences about the illness with each other able experiences tended to be couched in second-
more openly. The therapist reflects this new way ary emotions such as anger and frustration when
of interacting and reminds the couple that they Daniel interacted with Jane. With the help of some
combat the disease more effectively as a team. empathic conjectures and validation of this fright-
ening experience, the therapist also brought into
the open Daniel’s tendencies to try to control
Clinical Example Jane’s behavior (e.g., what she could eat, how
much, and when) and to criticize her when he
Jane (age 44) and Daniel (age 46) have been thought she was not trying hard enough to stick
together for 20 years. They have two children: to her diet and control her blood sugars. The
Samantha (age 16) and George (age 13). Jane is therapist framed these behaviors as attempts to
a lawyer and Daniel is a family physician. Jane make sure that Jane would stay healthy and
was diagnosed with type II diabetes 2 years prior alive, driven by powerful fears of losing her
to the beginning of emotionally focused couple (attachment framework). However, he noted that
therapy (EFT) and is now an outpatient at the when Daniel behaved in this blaming, critical way
diabetes clinic of a local hospital. She had been without showing Jane any overt signs of his deep
having a great deal of difficulty keeping her blood concern, it had a negative effect on her and actu-
sugar levels under control and she reported feeling ally contributed to her stress and to her tendency
depressed and overwhelmed to the nurse diabetes to withdraw from him.
educator that she had been seeing. She also men- The therapist also worked with Jane in Stage
tioned that she had been having problems in her I to uncover more about her experiences in the
874 Emotionally Focused Couple Therapy and Physical Health in Couples and Families
relationship. She mentioned feeling ashamed in-session, Daniel’s intense fear of losing Jane to
that she had gained weight since her diabetes her illness, his loneliness when she pulled away
diagnosis and was having so many problems from him, and his sadness at the distance that had
keeping the disease under control. She was come between them. The therapist supported Dan-
afraid that Daniel would fall out of love with iel to express these fears and vulnerabilities
her because of this, which made her feel sad and directly to Jane, followed by the direction of
alone. The therapist heightened these primary Jane’s attention to Daniel’s longing for closeness
emotions and attachment-related experiences with her and his terror that she might die. Daniel
in-session and noted that they were similar to said at one point, “To me, a chocolate bar is like a
Daniel’s, although Jane tended to cope with gun that you’re pointing at your head,” and he
them differently. Whereas Daniel would started to weep. This emotional experiencing
become critical, Jane tended to minimize the made Daniel appear less threatening to Jane and
impact of her health habits on her disease, to it helped him ask her, from a place of vulnerabil-
defend herself in the face of Daniel’s ity, to work with him to tackle diabetes more
reproaches, and to distance herself from him effectively as a team. Over the course of a few
emotionally and physically. The therapist sessions the couple became more attuned to each
pointed out that when Jane withdrew from Dan- other and they learned to speak to each other
iel in this way, it increased his tendency to clearly and directly about their respective fears
pursue her. He presented this interaction cycle and needs. Thus, Jane reengaged emotionally
as the principal problem and the primary target and Daniel softened.
of therapeutic intervention. After a few ses-
sions, the couple began to perceive the cycle in Stage III
their daily lives and to recognize their respective Once the bond between partners was secure, the
roles in creating and maintaining it. They therapist reflected to them their new positions in
expressed relief at this new understanding of the relationship and their new ways of interacting
their problems. with each other. As they spoke about diabetes, the
therapist brought their attention to the fact that
Stage II Daniel now talked more openly about his con-
The EFT therapist began Stage II by exploring, cerns instead of criticizing Jane, who now
deepening, and expanding on Jane’s feelings of moved closer to Daniel and tried to reassure him
shame, fear, and sadness in-session. He supported of her presence and concerted efforts to manage
her to talk in more detail than she did in Stage her diabetes. The therapist suggested that the cou-
I about how she has always felt unattractive and ple develop a systematic plan for diabetes man-
how the diabetes diagnosis just confirmed that she agement that they could work on together. Jane
was, in her words, “a pig.” The therapist explored and Daniel decided that they would exercise
how this perception of herself fed into her fears together three times a week and that they would
that Daniel would ultimately leave her, especially both embark on a healthy diet with the help of a
now that she could not effectively control the nutritionist. If Jane’s sugars resisted her efforts to
symptoms of her disease. She talked about feeling control them she asked Daniel to encourage her,
defective. The therapist invited Jane, in a series of which he did. If Daniel became concerned about
enactments, to express these fears directly to Dan- one aspect or another of Jane’s diabetes he
iel. He then immediately supported Daniel to hear expressed those to her directly instead of criticiz-
and to respond in a comforting, reassuring manner ing her. In a 6-month check-in following their
to Jane’s expressions of vulnerability and need for final session, the couple reported that they felt
his support. The therapist helped Jane ask Daniel closer than they ever had. Managing Jane’s diabe-
directly for encouragement rather than scorn. tes was still a challenge, but her blood sugar levels
The therapist worked with Daniel in a similar were more under control than they ever had been
fashion in Stage II. He deepened and expanded, in the past, to the relief of both partners.
Emotionally Focused Couple Therapy and Trauma 875
Cross-References The emotionally focused casebook: New directions in

treating couples (pp. 141–164). New York: Routledge.
▶ Attachment Injury Resolution Model in Emo- research in emotionally focused therapy for couples.
tionally Focused Therapy Family Process, 55, 390–407. https://doi.org/10.1111/
▶ Clarifying the Negative Cycle in Emotionally famp.12229.
Focused Therapy Zeifman, D. M., & Hazan, C. (2016). Pair bonds as attach-
ments. In J. Cassidy & P. R. Shaver (Eds.), Handbook
▶ Deepening Emotional Experience and of attachment: Theory, research, and clinical applica-
Restructuring the Bond in Emotionally Focused tions (pp. 416–434). New York: Guilford.
Couple Therapy
E
▶ Emotionally Focused Couple Therapy and
Trauma
▶ Emotionally Focused Family Therapy Emotionally Focused Couple
▶ Health Problems in Couple and Family Therapy Therapy and Trauma
▶ Training Emotionally Focused Couples
Therapists Kathryn Rheem1 and T. Leanne Campbell2
1
Washington Baltimore Center for EFT, Falls
Church, VA, USA
2
Vancouver Island Center for EFT, Nanaimo, BC,
References Canada
Bowlby, J. (1979). The making and breaking of affectional
bonds. London: Tavistock/Routledge.
Castellano, R., Velotti, P., & Zavattini, G. C. (2014). What Name of Strategy or Intervention
makes us stay together? Attachment and the outcomes
of couple relationships. London: Karnac Books. Emotionally Focused Couple Therapy and
attunement for couples. New York: W. W. Norton. Trauma
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-
focused couples therapy: The dynamics of emotion,
love, and power. Washington, DC: American Psycho- Synonyms
Greenman, P. S., & Johnson, S. M. (2012). United we
stand: Emotionally focused therapy for couples in the Emotionally Focused Therapy; EFT
treatment of post-traumatic stress disorder. Journal of
Clinical Psychology, 68, 561–569. https://doi.org/
10.1002/jclp.21853.
Greenman, P. S., & Johnson, S. M. (2013). Process Introduction
research on emotionally focused therapy (EFT) for
couples: Linking theory to practice. Family Process, Emotional dysregulation, including numbing, is a
52, 46–61. https://doi.org/10.1111/famp.12015. primary hallmark of trauma and PTSD. Since emo-
Greenman, P. S., Tassé, V., & Argibay-Poliquin, E. (2015).
Effective management of diabetes and comorbid tions are the messenger of love, emotional
depression: Contributions of emotionally focused ther- dysregulation – especially the very understandable
apy (EFT) for couples and individual Cognitive- but problematic coping strategy of numbing – is
behaviour therapy (CBT). Oral presentation at the particularly damaging in couple and family relation-
76th Annual Convention of the Canadian Psychologi-
cal Association, Ottawa. ships. Emotionally focused couple therapy (EFT)
Johnson, S. M. (2004). Creating connection: The practice (Johnson 2004) is particularly relevant in the con-
of emotionally focused marital therapy (2nd ed.). joint treatment of trauma since it is based on adult
New York: Brunner/Routledge. attachment theory (Bowlby 1969) and prioritizes the
Naaman, S., Radwan, K., & Johnson, S. M. (2011). Emo-
tionally focused couple therapy in chronic medical processing of emotions so that each partner can send
illness: Working with the aftermath of breast cancer. a clear emotional signal, a requirement to strengthen
In J. L. Furrow, S. M. Johnson, & B. A. Bradley (Eds.), and repair their bond and heal trauma.
876 Emotionally Focused Couple Therapy and Trauma
Theoretical Framework just when they need each other the most. Seeking
and maintaining closeness with an important other
EFT, an empirically validated approach, combines is viewed as the primary motivating principle in
an experiential, intrapsychic focus with a systemic humans and an innate survival mechanism, provid-
emphasis on cyclical interactional responses and ing us with a safe haven and a secure base in a
patterns (Johnson 2004; see other chapters on EFT potentially dangerous world (Bowlby 1988).
in this volume). Key elements of each partner’s
experience, such as attachment fears, needs, and
longings, are evoked, distilled, and shared Description of Strategy or Intervention
(through enactments) in order to restructure the
relationship bond. Expanding beyond traditional The goals of EFT are, firstly, to expand
individual treatment of trauma, EFT is revelatory attachment-related affect which, in turns, clarifies
for treating the echoes of trauma in the context of each partner’s position in their interactional pat-
couple therapy: when partners have a felt sense of tern and, secondly, to help partners access their
security, their relationship contains and antidotes underlying vulnerable emotions which, when
the distress associated with trauma. shared, restructure the couple’s bond. When
using EFT with couples where one or both part-
ners have endured more than most (our frame for
Rationale for Strategy or Intervention trauma), there are specific goals: (1) regulate
affect, particularly containing anger and working
Emotion is seen as a primary signaling system that with fear; (2) create moments of sharing vulnera-
organizes relationship patterns. Acting as a GPS, bilities so a corrective experience of safe connec-
it is impossible to navigate relationships without tion is had and new meaning can be attained; and
regularly referencing how we feel. Since emotions (3) integrate the revised view of self/other
are impossible to hide, partners also regularly (Johnson 2002).
gather data about each other’s inner worlds The EFT therapist works toward a sense of safe
which drive behaviors and influence interactions emotional connectedness where the partner
with each other. In attachment terms, a bond refers becomes an ally or co-regulator of a trauma sur-
to an emotional tie, i.e., a set of attachment behav- vivor’s feelings of helplessness. The relationship
iors to create and manage proximity to attachment is used as a source of protection where partners are
figures and regulate emotions. The accessibility able to confide in each other and soothing and
and responsiveness of attachment figures are nec- comfort are provided. EFT provides an ideal
essary to create a feeling of personal security. opportunity to help couples break the inevitable
Attachment theory (Bowlby 1969, 1988) is a trap of trauma: relationship escalations increase
developmental theory of personality and a theory symptoms of trauma and often lead to more neg-
of love, but it is also a theory of psychological ative coping strategies; increased symptoms
trauma and the impact of isolation, neglect, and coupled with problematic ways of coping inten-
emotional starvation on the developing personality. sify the relationship’s distress (Johnson and Faller
Bowlby and others recognized that separation from 2011). Nothing is more relevant than treating the
primary caregivers and lack of human contact over echoes of trauma in the relationships in which
even a short period of time during critical periods of they reverberate.
development could have severe personal and rela- Dealing with trauma together creates an envi-
tional consequences. A significant body of research ronment of recovery between partners. Partners
has been accumulated over the last half-century. have much more proximity (nearness, immediacy,
When an attachment figure is perceived as inac- and closeness in key moments of distress) and,
cessible or unresponsive, potent fear, anger, and hopefully, longevity in their relationships with
sadness emerge. These emotions often lead to survivors. A sense of belonging mitigates the ech-
behaviors and interactions that disconnect partners oes of trauma, and closeness to a loved one
Emotionally Focused Couple Therapy and Trauma 877
soothes the nervous system. Helping the survivor echoes of trauma and the isolation endured,
learn to reach emotionally and helping the partner offered each other reassurance which comforts
learn how to be emotionally responsive decrease and soothes, and built trust that together they can
helplessness and numbing, other symptoms begin help each other through the dark moments
to diminish, and partners are able to use the rela- (Johnson 2002). In completing EFT, trauma sur-
tionship to cope together (rather than the partner vivors and their partners have earned their attach-
being a bystander or even a target). ment security (Bowlby 1969) which continually
The foundation of all EFT interventions is contains and provides antidotes for the echoes of
empathic responsiveness. When working with trau- trauma. The neurological benefits of love are hid-
matized couples, the empathy and safety provided den when pain and fear are not processed or
E
by the EFT clinician allows the client to focus shared. Slowly but purposefully leaning into and
inwardly and touch fears and pain. For trauma sur- loosening the grip of fear and pain allows the
vivors, making experiential contact with pain and comfort of love to soothe a traumatized heart.
fear can feel dangerous. The EFT therapist is the
trusted guide who safely brings clients into their
inner worlds. By using EFT interventions to evoke Case Example
and heighten vulnerable emotions, by using parts
language in order to leverage the fear with the Gary’s voice rose and his tone sharpened as he
clients’ longings, and by processing the fear and turned to Lisa, accusing her of not loving him as
pain experientially with conjectures and evocative much as he loves her.
responses, each partner’s inner world becomes less “You work late,” he said, “and are always busy
dysregulated and less chaotic. As a result, there is with the kids. I seem to come last on your list of
more intrapsychic coherence and organization, allo- priorities. I rush home to see you. I seem to be way
wing each partner to feel more competence with more committed to you than you are to me.”
their own inner worlds. At this point, Lisa’s gaze turned down, and she
Once the intrapsychic landscape of each part- shifted further into the back of her chair.
ner is more organized, linking it to the interper- He continued, now more aggressively and
sonal is vital. The only way to restructure the loudly, “Forget it! It’s over!” and started to leave
couple’s bond (the goal of EFT Stage 2) is to use the room.
enactments to bring the fear and pain to the part- The couple had been struggling for months,
ner, allowing the partners to hold the emotion had a period of separation, and were now working
together. Emotions are the link between the intra- toward reconciliation. Lisa, with a background
psychic and the interpersonal and the EFT thera- of trauma characterized by family violence, as
pist structures, a process where partners share fear well as abandonment by a parent, had little toler-
and pain with each other through enactments. ance for such threats and limited capacity to
Small, simple enactments help the trauma survi- manage them.
vor build an interpersonal template of safety, per- The therapist interrupted. Her voice soft, and
haps for the first time. Risks are sliced thinly in with eyes locked on Gary’s, she invited him to
order to decrease danger; validation is offered stay. Gary sat down again. With a deep breath, his
frequently by the EFT therapist to resource and chest crumpled slightly and he appeared less intim-
hold the client. Slowly and methodically, reaches idating. The therapist then turned to Lisa who was
are made by one partner, and responses are pro- by now gazing off into the recesses of the wall. Her
vided by the other, in order to build a bond that is face was frozen. Her eyes were blank.
trustworthy and soothing. “Where are you?” the therapist queried in a soft
As a result of completing Stage 2 of EFT, inviting tone.
partners will have had many corrective emotional Lisa quietly replied, “I don’t know.”
experiences as each has shared pain and fear with The therapist gently leaned toward Lisa and
the other. They will have confided about the invited her to stay with her experience. “What is
878 Emotionally Focused Couple Therapy and Trauma
happening inside of you Lisa? Not in your brain, (Speaking as therapist again). . .“And when
in your body, what happens in your body when Gary feels you ‘disappear’ [go silent, withdraw,
you hear Gary reach for you in this way, when you retreat rather than expressing fear] he feels alone
notice his tone change. . .?” and unimportant, he feels like he doesn’t matter,
Lisa sat quietly for a moment and then said, “I that he’s not important to you . . .but that’s not
feel numb. I feel empty. I don’t feel anything.” quite it, is it? To the contrary, you are hyper-
“Okay Lisa, this is good,” the therapist noted attuned to him, and that also served you well as
encouragingly, “Let’s just stay here . . . this will be a child, it was helpful to be vigilant to danger
good. . ..” . . .but what I’ve heard you say is that Gary is not
Over the course of the next few minutes, and dangerous . . . he has never been violent, but his
with similar slow, evocative probing and intona- tone, his look can at times feel dangerous . . .and
tion of voice from the therapist, Lisa then was able as a little girl, it was never safe to share your fear
to access and acknowledge a sense of fear and . . . it was safer and it was adaptive to go numb and
anxiety – characterized by a tightness in her chest quiet . . . but now that is keeping you away from
and a lump in her throat that seemed to choke her the person that matters to you most. . ..”
and leave her speechless. Again, with an evocative, rhythmically paced,
“If that lump could speak Lisa, what would it and empathic voice, and also allowing herself to
say?” the therapist asked. be openly and tearfully touched by the profound
With that, Lisa’s face shifted. Her lips softened, nature of Lisa’s authentic sharing and experiencing
her eyes filled with tears, and she turned tenta- of associated childhood memories and pain, the
tively toward the therapist. Staring at the therapist therapist holds the couple in their experience and
now, and with tears streaming down her face, she invites them both to feel compassion for the younger
quietly responded, “scared.” Lisa. Against this backdrop, the therapist then
“I’m scared,” the therapist reflected. returns to Lisa with the aim of helping her further
Now glancing at Gary from the corner of her embody the fear underlying her sense of numbness
eye – to ensure and facilitate further engagement – and withdrawal.
the therapist evocatively and empathically framed Once distilled and heightened, Lisa is directed
Lisa’s experience in the context of her attachment to share her fear from a position of vulnerability –
history and the couple’s negative cycle. Specifi- that is, the therapist now invites Lisa to do the
cally, the therapist reflected, “I hear you Lisa . . . enactment – and Gary is invited to respond from a
does it go something like this? . . .is this what place of compassion and empathy (e.g., “when
happens? . . . what I hear you saying is . . . Lisa so beautifully shares her fear with you, in
(therapist now begins speaking for Lisa, to Gary) your eyes, and you see her beautiful tear-filled
‘when I hear your voice change, even a little tiny eyes, . . . when she looks at you and shares in
bit, or when I see your brows raise, even ever so this way, what are you drawn to do?”). As Gary
slightly. . .[what I hear you say is that when you] reaches back, both with his eyes and presence, and
. . . hear or see any hints of anger, or any threat of Lisa remains present in her vulnerability, a bond-
abandonment, . . . [what I hear you saying is. . .] ing moment occurs that provides both the founda-
I freeze, I go right back to that place I lived as a tion for a corrective emotional experience as
little girl, the only place that I could feel safe. . .I highlighted earlier, and a new template for con-
disappear, I go silent. . .no one can see me, and nection (i.e., model of other), and an experience of
I lose myself.’” herself in relationship as worthy and lovable (i.e.,
(Here the therapist is setting the stage for an model of self).
enactment, reflecting the negative cycle, embed- The excerpt above provides a brief snapshot of
ding it in an attachment framework, and normal- a partial session of emotionally focused therapy
izing their responses based on their relationship for couples. The therapist is working with Lisa in
and attachment histories in an effort to create particular (in step three, stage 1/de-escalation of
increased safety, as well as awareness.) the process). By accessing feelings underlying her
Emotionally Focused Family Therapy 879
withdrawal (under conditions of stress/threat) in ▶ Johnson, Susan

the relationship, Lisa is able to also tap into child- ▶ Posttraumatic Stress Disorder (PTSD) in Cou-
hood experiences associated with trauma and loss. ple and Family Therapy
As she begins to openly and directly express such ▶ Violence in Couples and Families
emotions in her relationship with Gary, and as
Gary is accessible and responsive (is less reactive,
less escalated, and more open emotionally), Lisa’s References
long-standing patterns of avoidance and with-
drawal are interrupted, and Lisa’s template for Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment.
relationships (and her view of herself) is similarly
Bowlby, J. (1988). A secure base. New York: Basic Books. E
challenged. In turn, as Gary is able to respond to Johnson, S. M. (2002). Emotionally focused couple ther-
Lisa in a time of need (i.e., as she shares the pain/ apy with trauma survivors: Strengthening attachment
fear underlying her numbness and withdrawal), he bonds. New York: Guilford.
too is able to begin to view the relationship and
himself differently (e.g., as someone who does New York: Brunner-Routledge.
matter to Lisa, given the importance of the work Johnson, S. M., & Faller, G. (2011). Dancing with the
he has witnessed and the vulnerability she has dragon of trauma: EFT with couples who stand in
harm’s way. In J. L. Furrow, S. M. Johnson, &
shown). Stated more simply, as Lisa is able to
B. Bradley (Eds.), The emotionally focused casebook:
explore, access, and then share aspects of her New directions in treating couples (pp. 165–192).
pain outside her typical awareness, transformation New York: Routledge.
(as well as healing of past trauma) begins both
personally and relationally for both partners.
Emotionally Focused Family

Cross-References Therapy
▶ Adult Survivors of Sexual Abuse in Couple and James L. Furrow1 and Gail Palmer2
1
Family Therapy Fuller Graduate School of Psychology,
▶ Attachment Injury Resolution Model in Emo- Pasadena, CA, USA
2
tionally Focused Therapy International Centre for Excellence in
▶ Attachment Theory Emotionally Focused Therapy, Ottawa,
▶ Bowlby, John ON, Canada
▶ Child Sexual Abuse in Couple and Family
Therapy
▶ Circle of Security: “Understanding Attachment Name of Model
▶ Clarifying the Negative Cycle in Emotionally Emotionally Focused Family Therapy.
Focused Therapy
▶ Deepening Emotional Experience and
Restructuring the Bond in Emotionally Synonyms
▶ Emotion in Couple and Family Therapy EFFT
▶ Emotionally Focused Couple Therapy and
Physical Health in Couples and Families Introduction
▶ Empathy in Couple and Family Therapy
▶ Enactment in Structural Family Therapy Emotionally Focused Family Therapy (EFFT)
▶ Family Violence in Couple and Family Therapy provides therapists with a process-focused
880 Emotionally Focused Family Therapy
approach to restoring attachment bonds in parent- separation distress, following John Bowlby’s the-
child and sibling relationships through increasing ory of attachment (Bowlby 1969, 1988). In dis-
felt security in the family system (Johnson 2004). tress, a couple’s problematic attempts to
In EFFT, family distress results from rigid family re-establish their attachment bonds fuel insecurity
patterns and persistent negative emotional ex- as partners rely on anxious or avoidant strategies
periences that block a parent’s ability to ef- to cope.
fectively address a child’s attachment needs. Similarly, a family’s distress escalates in the
The therapist guides family members toward a face of insecure attachment bonds and result-
more secure pattern of relating by shifting these ing separation distress. Family patterns are often
negative interactional patterns into positive cy- more complex than couples given the hierarchical
cles characterized by greater parental accessib- bonds of parents and children and mutual bonds of
ility, responsiveness, and emotional engagement partners working together as parents. Escalating
and more effective attachment responses from insecurity in family interactions prompts fear of
children. possible separation, loss, and isolation (Johnson
In EFFT, the therapist acts as a process consul- 2004). The inability to relate clear attachment and
tant focusing on the emotional blocks and behav- caregiving communication further amplifies the
ioral patterns that interrupt a family’s ability to family distress. Strategies of anxious control, pre-
respond effectively to the needs and concerns of occupation, or avoidant withdrawal organize the
other members. A family’s presenting problem is family’s attachment communication deepening
conceptualized as a rigid pattern of negative inter- the insecurity felt by family members.
actions that are informed by reactive and rigid The principle goal of EFFT is to re-establish
responses based in attachment insecurity. As the more secure patterns where attachment and care-
therapist works through these emotional blocks, giving responses are effective and emotional
parents are guided toward new positions of avail- bonds are reassured. Family bonds are adaptive
ability and children are encouraged to share their and essential to a natural system that promotes
attachment needs with their emotionally engaged optimal development and environmental mastery
parent. The process of re-establishing bonds of for children (Bowlby 1969). When these bonds
security in parent and child dyads promotes resil- are secure, parents are more likely to provide
ience in the face of ordinary developmental needs children with a “secure base” to foster exploration
and stressors common to family life. promoting the development of a child’s potential
and uniqueness and a “safe haven” from the
uncertainties and difficulties of life. Together
Prominent Associated Figures these resources inform a network of security that
insures the flexibility and cohesion necessary to
Susan Johnson. maintain individual growth and meaningful rela-
tionships across the lifespan (Byng-Hall 2001).
Theoretical Framework Core Concepts

Four key concepts guide an EFFT therapist’s
Rationale for the Model conceptualization and work with families: Neg-
Emotionally Focused Family Therapy (EFFT) ative Interactional Patterns; Felt Security; Pro-
is founded on the principles and practices of Emo- cessing Emotional Experience; and Restructuring
tionally Focused Couple Therapy (EFCT). Theo- Interaction.
retically, EFCT draws from humanistic-
experiential (e.g., Rogers 1951) and systemic the- Negative Interactional Patterns
ories (e.g., Minuchin and Fishman 1981). Susan A family’s inability to respond to developmental
Johnson (2004) characterized couple relationships and situational demands is often evident in rigid
as attachment bonds and their disruption as patterns of reactive behavior organized by
negative emotional experience. These negative Restructuring Interaction

interaction patterns produce mutually reinforcing The resolution of a family’s attachment-related
reactive patterns of dysregulated affect. These distress results from transforming negative inter-
negative absorbing states lock family members actional patterns through corrective emotional
into fixed interactional positions informed by experience. Shifts toward greater parental open-
underlying anxious or avoidant attachment strate- ness set the stage for increased attunement and
gies (Johnson 2004). In EFFT, these patterns are interest in the child’s attachment-related needs.
the initial focus of treatment, where specific dis- Parental accessibility provides new opportunities
ruptive and dysregulated interactions offer access for children to explore their attachment-related
to emotions underlying the family’s presenting needs and concurrently for parents to take new
E
problem (Johnson et al. 2005). steps to respond to these needs. The shared expe-
rience of vulnerability clarifies parental caregiv-
Felt Security ing intentions and provides a basis for more clear
Secure attachment in a family system results from expressions of a child’s attachment needs
accessible and responsive caregiving to clear (Johnson et al. 1998). These shifts result in new
attachment-related communication. Felt security is experiences and family conversations founded in
evident in family interactions where positive emo- more accurate, affectively engaged, and emotion-
tions enable families to effectively respond to devel- ally corrective responses. New patterns of secure
opmental needs and relationship change. Felt responding are choreographed by the therapist
security offers a child internal confidence in an using new experiences of emotion to move family
attachment figure’s support in exploration and avail- to cycles of felt security.
ability in the face of personal threat and emotional
distress. Parents as caregivers also turn toward one Theory of Change
another for mutual support, just as children turn The EFFT stages of change follow the EFCT
toward parents for care contact and comfort. These treatment approach with a unique focus on parent
positive cycles of security define the family as a and child interaction patterns (Johnson 2004). The
“safe haven” and a critical resource for facing ordi- process of change includes the de-escalation of a
nary stressors and developmental demands. family’s negative interaction pattern, restructuring
parent and child positions, and consolidation of
Emotional Experience felt security gained through these new positions.
Emotion is central to attachment communication In stage 1, de-escalation is premised on a ther-
and a key focus in the EFT process of change. apist ability to foster a secure base enabling a
Emotion primes attachment responses in family family to explore their presenting problem and
interactions and is a primary resource to felt secu- related distress. Individual family members’ ex-
rity. Attachment communication exists first and periences are accessed and understood in the
foremost at an emotional level because attachment context of family pain, fears, and hurt. Through
bonds are emotional bonds (Johnson 2004). accessing and processing these primary emotions,
Focusing on the emotional responses of family the therapist reframes problem patterns based on
members enables parents and children to better these underlying emotions and elicits more ex-
access their intentions, desires, and needs. More- plicit parental caregiving responses to emerging
over, separation distress is colored by reactive attachment-related emotions and needs. This en-
emotional responses. Processing emotional expe- ables the family to develop a coherent under-
rience is essential in working through maladaptive standing of their pattern and greater freedom to
responses and the EFFT therapist differentiates acknowledge each person’s responsibility in the
primary emotions from secondary emotion by family’s predictable struggle including greater
actively accessing and exploring the underlying parental openness and engagement.
emotions associated with attachment needs in the In stage 2, the EFFT therapist focuses on re-
family (Johnson et al. 2005). structuring the family pattern through deepening
882 Emotionally Focused Family Therapy
and delineating the child’s underlying attachment reformulated within specific relationships and,
affect and then distilling unexpressed or unclear second, new interaction patterns are formed
attachment needs. As a child’s primary emotions based on these new emotional responses. The
and needs are made more explicit, the therapist EFFT therapist uses reflection, validation, and
invites the child to share these experiences. The evocative questions to access and process the
therapist joins a parent in processing and work- emotional responses associated with stuck family
ing through her or his response to the child’s patterns and rigid positions. Reactive responses
newly expressed vulnerability. Parental blocks to are reframed in terms of predictable patterns of
caregiving are identified and worked through family distress, and underlying emotions are
leading to greater parental empathy and caregiv- understood in the context of attachment seeking
ing responses. The therapist then invites the and caregiver responding.
parent and child into an enactment of the child’s The second strategy focuses on forming new
attachment bid and the parent’s attuned caregiv- interactional patterns organized around positive
ing response. New family responses tend to cycles of attachment security. Enactments are
reflect clearer definitions of self, more assertive used to engage primary emotional experience
boundary definitions, and more explicit expecta- leading to the sharing of attachment-related emo-
tions of the relationships desired in the family tions and needs. EFFT differs from EFT with
(Johnson 2004). couples in recognizing the hierarchical role of a
The third and final stage of EFFT promotes parent and the primacy of parental caregiving in
consolidation of the new patterns of security response to attachment needs expressed by a
achieved by the family in the preceding stages. child. The EFFT therapist uses heightening inter-
The family takes new steps toward enhancing the ventions and enactments to choreograph change
felt security experienced by the family after work- events that foster parental responsiveness and
ing through blocks to emotional engagement and accessibility to a child’s vulnerability.
effective caregiving. More secure family interac-
tions demonstrate greater flexibility in responding
to developmental demands and are more effective Research
in problem solving (Johnson et al. 1998). New
rituals of connection are explored to increase Johnson et al. (1998) explored the use of EFFT
openness and emotional engagement, greater pos- with adolescents with bulimia and their parents
itive affect, and appreciation for their stronger ties in a hospital setting. Results from the small out-
as a family. come study demonstrated that EFFT was effective
in complete remission of binging behaviors for
44% and vomiting behaviors for 67% of the sam-
Populations in Focus ple. A series of case studies illustrate the use of
EFFT with different presenting complaints includ-
Internalizing and externalizing disorders in child- ing depression, nonsuicidal self-injury, conduct
hood and adolescence, stepfamily adjustment, and disorder, and issues related to divorce and step
family distress. family adjustment.
Strategies and Techniques Case Example
EFFT treatment strategies and techniques are Zane, a 15-year-old boy, was referred to family
based on similar interventions used in EFCT. therapy following a series of school-related prob-
Two strategies organize EFT interventions. lems. Zane’s difficulty concentrating, complet-
First, emotional responses are accessed and ing assignments, and truancy were a change from
his previous school success. These difficulties him particularly when he was missing his father.
followed a period of family instability including Zane rejected her initiative lashing out with con-
his father Mohammed’s death and his mother tempt, calling her a “whore” for her being unfaith-
Irma’s recent engagement. Zane described his fam- ful in choosing another man.
ily as a “battleground” of constant fighting with his Zane’s raw anger showed the intensity of his
mother and younger brother Yosef who constantly pain, which the therapist accessed in blocking his
sought his attention. The therapist engaged each attack and reframing his harsh protest to the losses
person’s experience by exploring, empathizing, in the family which left Zane utterly alone. Zane
and making sense of their responses to the family. fought back tears as he shared his despair: “Noth-
The harsh moments of negativity illustrated the ing is the same. Everything has changed. What’s
E
separation distress evident in Zane’s protest and his the point?”
mother’s attempts to regain control. Tracking the Irma again struggled to find words to respond
negative interactions gave opportunity to explore to Zane’s grief as she was invited to courageously
Zane’s anger, pain, and loss, which he and brother engage his vulnerability. Zane slowly responded
Yosef felt about their father’s death, which was to his mother’s effort to offer her regret and an
rarely discussed. As different experiences were apology that she had missed what he was going
acknowledged, specific attention was given to through given she was lost in her own pain. In
these more vulnerable experiences. turn, Zane was asked to express what he needed
Individual sessions with the mother and the sons most from his mother and he shared that he
deepened an understanding of Zane’s relationship wanted to know what was happening in the family
to his mother and Irma’s ambivalence about her and needed his mother to talk with him, not just
husband’s death and their distant marriage. Irma about school. Irma took Zane’s hand and
avoided discussing her late husband’s absence with reassured him, sharing how proud she was of
her sons as both rejected her fiancé whom she him and that his father would see the same, that
relied on for emotional support. Irma’s parental she sees him as a mature young man that has a
concerns were affirmed and the family’s distress very young age had to face this loss of his Dad.
was framed in relation to the father’s absence and Through this corrective emotional experience,
the threat of further loss through mother’s Zane faced his fears and reached for his mother
remarriage. The therapist highlighted Irma’s under- from a position of vulnerability. Irma responded to
lying care and concern for her sons. Both boys her son’s attachment need by seeing him and his
expressed questions about their father’s death and pain and in that place and offering love, support,
fears about family changes in a sibling session and and comfort. Following this work, Yosef was
both were encouraged to share these experiences invited back to a family session and shared hap-
with their mother in future sessions. piness that there was more caring and less fighting
Family treatment focused on Zane and Irma as in the home. The family shared plans to honor and
they shared the most distressed family relation- remember Mohammad through rituals of visiting
ship. Zane’s anger quickly escalated when Irma the burial ground together and being closer
dismissed his thoughts and opinions or criticized through sharing more family times together.
his school-related efforts. Irma’s reactive response
was validated and understood in terms of her
heartfelt concern for Zane and the frustration she Cross-References
felt when he would withdraw defensively. The
therapist identified her care and heightened her ▶ Attachment Theory
concern for Zane using an enactment to engage ▶ Attachment-Based Family Therapy
her softened emotions with her son. As she tear- ▶ Emotion in Couple and Family Therapy
fully reached her hand toward him, she explained ▶ Emotionally Focused Couple Therapy
her struggle to talk with him and show care for ▶ Emotion-Focused Family Therapy
884 Emotion-Focused Family Therapy
References Prominent Associated Figures
Bowlby, J. (1969). Attachment and loss: Attachment. Adele Lafrance

Joanne Dolhanty
Bowlby, J. (1988). A secure base. New York: Basic Books.
Byng-Hall, J. (2001). Attachment as a base for family and
couple therapy. Child Psychology & Psychiatry
Review, 6, 31–36. Theoretical Framework
New York: Brunner-Routledge. Part of the emotion-focused therapy family, EFFT
Johnson, S. M., Maddeaux, C., & Blouin, J. (1998). Emo- was initially developed as an adjunct to family-
tionally focused family therapy for bulimia: Changing based treatment for eating disorders in order to
attachment patterns. Psychotherapy, 35, 238–247.
help parents to support their children in dealing
Johnson, S. M., Bradley, B., Furrow, J., Lee, A., Palmer,
G., Tilley, D., & Wooley, S. (2005). Becoming an with both behavioral symptoms and the emotional
emotionally focused couple therapist: The workbook. processes fueling them. From the EFFT perspec-
New York: Brunner-Routledge. tive, emotion processing can play a key role in the
Minuchin, S., & Fishman, H. C. (1981). Family therapy
onset and maintenance of a variety of mental
Rogers, C. (1951). Client-centered therapy. Boston: health issues (e.g., depression, anxiety) and asso-
Houghton-Mifflin. ciated symptoms. Emotional avoidance (i.e.,
suppressing or ignoring emotions) is considered
a maladaptive coping strategy that drives a variety
of mental health conditions such as mood and
Emotion-Focused Family
anxiety disorders, eating disorders, and self-
Therapy harm. Although there are a host of factors that
can contribute to mental health issues (e.g., genet-
Allen Sabey1 and Adele Lafrance2
1 ics, culture, trauma), the ways in which individ-
uals and their families attend to and process
Evanston, IL, USA
2 emotions can be targeted and transformed, and
Laurentian University, Sudbury, ON, Canada
in short order. Thus, helping parents to support
their children to manage their emotions in adap-
tive and productive ways is an overall target for
Synonyms
intervention and treatment (Elliott et al. 2004;
Greenberg 2008; Greenberg and Pascual-Leone
EFFT
2006).
Parents have been under-utilized as active
Introduction agents of change in the context of their children’s
mental health treatment, particularly among ado-
Emotion-focused family therapy (EFFT) is an lescent and adult populations. An infant’s brain
approach to family therapy whereby parents develops in concert with their primary caregivers
are viewed as essential to their children’s mental and a powerful connection between parent and
health treatment. The primary aim of EFFT is child remains throughout life. As such, EFFT
to recruit and empower parents to engage in a pri- also privileges the parent’s role as a primary
mary supportive role in helping their child to cope agent of healing, and even more so than that of
with and/or recover from their behavioral the clinician. Influenced by the theory and neuro-
and emotional challenges. Although empirical science of parent-child bonding, EFFT purports
research is limited given its relatively brief that it is more therapeutically worthwhile to sup-
existence, preliminary outcome and process port parents to lead the behavioral and emotional
research show promise among a variety of clinical interventions for their children given that they are
populations and research is ongoing. “wired” together. In other words, the efforts of a
Emotion-Focused Family Therapy 885
parent will be more neurologically powerful than parent’s ability to carry out of the tasks in each
those of a stranger (therapist), even if those efforts of the aforementioned ways or that lead to
are imperfect. Thus, the therapist’s main respon- therapy-interfering parental attitudes or behaviors
sibility is to support the parent to become an active such as denial, criticism, or enabling behaviors.
agent of change in the home setting. Should the These emotional blocks can also occur in clini-
parent present as unmotivated, unwilling, or cians as they implement these interventions. As
uncaring, EFFT theory suggests that these clinical such the model includes a fifth and final module
presentations are merely symptoms of an related to the resolution of such blocks in both
unprocessed emotion “block.” Within the model, clinicians and teams.
the most common emotion blocks include fear,
E
shame, helplessness, hopelessness, and resent- Interrupting Behavioral Symptoms
ment. The goal of the therapist is then to support Children’s mental health issues often involve
the parent to work through the emotion block problematic behavioral symptoms. Parents are
driving the parent’s problematic attitude or behav- taught and empowered to take on the tasks of
ior and resume implementation of home-based interrupting problematic behavioral symptoms
interventions. and supporting health-focused and recovery
It is important to note that parents can take on behaviors instead. The ways in which parents
these roles regardless of their child’s level of can support their specific child will vary
motivation or involvement in formal treatment, according to the child’s behavioral symptoms.
creating hope for those families for whom the For example, parents with a child suffering from
affected child refuses service. EFFT is a lifespan an eating disorder will be taught strategies for
approach that can be delivered with parents only, meal support as well as tools to interrupt related
parent-child dyads, or entire families. behaviors such as purging and compulsive
exercising. A parent with a child suffering from
anxiety will be coached to co-develop a fear hier-
Populations in Focus archy with their child followed by the facilitation
of graduated exposures in the home. These inter-
EFFT evolved from work with families with a ventions can be delivered in person, over the
child diagnosed with an eating disorder. Its focus telephone, and even by text or e-mail.
has since expanded across emotion-based disor-
ders, and research is ongoing among families of Processing Emotions
children across the life span with mood and anx- To lay the groundwork for the techniques for
iety disorders, behavioral dysregulation, social parents to help their child process emotions, the
problems, as well as somatization disorders. EFFT clinician teaches parents about the nature of
emotion as well as its role (i.e., emotional avoid-
ance) as one of the factors related to the onset and
Strategies and Techniques Used in maintenance of mental health challenges. Parents
Model then learn the steps of emotion coaching, derived
from the steps of emotion processing in EFT
There are five main modules of intervention in (Greenberg 2002, 2004) and influenced by
EFFT. The first three include supporting parents Gottman (1997). The five steps of EFFT emotion
to (1) interrupt behavioral symptoms and encour- coaching are: (1) Attend, (2) Label, (3) Validate,
age health-focused behaviors, (2) help their child (4) Identify and Meet the Need, and (5) Problem-
process overt and underlying emotions, and Solve (if necessary). Perhaps the most important
(3) repair their relationship to facilitate healing step – that of validating the emotional experience –
of relational injuries and self-blame. The fourth is also the most difficult. The core skill of valida-
module involves the identification and processing tion involves replacing the word “but” with
of emotions that “block” or interfere with the “because” when supporting their loved one to
move through emotion. For example, parents are psychoeducation via discussion and videos as
taught to move from the conditioned response of: well as experiential coaching via role-plays. Dur-
“I understand that you feel sad about missing out ing role-play, the clinician shapes the parent’s
but there will be other opportunities,” to “I under- approach, for example, by directing their choice
stand that you feel sad because you were really of words, tone of voice, and body language.
looking forward to going.” These emotion
coaching strategies are essential for two main Parent Blocks
reasons. First, these strategies can help parents to A parent’s emotions can interfere with effective
de-escalate their child’s emotional outbursts that parenting efforts (Goddard et al. 2011; Lafrance
often occur in response to their parents/treatment Robinson et al. 2013; Maliken and Katz 2013). In
team’s efforts to interrupt symptoms. Second, fact, even though the primary aim of EFFT is to
with repeated exposure, the affected individual support parents to learn the advanced caregiving
will eventually internalize the skills of emotion skills developed to support the behavioral and
coaching, increasing their capacity for self- emotional recovery of their loved one, the EFFT
regulation and making symptoms unnecessary to therapist keeps a keen eye for the identification of
cope with emotional pain. emotional “blocks” in parent that may interfere
with their ability to adopt the skills of behavioral
Relationship Repair coaching, emotion coaching, and relationship
The relationship repair intervention is a powerful repair in the home environment. The expression
tool to support the healing of pain within the of these blocks can manifest in a variety of
family. The EFFT clinician would use this inter- ways, including refusal to engage in parent-led
vention with parents under three conditions: interventions, criticism of the child or co-parent
(1) family members exhibit a pattern of emotion or treatment team, and even denial of the severity
avoidance that seems to maintain behavioral of the problem. These behaviors are seen as efforts
symptoms; (2) parents and/or their children to regulate the parent’s own strong negative emo-
blame themselves for the mental health chal- tions, specifically fear, shame, helplessness, hope-
lenges; or (3) the parent-child relationship is lessness, and resentment. For example, parents
strained (distant or hostile) and thus making may struggle to set limits around their child’s
it difficult for parents to effectively engage in behavior if they fear a breach in the relationship.
treatment for their child. The relationship repair Thus, this parent will avoid setting limits to regu-
involves a specifically constructed apology late their own fears and “protect” the parent-child
influenced by emotion-focused therapy for cou- relationship. The most common fear underlying
ples in the service of relationship reconciliation. It parent blocks relates to the fear of suicide. Spe-
is also a process that deals head on with the reality cifically, many parents – and of all walks of life –
that children and parents often blame themselves struggle to support home-based interventions in
and involves an opportunity to target and trans- case the distress associated with the tasks lead
form these problematic states. In fact, it is our their child to become suicidal. As such, these
observation that acknowledging family circum- parents may present as disengaged, unmotivated,
stances and emotional style that may have con- or even defiant when they are unable or refuse to
tributed to the child’s current difficulties is as follow through with treatment recommendations.
healing for the parent as it is for their child – EFFT clinicians help parents work through these
perhaps more so in some cases. The parent, thus negative emotional states and associated behav-
freed from the burden of their own self-blame and iors in several ways. EFFT clinicians can employ
shame, is more emotionally available to their child the steps of emotion coaching to validate the
and has improved access to parental instincts and parents’ fear or self-blame, for example, in
acquired skills. the same manner that the clinician will teach the
For each of the abovementioned domains, par- parent to validate those of the child. In some cases,
ents are taught the relevant skills through as parents become aware of and feel validated
about the impact that these emotions have on their structured “chair work” to regain perspective and
parenting behaviors, they feel empowered to fol- empathy for the family as a whole.
low through with the behavioral coaching and
emotional coaching strategies. Parents can also
complete various self-assessment questionnaires Research About the Model
that help them to identify their emotional blocks
as well as any parenting patterns that may be Research on EFFT has largely focused on differ-
problematic. They are also presented with the ent formats of treatment with parents of children
New Maudsley’s Animal Models as a nonthreat- with eating disorders. For example, a two-day
ening way to identify their underdeveloped capac- EFFT intervention for parents of adolescent and
E
ities as well as optimal parenting styles toward adult children with ED led to healthier attitudes
which to work (Treasure et al. 2009). about their children’s emotions and increased
If parents continue to struggle to engage in parental self-efficacy, a positive shift in parents’
treatment tasks, therapists can work with the par- attitudes regarding their role as emotion coach and
ent using an EFFT version of “chair work” a reduction in the fears associated with their
(inspired by self-interruptive split in traditional involvement in treatment, including a decrease
EFT) to identify and work through the parent’s in self-blame (Lafrance Robinson et al. 2016).
emotional block. The goal of intervening in this Parents also reported greater intentions to imple-
way is to loosen the parent from their emotional ment strategies to support their child’s recovery
block in order to get them back on track with that were consistent with the targeted treatment
supporting their children and resisting the urge domains.
to engage in treatment-interfering behaviors. Process research has also been conducted to
explore the theoretical underpinnings of EFFT.
Clinician Blocks First, relationships were explored between com-
Similar to identifying and processing parental mon emotion blocks and parent outcomes. Spe-
emotional blocks, EFFT clinicians identify and cifically, results revealed that both parental fear
work through their own emotional blocks and self-blame were negatively related
that arise as they provide treatment through to parental self-efficacy and positively related
“emotion-focused” supervision. For example, to accommodating and enabling behaviors
well-intentioned therapists may discourage a par- among parents (Stillar et al. 2016). In other
ents’ active involvement in their child’s treatment words, the more fear and self-blame that a par-
if they believed it would interfere with the recov- ent reported, the less empowered they felt about
ery process. In fact, we have observed that parents supporting their child in treatment and the more
of adult children and/or parents who (1) present likely they were to engage in accommodating
with high expressed emotion, (2) engage in overt and enabling behaviors. An EFFT process
criticism of the child, or (3) display symptoms of a model was then tested in the context of a 2-day
mental health issue or personality disorder are EFFT intervention for parents of loved ones
kept on the outskirts of the recovery process. with an eating disorder. The results showed
Although there may be valid limitations or con- that the intervention was effective in decreasing
cerns about involving parents in treatment, work- parental fear and self-blame which subsequently
ing through the emotions that accompany such led to an increase in parental self-efficacy and an
cases can open new avenues for working with increase in positive intentions to engage in
parents in some fashion. This type of supervision treatment-enhancing behaviors (Strahan et al.
can take place through case discussion, with a 2017). These results underscore the importance
focus on the difficult emotions that the clinician of transforming parental fear and low self-
is feeling in response to working with the family, efficacy to support parents to become positive
completing an emotion-focused questionnaire to and active agents of healing their children’s
identify clinician blocks, and engaging in treatment for mental health challenges.
A randomized wait-list controlled trial of therapist introduced to Sharon the concept of the
EFFT for general mental health issues is in pro- “super-feeler,” and she quickly recognized her son
gress to examine various parent and child out- in the description in that he is very concerned
comes over time. Preliminary results indicate about his mother’s well-being and acutely aware
that the EFFT intervention predicted positive of any tension in his environment. The therapist
outcomes for both parents and children. The inter- explained to Sharon that children with this profile
vention decreased parental fear, increased paren- may consciously or unconsciously suppress their
tal self-efficacy, and led to improvements in emotional pain, and perhaps out of fear of upset-
children’s emotional and behavioral difficulties. ting their caregivers given that they would then
Finally, task analysis research is ongoing to exam- experience both their pain and their parents’ as
ine the processes through which therapeutic well. The therapist further explained that due to
change and resolution occurs via the parental his age and brain development, it would be very
block chair-work intervention. difficult for him to suppress his emotions without
eventually acting out in some ways (e.g., out-
bursts). Upon reflection, Sharon noted that indeed
Case Example her son reacted in an atypical manner in that he did
not cry when informed of the end of his parents’
Sharon called an EFFT therapist, concerned about marriage, and instead acted rather stoically, even
her son Jacob, age 16, who had been struggling at asking if he could take on extra chores to help his
school. He had been involved in several fights mother around the house.
over the past few weeks. She said that he “proba- To further identify systemic variables related
bly is depressed” and that she had tried everything to her son’s inclination to deny or suppress
to try to motivate him with his school work but emotion, the therapist presented to Sharon the
nothing was working. She was also worried that various animal models and she easily identified
he might want to kill himself, even though he herself as a jellyfish (emotional) and kangaroo
denied any suicidal thoughts or urges when (overprotective). The therapist taught Sharon
questioned directly. Sharon asked the therapist to about the ways in which her own emotional dis-
talk with Jacob and see if he could be helped. The tress might fuel these problematic parenting pat-
therapist explained that it would be important to terns or styles. The therapist described how it is
meet with her (i.e., mom) as parents can be much normal for parents to have concerns and fears
more effective in helping their children given the when supporting the behavioral and emotional
power of the neurological connection between recovery of their children. Sharon completed
them. Although skeptical at first, Sharon agreed a self-assessment tool to identify where she
to a trial of six two-hour parent-focused sessions. might be most vulnerable to these blocks when
During the intake session, Sharon shared that supporting her son behaviorally and in the pro-
she and Jacob’s father, Ryan, had a history of cessing of his emotions. Not surprising, she
conflict and had recently divorced. Jacob was scored high on the item “fear of pushing my
currently living with his mom and would stay loved one too far and making symptoms worse.”
with his dad on most weekends. Sharon listed Sharon then shared that several years ago she had
the many ways she had been trying to help Jacob a psychiatric admission for suicidal ideation and
with his academics (e.g., helping him with his that she was terrified that acknowledging her son’s
homework; hiring a tutor) but shared that she did distress would make him feel worse and lead him
not know what to do about him getting into fights. to feel suicidal as well. She made the connection
The therapist spent the first session exploring and between these fears and her tendency to back off
validating Sharon’s concerns about Jacob’s recent from talking to him about the family’s challenges.
struggles and discussed how his academic and Over the next few sessions, the therapist taught
behavioral problems most likely reflected his Sharon about the principles and steps of emotion
efforts to cope with emotional distress. The coaching, and they practiced together the
scenarios she thought would be most challenging ongoing issue. In this intervention, Sharon
(her son’s hopelessness or refusal to share about explored and identified her fears of broaching
his anger). Sharon also prepared to deliver a rela- the topic and creating even more conflict
tionship repair intervention regarding the ways in between them. She was afraid that if she insisted
which the divorce was handled, including what on discussing the events and the underlying
she could have done differently, and how she drivers that he feel worse about himself, disen-
was going to allow for all his feelings – even the gage from the conversation and even the rela-
unpleasant ones – to the best of her ability. tionship. Her worst fear was that he would run
The therapist was sure to explain that the inter- away from home and instead move in with his
vention’s objectives were three-fold: (1) validate father. She said that if all of that happened, she
E
her child’s experience and strengthen the relation- would feel like “an absolute failure of a mom.”
ship, (2) prevent the child from blaming himself Through enacting an imagined conversation
for the divorce (as so many children do – either with her son about these fears, Sharon was
unconsciously or consciously), and (3) process able to work through these fears and feel
and move through her own undeserved self- empowered by her love for her son to talk to
blame for the path her son’s life had taken. They him about his inappropriate behavior and dis-
also discussed how Jacob might respond to the cuss better ways of dealing with his peers. Sha-
apology and the therapist prepared Sharon to ron reported back several months after therapy
effectively respond to the most common possible had ended that Jacob was again doing well in
reactions: a blast of anger, silence, or a denial. school and had been getting into very little trou-
Over the next few weeks, Sharon reported ble with his peers. She also reported that she was
back she had indeed engaged in the planned working much better with her ex-husband as
relationship repair intervention. She said that co-parents. And although Jacob still behaved
Jacob first dismissed her apology (i.e., “You rather typically for a teenage boy when it came
didn’t do anything wrong mom! You did the to talking about his emotions, she did report that
best you could.”), and she was able to recognize he came to her for advice once in a while and
his response as denial and respond accordingly they were able to talk about some of his fears
by sticking with it and shouldering the burden and vulnerabilities. Overall, she felt confident
until he broke down in tears and shared a bit about the way forward.
about how much he wanted his parents to “just
get along.” He also shared the extent to which he
missed his dad but was afraid to share this with Cross-References
his mom in case it hurt her feelings. Sharon felt
great about her ability to support her son to open ▶ Adolescents in Couple and Family Therapy
up to her, and she was surprised at how capable ▶ Attachment Theory
she felt to handle all that he shared. She also ▶ Attachment-Based Family Therapy
noted how much more he had shared over those ▶ Bowlby, John
next few days. ▶ Children in Couple and Family Therapy
That being said, Sharon reported that she ▶ Circle of Security
struggled with setting limits on his behavior. ▶ Circle of Security Parenting Enrichment
Despite being able to talk to him about the Program
importance of his schoolwork and day-to-day ▶ Circle of Security: “Understanding Attachment
expectations, Sharon described how difficult it in Couples and Families”
was for her to address his inappropriate behav- ▶ Emotion in Couple and Family Therapy
ior (e.g., fighting with peers). The therapist took ▶ Emotionally Focused Family Therapy
this opportunity to engage Sharon in an empty- ▶ Emotion-Focused Therapy for Couples
chair intervention to help Sharon to work ▶ Empty Chair Technique in Couple and Family
through her emotional “block” in raising this Therapy
890 Emotion-Focused Therapy for Couples
▶ Gottman, John Strahan, E. J., Stillar, A., Files, N., Nash, P.,
▶ Greenberg, Leslie Scarborough, J., Connors, L.,. . . Orr, E. S. (2017).
Increasing parental self-efficacy with emotion-focused
▶ Maudsley Family Therapy for Eating Disorders family therapy for eating disorders: A process model.
▶ Primary Adaptive Emotions in Emotion- Person-Centered & Experiential Psychotherapies,
Focused Therapy 16, 256–269.
▶ Primary Maladaptive Emotions in Emotion- Treasure, J., Schmidt, U., & Macdonald, P. (Eds.). (2009).
The clinician’s guide to collaborative caring in eating
Focused Therapy disorders: The new Maudsley method. London:
Routledge.
References
Emotion-Focused Therapy for
Elliott, R., Watson, J. C., Goldman, R. N., & Couples
Greenberg, L. S. (2004). Learning emotion-focused
therapy: The process-experiential approach to change.
Washington, DC: American Psychological Rhonda N. Goldman1 and Irene C. Wise2
1
Association. Illinois School of Professional Psychology,
Goddard, E., Macdonald, P., Sepulveda, A. R., Argosy University, Chicago, IL, USA
Naumann, U., Landau, S., Schmidt, U., & 2
Treasure, J. (2011). Cognitive interpersonal mainte-
Illinois School of Professional Psychology at
nance model of eating disorders: Intervention for Argosy University, Schaumburg, IL, USA
carers. The British Journal of Psychiatry, 199,
225–231.
Gottman, J. (1997). Raising an emotionally intelligent
child. New York: Simon & Schuster Paperbacks.
Name of Model
Greenberg, L. S. (2002). Integrating an emotion-focused
approach to treatment into psychotherapy integration. Emotion-Focused Therapy for Couples
Journal of Psychotherapy Integration, 12, 154–189.
Greenberg, L. S. (2004). Emotion–focused therapy.
Clinical Psychology & Psychotherapy, 11, 3–16. Synonyms
Greenberg, L. S. (2008). Emotion and cognition in psycho-
therapy: The transforming power of affect. Canadian
Psychology, 49, 49–59. EFT-C
Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in
psychotherapy: A practice-friendly research review.
Journal of Clinical Psychology, 62, 611–630. Introduction
Lafrance Robinson, A., Dolhanty, J., &
Greenberg, L. (2013). Emotion-focused family therapy Emotion-focused therapy for couples (EFT-C) is a
for eating disorders in children and adolescents.
Clinical Psychology & Psychotherapy, 22, 75–82.
person-centered and empirically supported treat-
Lafrance Robinson, A., Dolhanty, J., Stillar, A., ment model for couples in distress. EFT-C can
Henderson, K., & Mayman, S. (2016). Emotion- also be applied with nondistressed couples seek-
focused family therapy for eating disorders across the ing to deepen intimacy and improve the quality of
lifespan: A pilot study of a 2-day transdiagnostic inter-
vention for parents. Clinical Psychology & Psychother-
their interactions. The premise of EFT-C is that
apy, 23, 14–23. affect regulation organizes couple dynamics and
Maliken, A. C., & Katz, L. F. (2013). Exploring the is the core motivation for coupling. Using a blend
impact of parental psychopathology and emotion regu- of systemic and experiential concepts and tech-
lation on evidence-based parenting interventions:
A transdiagnostic approach to improving treatment
niques, therapists employing EFT-C enhance
effectiveness. Clinical Child and Family Psychology affect regulation in the relationship by first help-
Review, 16, 173–186. ing couples replace their negative relational cycles
Stillar, A., Strahan, E., Nash, P., Files, N., Scarborough, J., with positive ones and then fostering each part-
Mayman, S., . . . & Marchand, P. (2016). The influence
of carer fear and self-blame when supporting a loved
ner’s ability to self-soothe. Problematic interac-
one with an eating disorder. Eating Disorders, tional cycles are transformed by each partner
24, 173–185. accessing vulnerable emotions in the presence of
Emotion-Focused Therapy for Couples 891
the other. Guiding the couple to focus on their experience and how they make sense of their
negative relational patterns also has the advantage world. Emotion schemes are, in essence, internal,
of reducing the tendency of blaming the other learned, and laid down in emotion memory struc-
partner for relational difficulties. When partners tures. Unlike schemas, emotion schemes are not
are able to receive, support, and validate each static or merely conceptual; rather, they can be
other’s primary emotional experiences, transfor- viewed as an ongoing, moment-to-moment, self-
mation can occur. Healing and bonding events organizational processes that unite emotion with
occur through the sharing and soothing of each an action tendency (Elliott et al. 2004). These
partner’s primary vulnerable emotions. In addi- action-oriented processes also encompass imme-
tion, working through of attachment and identity diate awareness, episodic memories, bodily sen-
E
injuries leads to healing through processing of sations, language symbolizations, and embedded
unprocessed primary vulnerable emotions. More- needs and desires. An emotion scheme is acti-
over, enhancing each partner’s ability to self- vated by its corresponding emotion that arises in
soothe also leads to healing and can reduce pres- response to unmet needs or concerns (Greenberg
sure on partner’s to be the sole source of affect and Watson 2006). The action tendency embed-
regulation. The relationship is thus strengthened, ded in an emotion scheme motivates an individual
distress lowered, and mutual feelings of connec- to pursue the desires and satisfy the needs associ-
tion and closeness increased. ated with the emotion scheme. In this way, EFT
conceptualizes that emotions are necessary for
motivation.
The Effect of Motivational Dimensions on
The original formulation of EFT-C was developed Relational Dynamics
in the mid-1980s by Les Greenberg and Sue John- EFT-C posits that affect regulation is the core
son (Greenberg and Johnson 1988). Subsequently, motivation that leads individuals to seek intimate
Greenberg and Johnson have independently modi- relationships. Greenberg and Goldman (2008)
fied the formulation of EFT-C, resulting in two define affect regulation as the process of increas-
different, but related, protocols. Johnson’s Emotion- ing desired emotions while simultaneously
ally Focused Couple Therapy emphasizes attach- decreasing unwanted ones. According to EFT-C,
ment as the organizing principle of couples’ affect is regulated with a partner, along one or
behavior (Johnson 2004). Emotion-Focused Ther- more of the following dimensions: attachment,
apy for Couples (EFT-C), further developed by Les identity, and attraction. As such, these dimensions
Greenberg and Rhonda Goldman, posits that affect become motivational systems that define the tone
regulation drives the relational dynamics of couples and nature of a couple’s relationship. Both attach-
and governs motivation through the subsystems of ment and identity systems are considered more
attachment, identity, and attraction (Greenberg and fundamental than the attraction system although
Goldman 2008). In addition, Greenberg and the attraction system is seen as distinct from the
Goldman have further incorporated individual pro- attachment system. Attachment is seen as slightly
cess in the context of couples therapy, recognizing, more fundamental than the identity system,
for example, that while an overall goal may be to although identity is an important and sometimes
promote partners soothing each other, at times, self- neglected system in conceptualization and treat-
soothing is an important process. ment of couples. A breakdown in any one of these
motivational dimensions leads to tension between
the partners. In addition to the relational bond
Theoretical Framework providing a means of affect regulation, each part-
ner may also engage in self-regulation of affect.
Emotion-focused therapy (EFT) posits that “emo- Again, a breakdown in this type of self-regulation
tion schemes” guide and organize people’s may also negatively impact the relationship.
When both mutual regulation and self-regulation provoke efforts to control or dominate. Therefore,
of affect are impaired, couple conflict ensues the identity dimension expresses itself in couple
(Goldman and Greenberg 2013). Marital dissolu- dynamics as degree of influence ranging from
tion occurs when the relationship no longer pro- dominant to submissive. A partner who operates
vides effective affect regulation and the partners out of the dominance pole may attempt influence
no longer express and respond to affect from the or control his or her partner. In contrast, a submis-
other. sive partner tends to yield, submit, or enmesh with
the other partner.
Attachment Dimension
For infants with their caregivers as well as for Attraction Dimension
romantic pairs, attachment bonds are character- The characteristics of the attachment dimension
ized by a person maintaining proximity to her taps into neurological reward pathways. For cou-
attachment figure, feeling distress when separated ples, the attraction dimension fosters positive feel-
from him, and using her attachment figure as a ings in each other such as joy and love and
safe haven and base for exploration (Bowlby expressions of warmth, fondness, liking, and sex-
1988; Hazan and Shaver 1987). By forming an ual excitement. In addition to promoting bonding,
attachment with another, individuals regulate their the attraction dimension is necessary for relation-
affect through finding security in the relationship ships to flourish and maintain longevity. EFT-C
with their partners. A healthy attachment cycle therapists can leverage this dimension to regulate
expressed within a couple is characterized by the the emotions through increased joy and love by
expression of fear and anxiety in one partner and encouraging the couple to express warmth and
the subsequent offer of nurture and comfort in the liking to each other.
other. Anxiety, feelings of loneliness, or a sense of
abandonment may arise in an individual if his or Relational Cycles
her partner is not physically or psychologically Greenberg and Goldman (2008) have developed a
present. To regulate these distressing emotions via model to describe verbal and nonverbal couple
the attachment subsystem, the individual may interactions based on the motivational systems
either approach the partner to experience connec- used to soothe affect. First, the authors observe
tion or nurturance, or the individual may tempo- that each partner in a couple interacts in a recip-
rarily disengage from the partner in order to self- rocal manner where one partner’s reaction evokes
soothe. These two differing responses to attach- a complementary reaction in the other. Next,
ment anxiety represent the two opposite poles of Greenberg and Goldman map these reciprocal
the attachment dimension, namely, seeking close- responses along two dimensions, affiliation and
ness and distancing. influence. For romantic relationships, the affilia-
tion axis incorporates the motivational dimen-
Identity Dimension sions of attachment and attraction, and the
The identity or influence subsystem is important influence axis represents the identity motivational
for the development of self-esteem, self- subsystem. This model implies that couples
coherence, and mastery. Positive emotions related develop positive and negative interactive cycles
to identity include interest and pride. A healthy through both the reciprocal nature of their inter-
identity system is associated with appropriate actions and their drive to regulate affect with each
assertion, setting boundaries, and feeling recog- other via the motivational subsystems.
nized. A sense of shame, powerlessness, or anger A harmonious relationship develops when
occurs when identity has been invalidated or each partner is aware of his or her emotions, can
diminished. Within a couple, expressions of communicate these feelings and the associated
shame or powerlessness in one partner may elicit needs to his or her partner, and have the partner
a soothing response of empathy and validation in respond to these needs in an appropriate manner.
the other partner. Furthermore, threats to identity For example, if an individual expresses self-doubt
and shame to his partner (mapped along the influ- of secondary reactive emotions is to replace or
ence axis of the model), the expression of empa- obscure difficult primary emotions. For example,
thy and validation from his partner comforts and an individual may exhibit reactive anger to cover
may boost the self-esteem in that individual. unacceptable feelings of vulnerability when criti-
When a partner is unavailable or cannot respond cized by his partner. Finally, a person uses instru-
in the hoped for manner, relational harmony is mental emotions to consciously or unconsciously
compromised or challenged. control others. For example, one partner may
Relational harmony disintegrates when part- burst into tears in order to avoid a difficult con-
ners cannot find ways to soothe their affect, either versation. Negative relational cycles are
with each other or by themselves. Because of the maintained by secondary reactive, maladaptive,
E
reciprocal nature of couple dynamics, a negative and instrumental emotions triggered in each part-
interaction cycle can develop in one or more moti- ner by the other partner.
vational systems as partners reactively attempt to A common negative interaction cycle along the
address their unmet attachment or identity needs. affiliation dimension is the pursue-distance pat-
Both partners in a couple may feel distress arising tern where partner A’s unmet attachment needs for
from unmet needs in the affiliation dimension of closeness lead her to pursue her partner through
the relationship, or both may experience deficits in requests, appeals, or demands for more attention
the influence dimension. Greenberg and Goldman or intimacy. Partner A’s bids for closeness may
(2008) have also identified mixed-dimension appear to her partner as criticism, blaming, or
cycles where one partner operates out of needs even condemnation. These negative perceptions
from the affiliation dimension and the other from in partner B of partner A’s pursuit lead him to
the influence dimension. Another type of mixed- withdraw in order to protect himself and regulate
dimension cycle occurs when each partner reacts his affect. As partner B withdraws, Partner A’s
out of mixture of identity and attachment needs. need for closeness becomes even more activated
Relational cycles are kept in place by the and she increases her attempts to connect with
expression of one of the four types of emotions partner B. He then feels even more threatened
identified in EFT (Elliott et al. 2004). Primary and therefore withdraws further thereby deepen-
adaptive emotions are the appropriate and evolu- ing and perpetuating the pursue-distance cycle.
tionary adaptive emotional response to a stimulus. The pursue-distance conflict may be resolved by
For example, fear automatically signals danger helping each partner contact his or her underlying
and prepares a person to fight or take flight from attachment related fear, anxiety, or sadness. The
the situation. In the context of couple interaction, partner’s expression of these vulnerable feelings,
primary adaptive emotions elicit an appropriate which are primary emotions, replace the second-
response from the partner, and therefore help ary reactive expressions of anger or contempt
maintain positive interactional cycles. Primary which fueled the negative cycle. The other partner
maladaptive emotions, found at the core of mal- then continues the development of a positive rela-
adaptive emotion schemes, are also automatic but tional cycle by responding to these vulnerable
are overlearned responses to formative situations primary emotions with caring and comfort.
that are no longer adaptive for a particular situa- Negative interaction cycles along the identity/
tion. For example, a frightened child may have influence axis generally fall into a pattern of lead-
learned to hide from a verbally abusive parent in follow where one partner is dominant and the
order to feel safe. When the child grows up, she other is submissive. In this cycle, both partners
may still have a disproportionate level of fear have maladaptive feelings of fear or shame related
when her partner argues with her, causing her to to his or her identity. The dominant partner man-
withdraw from him physically and emotionally. ages her feelings of shame and inefficacy by seiz-
The third type of emotions – secondary reactive ing control and projecting her own sense of
emotions – are reactions to primary emotions, weakness onto her partner. By accepting his part-
whether adaptive or maladaptive. The function ner’s dominance, the submissive partner deals
with his identity-related shame by abdicating in couples are blaming, anger, and withdrawal.
responsibility so that he cannot be blamed for Therapists must work to de-escalate cycles by
any ensuing negative outcomes. Over time, the getting underneath secondary emotions to pri-
dominant partner becomes more protective of mary emotions. Instrumental emotions are uncon-
her position while the submissive partner sciously learned and expressed but have an
becomes afraid to make mistakes or decisions interpersonal effect such as crying to garner sym-
and thus ends up feeling discounted and pathy or anger to push others away. Instrumental
invalidated. The submissive partner may feel emotions must be brought to awareness and their
unhappy and wish to dissolve the union with his primary aim understood.
partner. Conflict resolution in such a cycle along In EFT-C, therapeutic change occurs when
the influence axis involves the dominant partner partners access and express primary emotions to
expressing her primary underlying fear and shame each other. Couples resolve relational conflicts by
rather than her secondary reactive anger or rage. stepping out of their vicious cycles and truly
As the dominant partner processes these maladap- accepting themselves and their partners. The
tive emotions, she will build a sense of adequacy EFT-C therapist helps couples recognize the mal-
as she uncovers primary emotions such as asser- adaptive, secondary reactive, and instrumental
tive anger or grief and expresses the needs asso- emotions that keep their negative interactional
ciated with these emotions. As the urge to control cycles in place. The roots of these maladaptive
diminishes in the dominant partner, the submis- emotions often predate the couples’ union. Empa-
sive partner will also process his shame or fear and thy and validation is facilitated when partners
get in touch with his primary anger or pride, which realize that they are not to blame for the historical
in turn leads him to gain confidence as he asserts origins of their partners’ maladaptive patterns of
his needs for validation and recognition. His part- relating. Negative cycles are interrupted when
ner’s soothing response of empathy and validation each partner can express vulnerable primary emo-
deepens the couple’s new positive relational tions related to primary attachment and identity
cycle. needs. Attachment needs include bids for close-
ness and comfort while expressing abandonment
Theory of Change fear or sadness. Identity needs include validation
Emotions regulate individual functioning and and acceptance by the other partner as the indi-
organize couples’ interactional cycles. Emotion- vidual expresses shame or powerlessness. These
focused therapy in general (Elliott et al. 2004) and identity needs and the accompanying shame may
Emotion-focused couple therapy specifically not be resolved in the context of the couple’s
(Greenberg and Goldman 2008; Goldman and relationship because the core maladaptive emo-
Greenberg 2013) describe different types of emotion scheme is rooted in unmet childhood needs.
tions that seen in therapy. Primary emotions can In such cases, the couple’s relational pattern can
be either maladaptive or adaptive and are seen as be improved by working with the injured partner
core emotions driving interactional cycles. Exam- to address her unmet childhood needs and
ples of adaptive emotions are sadness in relation enhance her capacity to self-soothe.
to loss and anger in relation to boundary violation.
Maladaptive emotions are adaptive emotions that
have been associated with negative learning expe- Populations in Focus
riences. Maladaptive emotions are at the core of
maladaptive cycles or patterns that couples EFT-C is ideal for committed couples experienc-
engage and that typically bring them to therapy. ing relational dissatisfaction, difficulties, or dis-
Examples are many, but typically maladaptive tress. EFT-C may also be successfully applied
core emotions are shame, fear, and sadness of with couples who have experienced an emotional
lonely abandonment. Secondary emotions hide injury such as infidelity, betrayal, or neglect dur-
or cover primary emotions and typical ones seen ing time of critical need. EFT-C has also been
specifically developed for work with such Stage 1: Validation and Alliance Formation
populations (Greenberg et al. 2010). Ethnically During this first stage, the therapist fosters a sense
diverse partners, LGBTQ couples, as well as of safety and works to establish a collaborative
those facing a variety of mental health issues alliance with the couple. She bonds with each
including depression, anxiety, or chronic stress partner by validating concerns and empathizing
have also benefited from this approach. EFT-C with underlying pain. The therapist also notes the
should not be employed when there is domestic conflict areas and assesses how these problems
violence in the relationship. reflect the unmet attachment or identity needs of
each partner.
E
Strategies and Techniques Used in the Stage 2: Negative Cycle de-Escalation
Model The goal of the second stage of EFT-C is to
reduce the emotional reactivity between the
The primary aim of EFT-C is to restructure the couple. One way of meeting this goal is for the
distressed couple’s emotional bond (Goldman and therapist to externalize the couple’s issues onto
Greenberg 2010). EFT-C has three basic interven- the negative relational cycle. The therapist also
tion strategies to meet this goal. First, the EFT-C helps each partner explore previously
therapist tracks interactional cycles and reflects unacknowledged emotions related to unmet
these patterns back to the couple. Second, as the attachment or identity needs and points out
couple becomes aware of their patterns, the how these feelings contribute to the couple’s
EFT-C therapist reframes the couple’s issues as a dynamics. Increased understanding is fostered
problem with the negative cycle. Viewing the by exploring the historical origins of each part-
cycle as the problems helps couples externalize ner’s vulnerabilities and sensitivities. The sec-
their issues and reduces the tendency for the part- ond stage concludes after the couple
ners to blame each other for their problems. understands that their problems are attributed
Finally, EFT-C utilizes enactments of emotional to a negative relational cycle triggered by core
engagement, bonding, and validating comments vulnerable emotions having their roots in unmet
to shape and consolidate the couple’s interactions. attachment and identity needs.
The second goal in EFT-C treatment is to
enhance each partner’s expression and self- Stage 3: Accessing Underlying Feelings
regulation of core maladaptive emotions based The third stage in EFT-C focuses on each partner
unmet childhood needs and unfinished business accessing, revealing, and experiencing his or her
with significant others. Self-soothing, when underlying feelings associated with unmet attach-
required, also helps to restructure emotional ment or identity needs. As the partners own and
bonds and stabilize the positive changes in the express previously unacknowledged vulnerable
couple’s interactional cycle. feelings to each other, the couple’s relational
dynamics change as safety is created between
Stages of EFT-C Therapy them. This safe atmosphere sparks empathy
Greenberg and Johnson have independently mod- between the couple, resulting in more freedom to
ified the original model for EFT-C intervention ask the other for help in meeting core needs. To
(Greenberg and Johnson 1988). Greenberg and facilitate this process, the therapist also identifies
Goldman (2008) formulated the five stages of and helps resolve any emotional blocks in either
EFT-C treatment described below. The first partner by shifting to individual work in the pres-
stage, validation and alliance formation, remains ence of the other. As this stage progresses, the
relevant throughout the therapy process. Over the EFT-C therapist continues to help the partners
course of therapy, stages may overlap, several identify and integrate into their interactions any
stages may be revisited, and progress may pro- remaining unmet needs or disowned aspects of
ceed in a nonlinear fashion. the self.
Stage 4: Restructuring the Negative Interaction Research About the Model

In the fourth stage, the therapist helps the couple
restructure their negative interactional cycle by Research in EFT-C has generally explored the pro-
helping each partner respond to revealed emo- cess of change and investigated treatment efficacy.
tions with validation and acceptance. If one or For example, EFT-C’s premise of revealing under-
both partners cannot accept the other, the thera- lying feelings to resolve conflict in couples was
pist helps the individual access, explore, and empirically supported in the treatment of general
transform these maladaptive emotional blocks. couple distress (Johnson, Hunsley, Greenberg, and
As each partner becomes more open to the other, Schindler, as cited in Meneses and Scuka 2015),
the therapist guides the couple in enacting new resolving emotional injuries (Fisher, as cited in
ways of adaptively interacting with each other Meneses and Scuka 2015), promoting forgiveness
by restructuring deeper levels of emotional pro- via the expression of shame (Meneses and
cessing. For example, the therapist may work on Greenberg 2011), and fostering mutual sharing of
helping one partner soften her internalized needs (Greenberg and Johnson, as cited in Meneses
critic. Rather than reacting to her partner with and Scuka 2015). Other studies support EFT-C’s
angry attacks, the softened critic allows this assertion of the importance of self-regulation to
partner to reveal her anxiety over her partner’s improve relational dynamics. For example, research
absence and ask for comfort. Her partner, in by Greenberg and Johnson (as cited in Meneses and
turn, no longer feels the need to protect himself Scuka 2015) revealed that softening a harsh inner
by withdrawing from his partner’s anger and critic of one partner led to a more positive relational
therefore can now be more responsive to his cycle.
partner. Healing or bonding events occur Many research studies have provided empirical
through the sharing and receiving of core pri- support for EFT-C being an effective treatment for
mary emotions, and the negative interaction is couple distress. For example, compared to
restructured. By the end of the fourth stage, each waitlisted controls and standard behavior couple
partner’s maladaptive emotion schemes are therapy, EFT-C was found to have a large treatment
transformed into primary adaptive emotions, effect and superior outcomes in enhanced intimacy
out of which each partner can express his or and marital adjustment (Johnson and Greenberg, as
her needs and desires. Once the partners are no cited in Meneses and Scuka 2015). Goldman and
longer reactive towards each other, the therapist Greenberg (1992) found that EFT and integrated
introduces self-soothing strategies to be used systems therapy had similar positive outcomes for
when the other partner is unavailable or unable severely distressed couples in conflict resolution
to respond. and goal attainment, but EFT yielded slightly
higher relapse rates. Additionally, Greenberg et al.
Stage 5: Consolidation and Integration (2010) found that EFT-C was effective in promot-
The goal of the fifth and final stage of EFT-C is to ing forgiveness and lowering marital distress in
consolidate and integrate the couples’ new and couples dealing with infidelity, betrayal, and other
positive interaction cycle. The therapist facilitates emotional injuries. In their meta-analysis, Johnson
a discussion with the couple on how to prevent a and her colleagues (1999) found a very large effect
negative interactional cycle from redeveloping as size for EFT-C of 1.3 and a 70–73% recovery rate
well has how to strengthen their positive interac- from relational distress.
tions. The therapist also recaps how the negative
relational cycle has been transformed and points
out growth in each partner and the relationship. Case Example
The work of EFT-C concludes when the couple
creates a revised narrative for their relationship Shari and Andy come to therapy saying they
that incorporates their areas of growth and their want to heal past wounds and stop escalating
positive relational cycle. conflict that seems to be leading to daily fights.
The therapist initially works on forming an alli- maladaptive emotions was understood by therapist
ance with the couple and validating each part- and partners.
ners’ concerns and underlying pain and distress. Through the therapy process, the therapist is
She also clarifies that they are committed to able to help the couple get to core emotions.
healing and working toward change together. This is aided by the use of empathic conjectures
The therapist initially gets a sense of what and explorations that help each partner explore
brought the couple together initially and what underneath secondary emotions driving the neg-
sustains their relationship. Andy is and con- ative interactional cycles and deepen core pri-
tinues to be attracted to Shari’s “joie de vivre,” mary maladaptive emotions. Through this
high energy, affection, and warmth. Shari is process needs embedded within primary emo-
E
attracted to Andy’s drive, determination, stabil- tions are also accessed and expressed. “Blocks”
ity, and certainty. were hit in the expression of primary emotions
After a few sessions, after hearing much about and needs that often got represented as “walls”
Andy and Shari’s regular disputes and conflicts and that had been built for good reasons (based on
assessing each partner’s role, emotions, and behav- each partner’s past wounds developed in child-
iors at the source of them, the therapist has a much hood, and life prior to the relationship, and
stronger understanding of what the negative mal- wounds brought on by each other). The walls
adaptive cycles. Essentially, Shari is the one who were also reframed as “survival strategies” that
pursues for closeness and affection and when secured and protected each partner but also con-
turned away feels rejected, sad, and lonely. Core tributed to distress and prevented healing and
sadness of lonely abandonment is triggered and emotional intimacy. When walls were both con-
takes over Shari’s world. While Shari experiences ceptualized and understood but then breached or
sadness of lonely abandonment often and is able to to some extent taken down, and primary emo-
share and express it in therapy, outside of the ses- tions and needs expressed, the therapist facili-
sions, and while engaged in escalating conflicts, tated Shari and Andy to respond to each other’s
Shari does not in fact express such primary emo- expression of core primary emotions. This
tions but rather expresses blame, contempt, and helped create bonding and closeness. Later in
criticism toward Andy, claiming he is robotic, therapy, the therapist also engaged in a self-
unavailable, incapable of love and affection, and soothing dialogue with Andy within the session,
completely inept at taking care of their two children with Shari present, wherein Andy was able to
and completing any tasks or chores around the soothe the inner child who was always seeking
house even when asked repeatedly. Andy in turn, approval from his father and coming up short,
feeling criticized, tends to withdraw, only fueling feeling as a result chronically inadequate. In the
Shari’s contempt and blaming anger further. This in inner dialogue, however, a more adult, parental
turn leads Andy to further withdraw. By the end of part of Andy was able to soothe the child who
stage 2, the therapist and the couple both have a missed feeling recognized and loved
sense of the cycle, how it gets started, how it unconditionally.
escalates (with blaming, contemptuous anger, and By the end of therapy, the couple felt much
withdrawal and each partner’s part, respectively), closer and more connected. Negative cycles could
and what the underlying emotions are that drive it be identified and understood and positive cycles
(Shari’s sadness of lonely abandonment and could be enacted and expressed. When conflicts or
Andy’s shame). Therapist and the couple have ruptures occurred they were much more able to
also identified that Shari’s sadness of lonely aban- speak from and express core primary emotions of
donment has a source in her experience growing up sadness related to lonely abandonment and
of being lonely and feeling emotionally neglected shame. Each felt more compassionate and sensi-
by both parents and peers. Andy, on the other hand, tive to the other’s core wounds and able to soothe
was continuously criticized and shamed by a criti- their partner when necessary and self-soothe
cal, harsh father. The source of the core when the other was not available.
898 Empathy in Couple and Family Therapy
Cross-References Johnson, S. M., Hunsley, J., Greenberg, L. S., & Schindler,

B. (1999). Emotionally focused couples therapy: Status
and challenges. Clinical Psychology Science and Prac-
▶ Greenberg, Leslie tice, 6, 67–79.
▶ Instrumental Emotional Response in Emotion- Johnson, S. M. (2004). The practice of emotionally focused
Focused Therapy couple therapy: Creating connection (2nd ed.).
▶ Primary Adaptive Emotions in Emotion- New York: Brunner-Routledge.
Meneses, C. W., & Greenberg, L. S. (2011). The construc-
Focused Therapy tion of a model of the process of couples’ forgiveness in
▶ Primary Maladaptive Emotions in Emotion- emotion-focused therapy for couples. Journal of Mar-
Focused Therapy ital and Family Therapy, 37(4), 491–502.
▶ Restructuring the Bond in Emotion-Focused Meneses, C. W., & Scuka, R. F. (2015). Empirically
supported humanistic approaches to working with
Therapy couples and families. In D. Cain, K. Keenan, &
▶ Secondary Reactive Emotions in Emotion- S. Rubin (Eds.), Humanistic psychotherapies: Hand-
Focused Therapy book of research and practice (2nd ed., pp. 353–386).
▶ Softening in Emotion-Focused Therapy Washington, DC: American Psychological
Association.
▶ Stabilization in Emotion-Focused Therapy
References Empathy in Couple and Family

Therapy
Bowlby, J. (1988). A secure base: Parent-child attachment
and healthy human development. New York: Basic Johanna Strokoff
Books.
University of Illinois at Chicago, Chicago,
Elliott, R., Watson, J. C., Goldman, R. N., &
Greenberg, L. S. (2004). Learning emotion-focused IL, USA
therapy: The process-experiential approach to change.
Washington, DC: American Psychological
Association.
Goldman, A., & Greenberg, L. (1992). Comparison of
Name of Concept
integrated systemic and emotionally focused
approaches to couples therapy. Journal of Consulting Empathy in Couple and Family Therapy
and Clinical Psychology, 60(6), 962–969.
Goldman, R. N., & Greenberg, L. S. (2010). Self-soothing
and other-soothing in emotion-focused couples ther-
apy. In A. S. Gurman (Ed.), Clinical casebook of cou- Introduction
ples therapy (pp. 255–280). New York: Guildford
Press. A pioneer regarding the utilization of empathy
Goldman, R. N., & Greenberg, L. S. (2013). Working with
in psychotherapy, Carl Rogers (1957) defined empa-
identity and self-soothing in emotion-focused therapy
or couples. Family Process, 52(1), 62–82. thy as “to sense the client’s private world as if it were
Greenberg, L. S., & Goldman, R. N. (2008). Emotion- your own,” without the clinician’s personal judg-
focused couples therapy: The dynamics of emotion, ments muddling the client’s experience (p. 99). Rog-
love, and power. Washington, DC: American Psycho-
ers posited that empathy was an essential driving
Greenberg, L. S., & Johnson, S. M. (1988). Emotionally force for behavior change, and indeed, substantial
focused therapy for couples. New York: Guilford Press. subsequent research has demonstrated the magni-
Greenberg, L., Warwar, S., & Malcolm, W. (2010). tude of empathy on the therapeutic process. Thera-
Emotion-focused couples therapy and the facilitation
pists’ use of empathy has been strongly associated
of forgiveness. Journal of Marital and Family Therapy,
36(1), 28–42. with the therapeutic alliance, which is commonly
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused referred to as one of the most significant contributors
therapy for depression. Washington, DC: American to treatment outcomes (Nienhuis et al. 2016).
Distinguished from sympathy, which is defined as
Hazan, C., & Shaver, P. (1987). Romantic love conceptu-
alized as an attachment process. Journal of Personality one’s personal reaction of concern and/or compas-
and Social Psychology, 52(3), 511. sion towards another, empathy involves mirroring
Empathy in Couple and Family Therapy 899
another’s feelings and perspectives (Stueber 2013). client, being attuned to subtle changes within ses-
While both components are useful agents for thera- sion (Elliott et al. 2004). The goal is to connect to
peutic change, this chapter will focus the power of the client’s internal experiences, reflecting one’s
empathy to propel couples and families towards understanding of what the client is expressing.
greater safety, emotional connection, and treatment Elliot et al. (2004) recommends that clinicians
success. are to refrain from directly repeating back what
they have heard, but rather provide reflections
derived from their internal experience as they are
Theoretical Context for Concept connecting to their client’s emotional state. Fur-
ther, therapists are to resist the urge of attaching
E
Multiple theories contend that emotional aware- their personal opinions or values with empathetic
ness and expression is paramount for our well- statements and instead relentlessly aim to align
being and maintaining healthy connections with with the client’s experience. Empathy can be
others. For instance, Affect Phobia (i.e., a short- expressed through one’s tone and word choice,
term psychodynamic modality; McCullough along with nonverbal communication (e.g., body
et al. 2003) highlights how attunement to one’s language). Clinicians are encouraged to provide
emotional experience drives behaviors that lead concise interventions, allowing ample time for
to personal fulfillment. However, when engros- client’s to speak, and continually provide empa-
sed in environments that discourage emotional thetic statements to build and maintain a sense of
expression, painful emotions may be suppressed, stability and safety in the therapeutic dyad (Elliot
often resulting in problematic consequences such et al. 2004).
as experiencing depression, anxiety, and guarded-
ness within interpersonal relationships. Thus,
with relationships lacking empathy and emotional Application of Concept in Couple and
support, individuals may experience an insuffi- Family Therapy
cient sense of safety and intimacy required to
sustain emotional bonds within families and Couple Therapy
romantic partners. While empathy is recognized as a central compo-
In contrast, when emotionally suppor- nent in most clinical approaches (Elliot et al.
ted and accepted by others, people flourish. 2004), it can be especially impactful with couple
Emotion-focused theory (EFT; Elliott et al. and family therapy where relatedness and encour-
2004) emphasizes the importance of feeling agement of emotional expression is highlighted.
understood, particularly when experiencing Emotionally Focused Couple Therapy (Johnson
intense emotions. Feeling listened to and accepted 2004) underscores the importance of secure rela-
by others allows individuals to in turn internalize tional bonds, rooted in attachment theory, to instill
more nurturing, accepting self-concepts, while a sense of safety and connectedness within the
increasing trust that relationships provide stability couple. Couples entering therapy commonly dem-
and comfort. Thus, demonstrating empathetic lis- onstrate rigid, negative dynamics that prevent
tening provides clients with an immediate sense of opportunities for emotional vulnerability and
relief, encourages insight surrounding deeper, understanding. Without couples feeling safe to
unrecognized affect, and models a new way of disclose their longings and needs (e.g., desire for
healthy interpersonal relatedness. acceptance, wish for love), couples may external-
ize their hidden needs (e.g., arguing about bills)
and respond harshly to each other. Through these
Description negative interpersonal cycles, couples become
more polarized with their critical views of each
Utilizing empathetic techniques in psychotherapy other and continue fostering a dynamic that sym-
requires the therapist to intensely listen to the bolizes emotional threat (Johnson 2004).
900 Empathy in Couple and Family Therapy
It is through empathy that therapists can members may need to recognize and humanize
actively accentuate, dismantle, and reorganize a their loved ones’ missteps in order to understand
couple’s destructive pattern. Through conveying and align with those who have hurt them. Encour-
empathy towards partners, the therapist can expe- aging family members to explore and connect
rientially model emotional attunement and the with each other’s emotional experiences can set
bond that forms from being understood, while a powerful stage for making amends.
also instilling trust about the therapeutic process
(Johnson 2004). Similarly, through encouraging
emotional vulnerability, partners will naturally
want to comfort and protect one another, as
Clinical Example
opposed to inflicting more emotional damage.
Marcos a self-identified, 36-year-old, Latino, gay
As couples create a new interactional style of
man and Will a self-identified 38-year-old,
listening, reflecting, and supporting one another,
African-American, gay man have been dating for
a great sense of connection and intimacy ensues.
2 years and moved into together 6 months ago. They
Indeed, Johnson (2004) described that successful
began couple therapy 2 months ago due to an
EFT couples therapy allows “each partner
increase in verbal arguments and emotional dis-
becomes a source of security, protection, and con-
tance. The couple commonly discusses difficulties
tact comfort for the other” (p. 10).
with Marcos’ hectic work schedule and Will’s
resentment over being responsible for daily house-
Family Therapy
hold responsibilities (e.g., cleaning, paying bills).
Families often enter into therapy with fears about
Marcos reports that he often feels that Will nags
the therapeutic process, with members exhibiting
him, resulting in wanting to “shut down” and walk
differing levels of engagement, displaying ten-
away. Will states that Marcos avoids discussing his
dencies to remain blinded by their own emotional
feelings and, consequently, feels responsible to ini-
needs, and lacking awareness of the needs of those
tiate conversations about their relationship. The
around them (Nichols 1987). Families who lack
interaction below illustrates how therapist utilizes
connectedness and safety may keep their emo-
empathy to deepen session content and enhance an
tions hidden from others, defending themselves
emotional understanding within the couple.
from loved ones. That type of emotional secrecy
prevents family members from understanding Will: I just don’t understand why it’s so hard to leave
each other and, subsequently, supporting each the office by 6:30pm. He knows it drives me
other. Therapists can identify unexpressed, hid- crazy. We had to reschedule plans twice last
den experiences within families, with the ulti- week, and I hate doing that to our friends. It’s
very inconsiderate, and he doesn’t care!
mate goal of having family members illustrating Therapist: Will, I can sense you are very upset
empathy and understanding toward one another. about this. Let’s slow down so we can under-
As family members display empathy toward each stand how you are feeling. As you are
other, they convey openness to future dialogue discussing this concern, what feelings are you
experiencing?
about challenges and acceptance of each other’s Will: Well, I feel irritated and helpless, like there’s
experience (Nichols 1987). nothing I can do to get through to him. When
It is inevitable for families to experience times I’m waiting for him at home, I get more and
of turmoil, resulting in feelings of disappointment more angry. And, it’s sad to be waiting all alone.
Therapist: I hear you saying that there’s an ache of
and potentially unresolved resentment. The path loneliness when you are waiting for him alone.
to healing involves emotional awareness regard- It sounds very vulnerable to wonder when he’ll
ing these infractions for those who inflicted pain be home and feeling like you have no control
and those who have been injured. Hill (2010) over that.
Will: Yes, very lonely. Even though I know he’ll be
discusses the interplay between empathy and for- home any minute, a part of me can’t help but
giveness as a way to repair emotional ruptures. wonder if he doesn’t want to come home.
In particular, prior to forgiving others, family Doesn’t want to be with me.
Empathy in Couple and Family Therapy 901
Therapist: It’s as though there is a lot of fear and Through this type of emotional exploration, Will
pain that maybe he does not love you, that and Marcos gain a better understanding of the emo-
maybe he will leave you. You so badly want
him to stay. Is that right? tions underlying their arguments, thereby allowing
Will: (responds softly) Yes, that’s it. them to have more meaningful conversations and feel
a stronger emotional connection to each other. As
As therapist reflects Will’s feelings, Will safety builds within the therapeutic triad, the therapist
acknowledges more painful affect hidden under can continue to deepen their work, exploring the
emotions that are easier to access like frustration origins of their fears (e.g., fears of inadequacy, fears
and anger. The therapist then invites Marcos to of abandonment) and illustrating how they can com-
fort and help their partner heal with these concerns.
share his understanding of Will’s experience, E
thereby encouraging Marcos to mirror a similar
expression of empathy towards Will.
Cross-References
Therapist: Marcos, I’m wondering if you could tell
Will what you are hearing him say?
▶ Affect in Couple and Family Therapy
Marcos: (turns towards Will) I hear you saying that ▶ Circle of Security: “Understanding Attachment
you have a lot of fear and anxiety waiting for me in Couples and Families”
to come home. I had no idea. I just thought you ▶ Emotion in Couple and Family Therapy
were angry that I wasn’t contributing enough to
the relationship.
Therapist: Marcos, how did it feel to listening to ▶ Emotion-focused Therapy for Couples
Will’s experience feeling vulnerable and afraid ▶ Family Secrets
you may leave him? ▶ Modeling in Couple and Family Therapy
Marcos: It felt horrible. I would never want him to
feel that. I want him to trust our relationship and
be able to feel safe with me.
Will: I do feel safe, but I guess I need to hear that References
more often from you.
Elliott, R., Watson, J., Goldman, R. N., & Greenberg, L. S.
(2004). Learning emotion focused therapy: A process
Marcos and Will intuitively engage in more experiential approach to change. Washington, DC:
supportive dialogue once the conversation American Psychological Association.
becomes more vulnerable and emotionally open. Hill, E. W. (2010). Discovering forgiveness through empa-
Therapist now shifts attention to Marcos utilizing thy: Implications for couple and family therapy.
emotion-focused techniques and empathy to Johnson, S. M. (2004). The practice of emotionally focused
encourage further emotional exploration. couple therapy: Creating connection (2nd ed.).
New York: Brunner-Routledge.
Therapist: Marcos, can you share more about your McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf,
experience coming home late and feeling like J., & Hurley, C. L. (2003). Treating affect phobia: A
you aren’t contributing enough to the manual for short-term dynamic psychotherapy. New
relationship. York, NY: Guilford Press.
Marcos: It’s hard for me when Will is upset. I feel Nichols, M. P. (1987). Self in the system: Expanding the
like I can’t do enough to please him, like no limits of family therapy. New York: Brunner-Routledge.
matter what, I’m going to get yelled at. So, when Nienhuis, J. B., Owen, J., Valentine, J. C., Black, S. W.,
that happens, I kind of freeze. Halford, T. C., Parazak, S. E., . . . Hilsenroth, M. (2016).
Therapist: Sounds like you feel you aren’t good Therapeutic alliance, empathy, and genuineness in indi-
enough, like you keep failing. Does that fit vidual adult psychotherapy: A meta-analytic review. Psy-
with your experience? chotherapy Research, published online 7 July 2016, 1–13.
Marcos: It does. I want to be a good partner, but https://doi.org/10.1080/10503307.2016.1204023
I keep messing it up. It’s awful. Rogers, C. R. (1957). The necessary and sufficient condi-
Therapist: I’m hearing a lot of pain in your voice. tions of therapeutic personality change. Journal of
It’s like you desperately want to be there for Consulting Psychology, 21, 95–103.
Will, but when you feel like you are disap- Stueber, K. R. (2013). Empathy. In Encyclopedia of sci-
pointing him, you become overwhelmed and ences and religions (pp. 723–727). Dordrecht:
feel panicked. Springer.
902 Empty Chair Technique in Couple and Family Therapy
2010; Yontef 1999). Field theory refers to the idea

Empty Chair Technique in that the experience of a client should be examined
Couple and Family Therapy in the context of their environment or field (Mann
2010; Yontef 1999). Phenomenology refers to
Amy D. Smith1 and Kelley Quirk2 focus on the current moment, describing feelings
1
Marriage and Family Therapy/Applied and experiences rather than trying to interpret
Developmental Science Program, Colorado State them (Mann 2010; Yontef 1999). Dialogue refers
University, Fort Collins, CO, USA to the idea that in the context of therapy, two
2
Marriage and Family Therapy Program, Human realities exist, one of the therapist and one of the
Development and Family Studies, Colorado State client, and that a third reality is created as a part of
University, Fort Collins, CO, USA the relationship between the therapist and client
(Mann 2010; Yontef 1999).
Name of the Strategy or Intervention

Empty Chair Technique in Couple and Family Intervention
Therapy.
The empty chair intervention was designed to
increase clients’ awareness of different aspects
Synonyms of their experience, helping to resolve
conflicts that exist in their lives by resolving
Two-chair technique “splits” or differences in a person’s internal state
(Greenberg 1979; Greenberg and Rice 1997;
Mann 2010; Wagner-Moore 2004; Fagan et al.,
Introduction 1974). There are multiple types of splits which
can occur (Greenberg 1979). In conflict splits,
The empty chair technique – also known as the there are two parts which are in opposition to
two-chair technique – originated from the gestalt one another (Greenberg 1979). An example of
approach to therapy. Similar to other interventions this type of split would be if a client were to say
that were developed from gestalt therapy, this that there was a part of them that wanted to move
technique was created to help resolve conflict in with their partner and another part of them that
in the present moment through increasing aware- felt hesitant. In subject/object splits, one part of
ness (Fagan et al. 1974, Mann 2010). In this the self does something to another part – the
technique, awareness is increased by helping cli- recipient (Greenberg 1979). An example of this
ents discover new aspects of their experience type of split would be if a person reported that
which they may have been avoiding (Greenberg they were judging themselves, as they are both
and Rice 1997; Wagner-Moore 2004). judging and receiving the judgment. In attribution
splits, one believes there is a disagreement
between oneself and another person, or feels that
Theoretical Framework something has been done to oneself by another
person making oneself passive in the experience
The empty chair technique was originally devel- (Greenberg 1979). An example of attribution of
oped as part of gestalt therapy (Perls et al. 1951), opposition would be if a person felt that they
which focuses on the present experience to assist should have a child because this is what their
clients in understanding what and how they per- mother wants even if they are not entirely sure
ceive the situation (Mann 2010). This approach is themselves. An example of attribution of agency
based on what are known as the pillars of gestalt: would be if a client were to report that another
field theory, phenomenology, and dialogue (Mann individual made them feel a certain way such as
Empty Chair Technique in Couple and Family Therapy 903
embarrassed or angry. A meta-analytic study reported being committed to their relationship.

found that the empty chair technique is a success- Hailey also reported struggling to trust Matthew
ful intervention for conflict splits, indecision, mar- and that she was angry at the affair for “ruining her
ital conflict, and resolution of unfinished business trust.” Matthew reported that he felt guilty for
(Wagner-Moore 2004). having the affair and frustrated by the lack of
connection that existed in his relationship with
Hailey.
Description of the Strategy or After several sessions, the therapist suggested
Intervention they try using the empty chair technique in order
to help the couple externalize the affair from who
E
In the empty chair technique, a client is asked to they are as a couple. The therapist asked the
imagine that someone from the client’s life or a couple to place the affair in an empty chair in the
part of the client themselves – such as an angry or room, and then asked each partner to speak
depressed part – is sitting in an empty chair in the directly to the affair, allowing them to express
therapy room (Greenberg 1979; Mann 2010). Five their thoughts and feelings. Through this process,
principles guide the effective use of this interven- both Matthew and Hailey were able to authenti-
tion (Greenberg 1979). First, clear separation cally express their emotions to the affair, thus
needs to exist between the two parts; the separated decreasing defensiveness and allowing for
parts need to be able to speak directly to each responsibility taking. Hailey was able to talk
other. Second, the client is encouraged to experi- about how she both wanted to forgive Matthew
ence this fully and not avoid parts of their experi- and how a part of her did not want to, a conflict
ence by talking in the first person and expressing split, and Matthew was able to express how he
what they feel in the present moment both in terms was judging himself for having the affair, a sub-
of needs and resistance. Third, the therapist adopts ject/object split. After the intervention, Matthew
a role of helping the client become more aware of and Hailey reported that they felt closer together
their experience instead of trying to motivate because they could picture the affair as something
change by helping the client to become aware of separate from their relationship, and both felt
parts of their perspective that they may not have relieved being able to express what they were
previously been aware, and by helping the client feeling.
to focus on their internal feelings or sensations.
Fourth, the therapist asking the client to exagger-
ate or repeat certain statements or behaviors in
Cross-References
order to heighten the client’s awareness of the
moment to moment experience during the inter-
▶ Gestalt Experiential Therapy with Couples and
vention. Fifth, the therapist helps the client to
Families
become aware of how they express themselves
▶ Greenberg, Leslie
through guiding their attention to the way in
▶ Phenomenology and Family Therapy
which they speak or act during the intervention
(Greenberg 1979).
References
Case Example Fagan, J., Lauver, D., Smith, S., Deloach, S., Katz, M., &
Wood, E. (1974). Critical incidents in the empty chair.
Matthew, 29, and Hailey, 28, recently started cou- The Counseling Psychologist, 4, 33–42.
ple therapy to work on improving trust and com- Greenberg, L. S. (1979). Resolving splits: Use of the two
chair technique. Psychotherapy: Theory, Research and
munication. The couple decided to seek therapy Practice, 16, 316–324.
after Matthew told Hailey about an affair that he Greenberg, L. S., & Rice, L. N. (1997). Humanistic
had recently ended. Both Matthew and Hailey approaches to psychotherapy. In P. L. Watchel &
904 Enactment in Couple and Family Therapy
S. B. Messer (Eds.), Theories of psychotherapy: and areas of difficulty within a couple or family’s
Origins and evolution (pp. 97–129). Washington, DC: interactions as they work to implement behavior-
American Psychological Association.
Mann, D. (2010). Gestalt therapy: 100 key points and based solutions (Butler and Gardner 2003,
techniques. New York: Routledge. p. 312).
Perls, F., Hefferline, R. F., & Goodman, P. (1951). Gestalt However, enactments do serve a purpose
therapy: Excitement and growth in the human person- beyond the assessment of behavioral interaction.
ality. New York: Gestalt Journal Press.
Wagner-Moore, L. E. (2004). Gestalt therapy: Past, pre- According to Gottman and Levenson (1999),
sent, theory, and research. Psychotherapy: Theory, “. . .[Enactments] should reduce physiological
Research, Practice, Training, 41, 180–189. arousal and reactivity; facilitate positive interac-
Yontef, G. (1999). Awareness, dialogue and process: tion around discussions of disagreements, differ-
Preface to the 1998 German edition. The Gestalt
Journal, 22, 9–20. ences, and problems; increase display of positive
behavior affect, together with the other’s ability to
recognize those positive displays; reduce defen-
siveness, stubbornness, withdrawal, anger, and
Enactment in Couple and conflict engagement; increase expressed interest
Family Therapy in each other and increase ability to step back
and see their partner’s point of view” (p. 312).
Kareigh Tieppo and Corina Teofilo Mattson Enactments also give members of a couple or a
The Family Institute at Northwestern University, family the opportunity to express their emotions
Evanston, IL, USA in a context where negative or defensive reactions
are more easily managed and regulated. In
moments of high and vulnerable emotion, the
Synonyms therapist can help clients to be aware and inten-
tional about the role they play in interactions with
Behavioral rehearsals other members of the client system. By increasing
self-awareness, client systems are able to learn
how to self-regulate, which leads to better self-
Introduction care and care for others (Davis and Butler 2004,
p. 320). Enactments give clients an opportunity
Enactments are used as an intervention when the to recognize and experience their emotions in
therapist is prepared to target problematic behav- moments of somewhat spontaneous vulnerability,
ior by both assessing and directing the actions and and as those moments happen, the therapist can
interactions of a client system. Enactments are help the client system to experiment with different
made for a relational context, as they call for choices of active and responsive behaviors. The
both interaction and recognition of action between hope is that eventually, clients will incorporate
clients in the room. In order to better understand behaviors that lead to resolution within patterns
what particular problematic processes look like of interaction that they had perceived to be hope-
outside of the therapy room, the therapist will lessly fixed (Sprenkle et al. 2009).
impose a structure of conversation in which cli-
ents will to talk to one another about a specific
topic and the therapist will guide them through Theoretical Framework
it. Participating within this structure, the hope
is that the clients may come to find themselves Salvador Minuchin served as the prime example
in a new, and perhaps unexpectedly healing, expe- of what an active therapist can do when facilitat-
rience as the therapist helps them to interrupt ing an enactment. Working within the model of
seemingly permanent, problematic sequences. Structural Family Therapy, he both noticed and
Through practice and repetition, the therapist is named problematic patterns of behavior as they
able to more directly address the specific points were happening. He helped clients understand
Enactment in Couple and Family Therapy 905
how their words and their actions – even with the the client system is partaking in. For example, the
best intentions – could be so much more harmful therapist decides who participates, when they par-
than they were helpful within some of their most ticipate, and how long they participate for. The
important relationships (Butler and Gardner 2003, therapist is also able to notice what the system can
p. 314). In Emotion-Focused Therapy (EFT), ther- tolerate, what may be pushing the system too
apists work to restructure interactions, which are hard, when it may be time to slow the process
often done by having clients participate in an down, and when it may be time to press pause.
enactment (Sprenkle at el. 2009). However, in Therapists use enactments as a means to
EFT, enactments are not used as spontaneously observe several different parts of a system’s
as they are when working within other models of process all at once (e.g., family roles and dynam-
E
therapy, for emotion-focused therapists intend to ics, individual/couple/family strengths, problem-
use enactments solely for the purpose of “inviting atic and unproductive patterns of interaction, etc.)
softer responses from the other,” fostering new (Nichols and Davis 2017). Enactments are
experiences of intimacy that lead to healing process-oriented more than they are content-
(Sprenkle et al. 2009, pp. 117–118). Johnson her- oriented (Butler and Gardner 2003, p. 313).
self (2013) says, “One of the finest moments for They do often require clients to communicate
me is when partners finally disclose their worries directly with one another about content that is
and desires and engage with each other tenderly important, but the therapist is able to guide, man-
and compassionately,” which is most certainly the age, and adjust the conversation as is needed for
ideal result of intervening with an enactment practicality and productivity. The more people
(p. 55). that are involved in an enactment, the more diffi-
According to Davis and Butler (2004), ver- cult it may be to manage, and thus, the therapist
sions of enactments exist within all of the rela- must be aware of and prepared for the particular,
tional therapy models. For example, in Marital potential challenges that come with asking a fam-
Enrichment, Relational Enhancement, and Behav- ily to participate in an enactment versus asking a
ioral Marital Therapy approaches, enactments are couple or dyad to participate in an enactment.
called “behavioral rehearsals*.” In Narrative The mediation, direction, and topic of discus-
Therapy, clients who feel stuck may attempt to sion introduced by the therapist during an enact-
“re-story” the difficult narratives that they carry ment may sometimes catch the clients by surprise.
with them each day, and in Solution-Focused In turn, this may lead clients to produce reactions
Therapy, couples are sometimes asked to engage and responses that are more true to the person they
in “couple dialogue” (p. 320). are when the therapist is not present. When this
happens, it may become clearer to the therapist
what keeps each member of the system from mak-
Rationale for Enactments ing the more permanent changes they claim to be
seeking in their everyday lives. Thus, the therapist
Minuchin (1974) used enactments to “unleash is able to develop more realistic expectations and
sequences beyond the family’s control” (p. 78). hypotheses about a system’s capabilities to adapt
When members of a couple or family become lost to change at a specific moment in time. This
in their sequences, the therapist can take control allows the therapist to better understand how to
in order to help the family navigate what they do empower clients to open their minds to new, pos-
not yet understand. Minuchin (1974) explained, sible solutions for problematic communication
“Instead of a patient with pathology, the focus and interaction with their loved ones. Again, it
is now a family in a dysfunctional situation. must be emphasized that sustaining these kinds
Enactment begins the challenge to the family’s of changes takes practice and repetition. Once the
idea of what the problem is” (p. 81). The therapist therapist interrupts a system’s longtime pattern of
serves as the navigation system by exercising interaction and teaches its participants how they
some control over the rules of the interaction that can productively and positively go about change –
906 Enactment in Couple and Family Therapy
all done collaboratively – they must remember successfully be able to make it through these
that it is unrealistic to expect the lessons learned interactions without relying on directives from
to immediately become the norm. Enactments the therapist (Butler and Gardner 2003).
may have to be produced again and again in
session in order for them to have a chance of
being practiced, repeated, and implemented out Case Example
in the world and in people’s everyday lives
(Pinsof et al. 2017). In the following example of an enactment, the
family involved is coming to therapy to learn
how to cope with the parents’ impending divorce
Description of Enactments and understanding the mother’s depression. The
family members in the therapy room for this par-
Nichols and Davis (2017) describe the three ticular session include the mom (46) and eldest
steps the therapist must take when pursuing the daughter (17). Over the past 10 years or so, the
inclusion of an enactment in session. First, the daughter has become somewhat parentified, feel-
therapist must notice a problem within the sys- ing an incredible amount of responsibility to pro-
tem’s process of communication that is tect her three younger siblings from the conflict
impairing its functioning. Second, the therapist between their parents. The daughter’s perceived
must initiate the enactment while simulta- responsibility for her mother and younger siblings
neously getting all members that are present to has led her to feel overwhelmed. Still, the daugh-
agree to participate. The therapist must be clear ter is afraid to tell her mother that she feels this
with clients that an enactment is meant to allow way. The daughter is convinced that telling her
families or couples to interact or communicate mother how she feels about the role she has taken
directly with each other so that they do not begin on in their family will make the mother feel even
by using the therapist as a messenger with indi- more alone in her struggles. The daughter is terri-
rect and passive aggressive communication. fied that talking about her mother’s depression
Third, the therapist must remain present to the and being open with her about her fears may result
interactions of the enactment, for they are the in the mother’s depression spiraling out of control
person responsible for helping the family to (i.e., suicidality). Having observed this family’s
successfully make it through/partake in the process for several months, the therapist knows
interaction. that the daughter’s catastrophic fears will not be
When the system struggles, or things begin to confirmed. The therapist will ask the mother and
go awry (as is expected), “the therapist inter- daughter to participate in an enactment by asking
venes in one of two ways: commenting on what the daughter to tell the mother what she fears will
went wrong or pushing them to keep going” happen if she takes on less of a caretaker role, thus
(Nichols and Davis 2017, p. 123). The therapist allowing an opportunity for the daughter to see
is responsible for keeping track of the emotional how the mother will respond to her fears and
reactivity, the emotional intensity, and the overburdened sense of responsibility. Once the
amount of direct/indirect interaction between mother and daughter are informed of the task at
those in the system. There is always a risk that hand, it may unfold like this:
an enactment may result in high emotion and
high reactivity, and in an effort to guide, or Therapist: Lucy, over the past several months,
perhaps disrupt, these particular interactions, I have come to understand that you
the therapist may need to implement fairly are deeply afraid of what could
blunt directives. This way, the therapist is able happen if you chose to open up to
to directly suggest new ways for the system to your mother about how responsible
communicate and/or operate (Pinsof et al. you feel to take care of and protect
2017). The hope is that eventually, clients will her. I want to encourage you to take
Enactment in Couple and Family Therapy 907
this opportunity to talk to her about you guys. . .I’m so sorry. . .I’m the
that now. I believe that her response mom. . .and you’re the kid. . .I
to you will be much, much different never want to bring my children
than you think it will be. It may any pain. You are not responsible
even surprise you. I know that this for protecting me. . .or fixing any of
is very difficult. You are safe to the marital problems. . .I will try to
speak about this here, and you can stop putting all of that on you. . .I
begin whenever you are ready. want you to be able to focus on
Daughter: Mom, I have been feeling very your own life and
overwhelmed lately. . .more than responsibilities. . .I do not and will E
I ever have before. . .and it’s getting not feel alone in “all of this.” I am
in the way of everything more than going to be okay.
it usually does. . .
Mother: Oh, honey. . .What about? What’s
going on?
Therapist: Lucy, can you please tell your mom After thanking both mom and daughter for
when you feel the most their participation, the therapist may ask the
overwhelmed? daughter to share with the mom how she thought
Daughter: Mom. . .I really love when we go she would respond to her truth on this
on walks or talk before bed and our topic. Knowing how difficult it will be for the
conversations are really daughter to be honest with her mother about her
good. . .and about deeper fear of her mother’s depression and suicidality,
stuff. . .but sometimes. . . the therapist may help the daughter express to
Therapist: You can do this, Lucy. . .Keep the mother where her strong belief in this fear is
going. coming from. The therapist may then help the
Daughter: Sometimes, we switch topics away mother to validate, be curious about, and
from what’s going on with me so respond to her daughter’s fears. The therapist
that you can list all the reasons for will continue to guide the mother and daughter
the divorce. . .or talk about all the throughout this conversation, offering direc-
things he won’t do. . .or say. . .or tives that may help each of them to slow down,
talk to you about. . .and I’ve been pause, or reflect upon what the other has said as
the person you go to to vent about they discuss the fear that is related to the role the
that stuff for years. . .but I cannot daughter has taken on in the family and the ways
change any of the things you in which that may influence other particularly
complain about. . .He has to be the burdensome family dynamics. As the possibility
one to do it. . .This is between the of change is explored or attempted throughout
two of you. . .and I have never said the enactment, the therapist will encourage
any of this to you because I did not patience as she asks the mother and the daughter
want you to feel like you couldn’t to express and to understand what it is that they
talk to me about it all because each truly need from the other.
I didn’t want you to feel alone in all
of it. . .I did not want to hurt you.
I don’t want you to feel alone. I am
afraid of what will happen if you Cross-References
feel alone in everything.
Mother: I know that I talk about him more ▶ Behavioral Rehearsal in Couple and Family
than I should with all of you kids. Therapy
We both do. And it’s not fair at all to ▶ Enactment in Structural Family Therapy
908 Enactment in Structural Family Therapy
References Theoretical Framework
Butler, M. H., & Gardner, B. C. (2003). Adapting enact- Enactments are an essential component of Struc-
ments to couple reactivity: Five developmental stages.
tural Family Therapy (Minuchin 1974; Minuchin
Journal of Marital and Family Therapy, 29(3),
311–327. and Fishman 1981). They are used to explore and
Davis, S. D., & Butler, M. H. (2004). Enacting relation- change interactional and organizational problems
ships in marriage and family therapy: A conceptual and in families: how couples talk to each other, how
operational definition of an enactment. Journal of Mar-
parents relate to their children, and how relation-
ital and Family Therapy, 30(3), 319–333.
Gottman, J. M., & Levenson, R. W. (1999). Rebound from ship triangles influence family dramas. By bring-
marital conflict and divorce prediction. Family Process, ing the actual dynamics of those relationships to
38(3), 287–292. life in the consulting room, enactments lend
Johnson, S. (2013). Love sense: The revolutionary new
immediacy and authenticity to family therapy.
science of romantic relationships. New York: Little,
Brown, and Company. Although enactments are also used in other ther-
Minuchin, S. (1974). Families and family therapy. apeutic modalities, there is an important distinction.
Cambridge, MA: Harvard University Press. Outside of structural family therapy, the use is gen-
erally more directive, with therapists interrupting to
Concepts and methods. Hoboken: Pearson Education.
Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L., coach communication skills, often after almost
Rampage, C., & Chambers, A. L. (2017). Integrative every client utterance (e.g., Butler and Gardner
systemic therapy: Metaframeworks for problem 2003; Davis and Butler 2004). The familiar tactic
solving with individuals, couples, and families.
of having couples take turns talking and listening is
Washington, DC: American Psychological
Association. an example of this approach, as is the rehearsal in
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). behavioral marital therapy (Jacobson and Margolin
Common factors in couple and family therapy. 1979), the directed dialogues in emotionally focused
couples therapy (Greenberg and Johnson 1988), and
the role-playing and problem-solving practice in
couple enrichment programs (L’Abate and
Weinstein 1987). By contrast, enactments in Struc-
Enactment in Structural tural Family Therapy are relatively unstructured.
Family Therapy The therapist acts as a facilitator rather than a
coach. Although he or she may need to be active
Michael P. Nichols1 and Jorge Colapinto2 in setting an enactment up, once underway the ther-
1
College of William and Mary, Williamsburg, apist intervenes only when necessary to keep it
VA, USA going. Forced to rely on their own devices, some
2
Minuchin Center for the Family, Woodbury, clients will find a way to get through to each other;
NJ, USA others may continue to communicate in ways that
are counterproductive. When this happens, the ther-
apist points at what the clients are doing that keeps
Introduction them stuck.
In an enactment, family members are asked to talk

with each other rather than to the therapist. This Rationale
serves the dual purpose of allowing the therapist
to see firsthand how clients interact, instead of Because family members often describe them-
relying on their descriptions, and having clients selves more as they want to be seen than as they
experience different ways of interacting (Nichols are, structural family therapy works by doing
and Fellenberg 2000). rather than talking. It relies on the observation of
Enactment in Structural Family Therapy 909
actual family transactions – the “family dance” – Using enactments effectively is more com-
to identify and highlight the dysfunctional pat- plicated than generally assumed (Nichols 1997).
terns that embed the presenting problems; and on Though some clients are all too ready to argue
the family members’ practice of alternative ways among themselves, most are reluctant to address
of relating – a new choreography – as the way to their conflicts directly with each other in therapy
develop healthier patterns. The purpose of an sessions. They’ve tried, but it’s been painful and
enactment is not necessarily that the family mem- unproductive. So by the time they get to a ther-
bers will reach agreements or the solution to their apist’s office, many people are ready to give
problems, but that they will have the experience of up on each other and turn to the therapist for
a better relationship. New relational patterns need understanding.
E
to be experienced repeatedly until they hold; each Therefore, it’s useful to carefully prepare the
successful enactment contributes to the expansion groundwork for an enactment. Before staging it,
of the family’s repertoire, showing that change is the therapist gives everyone present a chance to
possible and what it may look like. share his or her point of view about the problems
that plague them. Unhappy families are often
short on mutual understanding, and therefore the
Description first task of a therapist is to give each of them a
sympathetic hearing.
Enactments can be used as an assessment tool or Once a therapist has acknowledged what each
as a therapeutic intervention. When used for as- family member has to say, he or she identifies a
sessment, the therapist initiates an enactment and problematic interaction. Perhaps, for example, a
waits to see where communication breaks down. father sits back silently while his wife and son
Suppose, for example, that a wife complains that argue fruitlessly. The therapist may probe the
her husband never talks to her. When the therapist flexibility of this arrangement by asking the father
asks the man to talk to his wife about a project at to talk with his wife about her concerns. If the
his work and she interrupts with frequent criti- father’s conversation with his wife is interrupted
cisms, the husband grows silent and the enactment by the son, and the father is silenced, this will
comes to a close. In this case, the therapist might support the hypothesis that the mother and son
conclude that the husband doesn’t talk to his wife, are overinvolved and the father is disengaged.
because when he does, she criticizes him – and After a specific subject of concern to both
because rather than answer her, he withdraws. parties has been identified, the therapist then ini-
When used as a therapeutic intervention, the tiates an enactment, making a production of it: he
therapist’s job is to push family members to continue or she describes a problem, show that it is an
talking until there is a breakthrough in the way they important issue for the family, asks the partici-
interact. In the previous example, when the husband pants if they’d be willing to talk about it, brings
grows silent in the face of his wife’s criticism, the them physically closer to each other, and may
therapist could simply say “Answer her.” prescribe who should begin the conversation.
In families with young children, enactments Pointing out a relationship problem that the
may take the form of action rather than conversa- therapist has observed increases the clients’ moti-
tion. To see how effectively parents deal with their vation to engage in enactments. It is important to
children, a therapist might ask them to control an choose a subject that both participants have some-
unruly child or encourage a shy child to play a thing to gain by discussing. Some subjects are a
game. Are the parents able to get their children to no-win proposition for certain family members.
sit quietly in the corner if the therapist asks them Suppose, for example, a teenager has trouble
to? Can a parent sit and play with his or her child expressing himself to his mother, and she has
without trying to control the game? trouble listening. Asking them to talk about why
910 Enactment in Structural Family Therapy
the boy should stay in school is unlikely to lead job to explain yourself to your father so he can
anywhere because the boy has nothing to gain in understand you.” (To the father:) “Your son is a
this conversation. This discussion is almost cer- member of an alien culture that thinks knees are
tain to take the familiar form of a parent nagging a beautiful. Who knows?” (To the son:) “Keith, can
recalcitrant adolescent. On the other hand, asking you explain this to your father?” “Please,” the
the mother to find out what the boy wants to do father says. As the therapist sits back, this stub-
after school may give him a better chance to speak born and unhappy father and son begin to open up
up, and her a better chance to listen. to each other. They talk about feeling excluded
To use enactments effectively, a therapist and feeling misunderstood, about needing to
should focus on the process, not the content, of belong and not belonging – and what had begun
communication. When the Johnsons complained as another failure of communication becomes a
that their teenage son David had frequent out- genuine breakthrough of understanding.
bursts of anger, the therapist asked David if his When an enactment comes to a close, the ther-
father understood what made him angry. The boy apist can comment on what the clients are doing
answered, “No. He never listens to me.” The that keeps them stuck, or how they were able to
therapist said, “This sounds like an important get through to each other. If a real conversation
issue. If a father can’t talk to his son, and a son has taken place, it is a good time for encourage-
can’t talk to his father, how will the boy learn to ment and suggestions for improving communica-
get along in the world? David, would you be tion and cooperation to resolve family problems.
willing to talk to your father about some of the
things that make you angry? Mr. Johnson, would
you be willing to help David explain why he gets Case Example
so upset?” They both agreed, and the therapist
turned their chairs to face each other. In the process of raising their children, the Dia-
Once an enactment has begun, the therapist sits monds have allowed the spark to go out of their
back to remove himself or herself from the dia- marriage. They work well together as parents, but
logue. By avoiding eye contact with the person as a couple they have drifted apart. Tony Diamond
speaking, the therapist encourages clients to con- complains that his wife is always too busy with
tinue talking to each other and not to her or him. the children to spend time with him; she com-
During this phase of an enactment, the therapist plains that he is always complaining about his
should say only enough to block third parties from job and never seems to care how she feels.
interrupting, and to redirect or “jump start” the After hearing these complaints, the therapist
dialogue if necessary. says, “It seems like you’re both feeling neglected.”
In the case of “A Father’s Rage” (Minuchin They nod. “Maybe the problem isn’t that you don’t
and Nichols 1993), Dr. Minuchin asks a father to make time for each other, but that unspoken resent-
talk with his 16-year-old son, Keith. Despite the ment makes you not want to.” She looks down, he
therapist’s best efforts to encourage a supportive looks away. “This seems like an important issue.
connection between father and son, the father Tony, would you be willing to ask Kristina to tell
begins by criticizing his son’s choice of clothing. you what she’s feeling about your relationship?” “I
“So you’d rather go around wearing rags . . . than guess,” he says, not too convincingly.
wear nice slacks and have them think you’re a The therapist turns their chairs to face each
nerd. . .” Keith nods. The boy and his father have other, and says, “Kristina, can you help Tony
had run out of lines. understand why you’ve been feeling neglected;
To restart the conversation, Minuchin says and, Tony, can you try to understand what she’s
“You see, this was a perfectly good conversation feeling?” They both agree, and Kristina talks
between two cultures. It happens in this crazy about how she misses the early years of their
culture in which these kids live, ragged pants are marriage when Tony always seemed willing to
in and dressy pants are out.” (To Keith:) “It is your listen to her concerns. When Tony counters by
Enmeshment in Couples and Families 911
saying that he also needs to be listened to, it seems Greenberg, L. S., & Johnson, S. M. (1988). Emotionally
that they are about to revert to the familiar pattern focused therapy for couples. New York: Guilford Press.
of complaining back and forth with neither one Strategies based on social learning and behavior
really listening to the other. exchange principles. New York: Brunner/Mazel.
So the therapist says, “Kristina, can I ask you a L’Abate, L., & Weinstein, S. E. (1987). Structured enrich-
very personal question?” “Sure,” she says, “I’m a ment programs for couples and families. New York:
Brunner/Mazel.
very open person.” Minuchin, S. (1974). Families and family therapy. Cam-
“Are you sometimes too angry for sex because bridge, MA: Harvard University Press.
you feel that Tony doesn’t care what’s going on Minuchin, S., & Fishman, H. C. (1981). Family therapy
with you?” techniques. Cambridge, MA: Harvard University Press.
Minuchin, S., & Nichols, M. P. (1993). Family healing E
“Exactly!” she says. “Whenever Tony listens Tales of hope and renewal from family therapy.
to me, I just melt.” New York: Free Press.
The therapist takes Tony’s hand and had him Nichols, M. P. (1997). The art of enactment. Family Ther-
take Kristina’s hand and says, “Keep talking. apy Networker, 21(6), 23.
Nichols, M. P., & Fellenberg, S. (2000). The effective use
I think this guy really loves you, and he wants to of enactments in family therapy: A discovery-oriented
understand how you feel.” process study. Journal of Marital and Family Therapy,
That simple gesture and the physical closeness 26, 143–152.
it fosters helps the two of them open up their
hearts to each other. They talk about feeling mis-
understood, about missing the good times they
used to have, and about feeling that the other Enmeshment in Couples and
one no longer cares. It is a good talk, and it goest Families
on for quite a while. After several minutes, the
therapist begins to sense that the conversation is Teresa D’Astice and William P. Russell
winding down, and wanting to punctuate their The Family Institute at Northwestern University,
success, he moves their chairs apart and says, “It Evanston, IL, USA
seems that you both miss the closeness in your
relationship. I’m impressed with how meaning-
fully you can talk with each other when you take Name of concept
the time to hear what the other one has to say.”
Enmeshment
Cross-References
Synonyms
▶ Boundaries in Structural Family Therapy
Overinvolvement
▶ Family Function and Dysfunction in Structural
Family Therapy
▶ Structural family therapy
Introduction
Salvador Minuchin (1974) used the term enmesh-

References
ment to describe the overinvolved relationships
Butler, M. H., & Gardner, H. A. (2003). Adapting enact- that develop from diffuse boundaries within fam-
ments to couple reactivity: Five developmental stages. ily systems and between family members and
Journal of Marital and Family Therapy, 29, 311–328. other systems. Enmeshed families or subsystems
Davis, S. D., & Butler, M. H. (2004). Enacting relationship
in marriage and family therapy: A conceptual and oper-
are characterized by a high level of communica-
ational definition of enactment. Journal of Marital and tion and lesser levels of distance, and differentia-
Family Therapy, 30, 319–333. tion (Minuchin 1974). Structural concepts,
912 Enmeshment in Couples and Families
including enmeshment, were foundational to the boundaries that are too rigid or too diffuse. Disen-
field of Marriage and Family Therapy and remain gaged families have rigid boundaries that limit com-
vital tools for systemic assessment and treatment munication between subsystems, such that family
(Fishman 2012; McAdams et al. 2016; Nichols members do not find sufficient connection, comfort,
and Davis 2017). Its established position in the or safety within the system. On the other hand,
field notwithstanding, the concept of enmeshment enmeshed families and enmeshed relationships
has been reexamined over the years by various have diffuse or porous boundaries that allow a
theorists who have suggested adjustments to its high level of involvement among members and
usage. establish expectations that tend to reduce the auton-
omy of members. Enmeshment brings a heightened
sense of belonging and a high level of sensitivity to
Theoretical Context for Enmeshment departures from expected behaviors and connec-
tions. The resulting lack of distance from one
The theoretical context for the concept of enmesh- another can lead to difficulty maintaining indepen-
ment is Structural Family Therapy (SFT), which dence and adaptation in stressful situations
was developed by Salvator Minuchin. SFT posits (Minuchin 1974). Though connectedness within a
that behavior, including the problems brought to system is important, enmeshment can diminish
therapy, develops within and is maintained by the “autonomous exploration and problem-solving”
interactional context of the family, its subsystems, (Minuchin 1974, p. 55).
and other systems in the community. SFT iden-
tifies various subsystems of the family and
focuses on the transactional patterns among Applications of Enmeshment in Couple
them. These patterns are understood in terms of and Family Therapy
two dimensions (Wood 1985; Colapinto 2015):
vertical (the family hierarchy) and horizontal Minuchin (1974) recommended that family
(boundaries of proximity/involvement among assessment include attention to the following fac-
members). Boundaries are defined as “rules defin- tors: description of the presenting problems, direct
ing who participates, and how,” (Minuchin 1974, observation of family interaction including the
p. 53). Boundaries regulate the level of contact or family’s response to the identified patient, the
engagement between the family and other systems family’s sources of support and stress, and the
and among individuals and subsystems within the developmental stages of the members and the
family. When the level of engagement is appro- family as a whole. If the presenting problem
priate to the needs and developmental levels of seems to be maintained by enmeshed relational
members, the boundaries are said to be clear. Such dynamics in the family, the therapist works to
boundaries allow family members to manage their highlight for the family that this is so. The thera-
individual functions while maintaining adequate pist takes the position that in order for the pre-
communication with the rest of the system. senting problem to improve, the family will need
to allow greater autonomy to particular members
or subsystems. Once this is established, the ther-
Description apist helps the family create new boundaries by
physically rearranging family members into dif-
Minuchin and Fishman (1981) states that families ferent subsystems in the room, restricting some
with clear boundaries maintain a balance between family members from participating in certain con-
autonomy and relatedness. In such a case, there is versations, coaching some members to back off in
enough closeness, support, and involvement to sup- order to let a member function more indepen-
port its members and enough distance to allow dently, and encouraging more autonomous func-
individuals and subsystems to develop independent tioning of particular members. (Colapinto 2015;
functional capacity. Minuchin also discusses Pinsof et al. 2018).
Enmeshment in Couples and Families 913
As SFT is arguably the most influential con- involved with parental or other subsystems in
ceptual model in the field of family therapy order to meet cultural expectancies, promote
(Nichols and Davis 2017), the concept of enmesh- development, or ensure safety.
ment has achieved and maintained prominence Pinsof et al. (2018) emphasized that ideas
over the years. It has also been the subject of about a family’s structure are best considered
continued discussion and, at times, hypotheses not facts. This promotes a collabora-
reexamination. tive approach to exploring “time members spend
The feminist critique in family therapy chal- together, physical closeness, emotional separa-
lenged the usage of this concept. Bograd (1988) tion, shared general information, confided per-
cautioned that family systems concepts may sonal information, and decision making” (Pinsof
E
reflect male standards of identity and relationship et al. 2018, p. 104) and joint determination of
and present a risk of pathologizing the preferred whether diffuse boundaries are something that
relational styles of women. The concept of constrain problem solving. These authors also
enmeshment had been associated with what have reinforce the importance of considering cultural
traditionally been described as female-typical issues and avoiding gender bias in the use of the
qualities such as relational closeness, whereas concept of enmeshment. Lastly, though they
disengagement had represented the more male- recognize the profound importance of structural
typical qualities such as independence or rela- concepts, their integrative approach asserts that
tional distance. Although STF identified both not all presenting problems are most practically
enmeshment and disengagement in their more and effectively addressed from a structural
extreme forms are problematic, Bograd perspective.
maintained that enmeshment as applied to After the family’s boundaries have been
women evoked stronger negative views than dis- assessed with awareness and sensitivity to culture
engagement. She urged that mothers not be and gender, and the therapist and family have
pathologized for their relational nature and collaboratively identified that the family system
suggested that family therapy models “blend and is constrained by its enmeshment, the task ahead
value both attachment and separation, productiv- is to create new boundaries that allow greater
ity and nurturance, rationality and emotion” autonomy for specific members and, perhaps,
(Bograd 1988, p. 78). more relatedness for others (Colapinto 2015).
Fishman (2012) highlighted that boundaries are
idiosyncratic to every family and that the impact of
the boundaries, as reported by the family members, Clinical Example
is key to understanding whether a family or relation-
ship is considered enmeshed. This more subjective Robert and Kate sought treatment for their
approach to structural assessment allows the thera- 14-year old son, Jacob, who had been coming
pist to consider family member’s points of view, home from school mid-mornings due to strong
cultural context, and special circumstances. feelings of discomfort. In the first phone call,
Fishman (2012) also upheld the importance of the Kate stated that Jacob was an only child who
application of structural concepts, including had been shy and sensitive throughout his life.
enmeshment, to the relationship between families She shared that they would often leave family
and the larger social context. parties and other events early because Jacob
It is important to consider culture and commu- needed to go home. This was inconvenient and
nity before labeling a family as enmeshed. In embarrassing at times, but she understood how
some family systems, diffuse boundaries are not difficult it was for him. She was especially
problematic (Pinsof et al. 2018). In collectivist concerned that since beginning high school
cultures, low-income populations, or neighbor- 6 weeks earlier, Jacob had rarely been able to
hoods with high crime rates, it may be adaptive stay at school due to feeling very uncomfortable
or necessary for children to be very highly there.
914 Enmeshment in Couples and Families
At the first session, Kate and Jacob sat on the creating more functional boundaries between par-
couch next to each other, and Robert sat in the ents and Jacob. Kate reported that Robert and
chair. When the therapist asked Jacob a question, Jacob had bought her flowers. She also reported
Kate answered for him, and Robert remained that it felt good for Robert to be directly involved
silent. The therapist asked if this pattern of Kate in Jacob’s concerns (vs. complaining about them).
answering for Jacob was a common occurrence at The therapist asked Kate and Robert to discuss
home and, with some apparent discomfort, Kate their goals for Jacob moving forward. They agreed
admitted that it was. As the therapist explored the that their main goal was to ensure Jacob attended
family’s concerns, Robert expressed frustration school regularly. The therapist emphasized that this
that Kate often gave in to Jacob’s request to would require the parents to work together to set
leave social situations. He was particularly frus- consistent boundaries for Jacob. Specifically, they
trated that she often picked Jacob up from school would need to require that he stay at school. Kate
mid-morning after he called to say he was unable agreed but expressed concern about how to handle
to stay at school. Kate expressed that she wanted Jacob’s distress calls. The therapist asked the parents
Jacob to attend school, but she also wanted to to talk about how they were going to respond to
support and protect him. She stated that she did Jacob’s calls, keeping the conversation between the
not want him to suffer. At the end of the session, parents and, at one point, directing them to ask
the therapist asked for permission to contact the Jacob to wait until they completed their conversa-
school and subsequently had an initial conversation before he interjected. They decided that for the
tion with the school social worker about the time being, Jacob could call if he needed to do so,
school’s way of dealing with Jacob’s discomfort. but they would not pick him up. The therapist asked
After two sessions of observing interaction Kate to directly communicate this plan to Jacob.
patterns and thinking about the family structure, Kate proceeded to tell Jacob that he had to stay
the therapist hypothesized that Jacob’s autono- in school, and if he calls her to come home from
mous functioning at school was constrained by school early, she will speak with him to support
disengagement of his father, enmeshment with him in staying, but she will not pick him up. Jacob
his mother, and a somewhat divided parental sub- indicated he understood this and would try not to
system. Consistent with this, the therapist call. Robert reinforced that it was okay to call and
suggested that in order for Jacob to cope better that he would be open to receiving the call too, but
in social situations, he would need to be given they would not pick him up. The therapist initiated
more space and responsibility to learn to do a meeting with Jacob, the parents, and the school
so. Jacob said that would be fine with him, but social worker to identify what the school staff
Robert expressed doubts that when the time came would do and how they could support the plan.
Jacob would resist calling for help. The therapist Then the plan was launched.
asked Jacob to sit in a chair near his father and By setting a clear boundary and sticking to it,
talk about what challenges he would face and how the parents obligated Jacob to begin to cope with
he could handle it. The conversation began awk- his discomfort rather than involving others in an
wardly, but Jacob was able to talk about the dis- effort to avoid it. This was an important step in
comfort he felt at school. The therapist asked the establishing more autonomous functioning for
father and son to discuss this further during the Jacob, reduced enmeshment between him and
week and to find a small way of thanking Kate for his mother, more engagement with his father,
always being there for Jacob. and a strengthened parental subsystem.
When the family system returned for their next
session, the therapist immediately rearranged the
seating pattern such that Robert and Kate sat Cross-References
together on the couch, and Jacob sat in his own
chair. This arrangement represented the therapist’s ▶ Boundaries in Structural Family Therapy
goal of strengthening the parental subsystem and ▶ Disengagement in Couples and Families
Epistemology in Family Systems Theory 915
▶ Hierarchy in Family Systems Theory Introduction

▶ Integrative Systemic Therapy
▶ Structural Family Therapy Epistemology, or the study of how we know what
▶ Minuchin, Salvador we know (the process of knowing), was first intro-
duced into family therapy ideas and literature by
anthropologist Gregory Bateson. Epistemology
References involves “...certain propositions about the nature of
knowing and the nature of the universe in which we
Bograd, M. (1988). Enmeshment, fusion or relatedness? live and how we know about it” (Bateson 1972,
Journal of Psychotherapy & The Family, 3(4), 65–80.
p. 478). This concept is closely related to and cannot
https://doi.org/10.1300/j287v03n04_05. E
Colapinto, J. (2015). Structural family therapy. In be separated from ontology, the study of what we
T. Sexton & J. Lebow (Eds.), Handbook of family know (the content of knowing), and often the term
therapy (pp. 120–133). New York: Routledge. epistemology is used to discuss both aspects of
Fishman, H. C. (2012). Intensive structural therapy:
knowing (Bateson 1972). Often, the term epistemol-
Treating families in their social context. New York:
Basic Books. ogy is used to indicate a lens, ideology, worldview,
McAdams, C. R., Avadhanam, R., Foster, V. A., Harris, perspective, or framework that informs how some-
P. N., Javaheri, A., Kim, S., . . . Williams, A. E. (2016). one thinks, the perceptions they have, and the mean-
The viability of structural family therapy in the twenty-
ings they make that influence how they interact in
first century: An analysis of key indicators. Contempo-
rary Family Therapy, 38(3), 255–261. https://doi.org/ the world and with others. In turn, recursively, the
10.1007/s10591-016-9383-9. premises and beliefs they hold about the world
Minuchin, S. (1974). Families and family therapy. inform and reinforce or alter their epistemology.
London: Routledge.
Within family therapy, this concept is applied not
Minuchin, S., & Fishman, H. C. (1981). Family therapy
techniques. Cambridge: Harvard University Press. only to understanding the epistemology of clients
Nichols, M. P., & Davis, S. D. (2017). Family therapy: and how that may be related to being in therapy and
Concepts and methods (11th ed.). Boston: Pearson. possible solutions, but also to the therapist’s episte-
Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J.,
mology, which significantly influences how they
Rampage, C., & Chambers, A. L. (2018). Integrative
systemic therapy: Metaframeworks for problem solv- view therapy, how they perceive and interact with
ing with individuals, couples, and families. the client (or even view them as such), what utter-
Washington, DC: American Psychological ances or actions they attend to, what they focus on in
Association.
the session, what they perceive the problem (or not)
Wood, B. (1985). Proximity and hierarchy: Orthogonal
dimensions of family connectedness. Family Process, to be, what direction they will take, their therapy
24, 487–507. approach, and agenda for therapy, all of which
inform the questions they ask and what they do
and do not pay attention to in sessions. The thera-
pist’s epistemology colors every utterance, move-
Epistemology in Family ment, action, reaction, thought, direction, stance,
Systems Theory questions, statements, interpretations, conclusions,
understandings, meanings, etc. that the therapist
Bethany Simmons1 and Jana Sutton2 makes. This cannot be avoided. Much of this pro-
1
California Lutheran University, Thousand Oaks, cess of knowing can be largely unconscious or
CA, USA outside of a person’s awareness. While a person
2
University of Louisiana at Monroe, Monroe, may be unaware of their epistemology and, to
LA, USA some extent, access to their whole epistemology
may be impossible, one cannot not have an episte-
mology (Keeney 1983). To deny the existence of
Name of Concept epistemology, be unaware of, or refuse to see one’s
own epistemology still indicates an epistemology of
Epistemology in Family Therapy. epistemology.
916 Epistemology in Family Systems Theory
Theoretical Context for Concept reality is, one can never really know reality with-
out it also being a reflection of ourselves and
Inherent within an epistemology and ontology are the limits of our perception and experience. The
assumptions, presuppositions, beliefs, and propo- knower is always actively involved in
sitions that are held or accepted by the holder that constructing what it is that they know. This is the
become the building blocks of their epistemology. concept known as “constructivism” (Watzlawick
This filtering process filters everything happening 1984). Constructivism suggests that reality is only
in the world around them and is necessary to knowable through our constructions of it. Because
simplify a vast amount of complex information we cannot escape our own minds, we can never
into understandable and manageable pieces, really know a reality outside of our perception of
accepting some and discarding or ignoring others. it. Therefore, any attempt at objectivity will fail
This process is mainly unconscious to us and we because we cannot avoid our interpretation and
are unaware that we are doing this at all times. Our the lenses through which we filter our perceptions.
assumptions guide our perception, and how the Often, many assumptions and presuppositions go
stream of events or information perceived is punc- unquestioned and are often unknowingly accepted
tuated will in turn suggest how that information is and perpetuated. Bateson (1979) argued that
to be construed and understood constructing our cultural institutions such as religion, philosophy,
experience and view of reality based on our inter- art, and science, etc. often dictate fundamental
pretation and meaning of that punctuation. Two “Truths,” which are accepted without question
people experiencing the same event with two dif- and many lack knowledge of the presuppositions
ferent epistemologies can lead to different punc- inherent not only in these “Truths,” but in
tuations of that same event, which can lead each everyday life.
punctuator to differ in their perception of that Bradford Keeney, along with Douglas
event leading to different understandings and real- Sprenkle (Keeney and Sprenkle 1982), empha-
ities, and ultimately different decisions, interac- sized the importance of thinking about epistemol-
tions, and outcomes. Later in this chapter, a ogy in family therapy practice. Keeney (1983)
clinical example will be presented demonstrating made clear the distinction between a cybernetic
how two therapists with the same case would or circular epistemology and linear causal episte-
approach it very differently based on their mology, highlighting the significant paradigm
epistemology. shift a cybernetic epistemology makes in thinking
From this perspective, punctuations, beliefs, about human interaction and performing therapy.
and perceptions filter all experience and thusly Within family therapy, a focus on epistemology in
determine reality, but taken further, these punctu- the late 1970s into the 1980s, along with the ideas
ations can be self-validating. Through this self- of constructivism and second-order cybernetics
validation process, beliefs, punctuations, and per- began shifting the field into the exploration of
ceptions become reinforced by and mutually rein- postmodern philosophy and approaches to
force behavior of self and others in line with those therapy.
beliefs affecting the outcome in the direction of
those beliefs. Watzlawick et al. (1967) termed this
the “self-fulfilling” prophecy. Description
Because our understanding, beliefs, and
knowledge of the world are filtered through our One’s epistemology leads to particular ways of
epistemology and ontology, a “True” representa- arranging observed data or information and all
tion of reality cannot be known. Since our way of therapists diagnose and treat based on their epis-
knowing reality, or making sense of the world temology (Keeney 1979). Keeney (1979) distin-
around us, is always filtered through our episte- guished between a linear epistemology informing
mology and ontology, which in turn constructs our treatment (such as traditional psychiatric and
knowledge about reality and what we believe medical models of conceptualizing human
behavior) and one emphasizing a focus on ecol- reductionism cause and effect sequences, and
ogy, context, interrelation, complexity, patterns, either/or dichotomies (black and white thinking
and the relations between. “Cybernetic epistemol- that excludes the possibility that it might be both
ogy indicates a way of discerning and knowing at the same time) (Becvar and Becvar 2013). This
patterns that organize events” (Keeney 1982, shift from thinking in a linear manner to thinking
p. 154) and refers to punctuating the stream of within a systemic framework is often difficult for
information into seeing patterns and the relations many because it is so different from the dominant
between. While a distinct way of knowing, cyber- Western philosophy (Ray and Borer 2007), and
netic epistemology is often also discussed in fam- language systems often contribute to lineal
ily therapy literature as a “systems/systemic,” descriptions (Selvini Palazzoli et al. 1978).
E
“ecological,” “circular,” “nonlineal,” “recursive,” Keeney (1982) contended that a cybernetic
or “ecosystemic” epistemology (that may or may epistemology is more than a holistic view,
not embody cybernetics in application) (Keeney concerned with parts and wholes (e.g. seeing fam-
1979, 1982, 1983). ilies rather than individuals), but rather focuses on
A cybernetic and systemic epistemology rep- how parts and wholes are organized and their
resents the departure from a linear/causal view of “patterns of organization. . .that characterize men-
psychotherapy to a broader perspective that tal and living process” (p. 155). Within cybernetic
accounts for interactions, contextual factors, com- epistemology, there is a focus on how information
plexity, and recursive interplays between humans, is communicated and organizes the system and
their environment biology, language and meaning how that system organizes through their commu-
systems, culture, symptomatic displays, communication and transmission of information. Infor-
nicational patterns, cognitive processes, emo- mation is exchanged and fed back into the
tions, experiencing of reality, and relational interactional system through feedback loops,
dynamics. From this perspective, the individual whereby the system either absorbs the informa-
is seen as part of a larger whole (a system) in tion into its existing parameters (epistemological
which the focus is widened beyond a single per- frame) or has to alter the parameters (epistemo-
son to the network of relationships and context in logical frame) to accommodate for the “news of
which the individual is inseparable. This episte- difference” that is different enough to make a
mological distinction is the foundation and hall- difference within their interactions and meanings
mark of the development of the field of family (Bateson 1972). Similarly, von Bertalanffy’s Gen-
therapy, breaking from traditional psychiatric eral Systems Theory offered an alternative way to
philosophy. study and understand complex systems, particu-
This orientation to thinking about humans was larly biological systems that were not within the
(and still is) a radical shift in thinking about peo- linear, positivist, reductionist scientific paradigm
ple and mental health issues from the dominant (Hammond 2003). The epistemological shift from
discourse and paradigm. Typically, human prob- an intrapsychic individualistic perspective to a
lems, especially psychiatric, mental or behavioral relational systemic and cybernetic perspective
health problems, are thought about in terms of represents a dramatic revolution not only in
something wrong inside of the person, without how one thinks about human beings, but poses
consideration to the larger ecology, context, or significant ramifications for difference in how
the relationships of which that person is a part. therapy is approached and conducted (Watzlawick
This idea jives with a Western way of viewing the et al. 1967).
world. Western philosophy encourages indepen- From this perspective, one cannot separate the
dence (I am separate from you), a positivist tradi- person from the relationships of which they are a
tion (discovering ultimate truth and reality), part. No person exists in a vacuum or lives inde-
strong value-laden orientation (certain things are pendently from influencing and being influenced
good and bad, rather than things just are and we by others. Watzlawick et al. (1967) asserted that
place the meaning or value onto them), all behavior must be understood in the relational
context of which it is a part and cannot be sepa- be defined as an interactional system within which
rated from that context. Therefore, relationships, the participants interact with one another for a
communication, and interaction are seen as a vital given purpose. Keeney (1983) pointed out that
key to understanding human behavior. This view operating from a nonlineal, cybernetic position
of human relations considers the patterns of inter- in therapy accounts for and recognizes both the
actions and denotes a recursive nature, whereby therapist’s and the client’s influence in the therapy
each mutually participates in the dynamics that system, stating that to focus on only the effect of
arise. Within family therapy, this is referred to as the therapist on the client is one-sided and lineal.
mutual or circular causality (Becvar and Becvar By seeing the therapist and client in a reciprocal
1999). Typically, from a linear perspective, cause relationship, everything that happens in therapy,
and effect are separated from the larger whole how each participant thinks, feels, responds, and
pattern of interaction and does not take into relates to one another indicates their own episte-
account those interactions that come before or mology as well as a new shared epistemology
after that particular sequence that has been about the nature of their relationship. This is a
abstracted. Systemically, linear cause and effect product of, and then in turn, influences the product
segments are only part of a larger circular whole of, that interaction and context.
(Keeney 1983). A systemic and cybernetic epistemology is a
As Keeney (1982) described, “The fundamen- way of drawing distinctions about the world and
tal act of epistemology is to draw a distinction therapy, which makes a significant difference in
. . .All that we know, or can know, rests upon the practice, the meanings that are made, and how
distinctions we draw” (p. 156), otherwise known therapy progresses. The concepts of epistemol-
as punctuation. A systemic perspective encour- ogy, second-order cybernetics, and constructivism
ages a view of interaction and relationship – see- are inextricably linked. Ironically, as these con-
ing that our thoughts, feelings, and behaviors are cepts gained momentum, some began to challenge
connected to the thoughts, feelings, and behaviors systemic/cybernetic premises that predominantly
of another and can only be separated by punctua- tied the variety of family therapy models together,
tion or how the sequences are separated and calling for a “new epistemology” (e.g., Hoffman
focused upon by the observer (Watzlawick et al. 1985; Goolishian and Anderson 1987). These
1967). How both the client and therapist punctu- authors summoned for a revisioning of family
ate the world and therapy and each other con- therapy and promoted a shift into “postmodern”
structs a shared therapeutic reality (Keeney approaches to therapy focused on an epistemol-
1982). Language and “linguistic conditioning” ogy of language and meaning making systems.
also informs and constrains how we describe, Yet, the way in which distinctions have been
define, and punctuate the stream of events around drawn around theory and ideas have spawned
us – ultimately playing a major role in our episte- epistemological debates that have spanned
mological frames and understanding (Selvini throughout family therapy history from the very
Palazzoli et al. 1978). beginning. While the “modern/postmodern” dis-
From a systemic and cybernetic framework, tinction may be a more recent “us/them” divide in
the observer is just as important as those being the family therapy field, competition and rivalry
observed. Viewing the observer as interconnected are no strangers to family therapy. In fact, thinking
with what they are observing, studying that rela- about epistemology and how we know what we
tionship between observer and observed, and rec- know has been perpetuated through family ther-
ognizing that observations from the observer will apy generations by drawing distinctions through
always include the observer’s epistemological the competition of ideas, models of therapy, and
premises and subsequent actions based on those philosophies. Epistemological challenges to psy-
premises. This view became known as second- chiatry defined the emergence of the family ther-
order cybernetics (Keeney 1983). This means apy field and continued through the development
that therapy is also a relational context and could of certain “schools” or “camps” of family therapy
and how they positioned themselves in contrast to Application of Concept in Couple and
others emerging. And, even though the family Family Therapy
therapy “originators” often collaborated and
co-developed the family therapy movement, the Each approach to therapy has a theory of practice.
division of the “originators” into “schools” often Every approach is built on an epistemological
obscured the common ground and connectivity of framework informed by presuppositions and
these theoreticians. As Minuchin and Nichols ideas guiding practice and how to interact with
(1993) described, each theorist, researcher, another person defined as a “client.” This philos-
“school,” of therapy honed in on and focused on ophy will influence what the person will do when
a specific aspect of therapy and human life based they come in contact with said “client.” As Kerr
E
on their biases, premises, ideas, perceptions, and and Bowen (1988) asserted, “. . .a therapist is what
clinical work distinguishing themselves from each his THEORY TELLS HIM TO BE” (p. 366).
other. Often these debates emulate a dualistic lin- Moreover, this cannot be escaped. As Whitaker
eal thinking about ideas, without acknowledge- (1989) contended, “all psychotherapy is based
ment of the self-referential nature of making upon a set of assumptions” (p. 159). And, Keeney
those distinctions, and have lacked viewing the and Sprenkle (1982) described theory as “. . .the
systemic dynamics of the larger ecology of family relation between one’s epistemology and habits of
therapy contributors and their philosophies as action. . .” (p. 5). The therapist’s epistemology
they evolved over time. In other words, the informs all aspects of their work and how they
debates have failed to include a systemic episte- interact with clients. If a therapist’s epistemology
mology of epistemology and how we know what stipulates that problems are the result of an illness,
we know in family therapy. they will look for pathology and medical ways to
And it can be argued that through a systemic cure the disease. If their epistemology permits
epistemology of epistemology, one can find the symptoms to be seen in a larger systemic rela-
patterns across epistemologies and identify the tional context, they may find something very dif-
relationships between even seemingly opposite, ferent and develop vastly different strategies to
dichotomous, or distinct epistemologies, specifi- assist that client. What the therapist sees indicates
cally within family therapy. By redrawing the their epistemology – “. . .descriptions reveal prop-
distinctions that have been made about family erties of the observer” (Keeney 1982, p. 163).
therapy ideas and how they have been portrayed If the clinician’s theory of practice says that
over time, even reified distinctions can be trans- people are stuck because of the ways they have
cended to a higher epistemological level to tried to solve the problem, they will try to help
include the relationships between and patterns of them find ways to solve their problem differently.
connection such as the “modern/postmodern” If their theory of practice says people are in their
dichotomy in family therapy (Simmons 2010). office because they overlook their own resources,
Keeney (1982) surmised “How we know (and they will most likely try to help them discover
don’t know) is inseparable from how we their resources. If their theory of practice says that
behave. . .Therapy becomes epistemology” the way a person tells their story overlooks other
(p. 167). “All description is self-referential” ways to interpret and experience those events,
(Keeney 1983, p. 77) – what we say and do says they might help them find new ways to tell their
just as much about our epistemology as it informs story or discover/create overlooked hidden assets.
what we say and do, which informs our episte- If their theory of practice says that people have
mology. Applying epistemology to how we think problems because they have poor boundaries,
about our thinking, therapy, human behavior and they most likely will help them have better, clearer
include our participation in that equation may be boundaries. If their theory of practice says that in
one of the most significant contributions and disorder to be helpful they must be creative in the
tinctions of family therapy in relation to other moment, they will go in the room trying to be
social sciences and psychological disciplines. creative. If their theory of practice says that the
way people talk about their problems constricts One cannot not have a therapeutic epistemol-
them, they might help open up space in the con- ogy or influence in the therapy room; there is
versation to create new possibilities or ways of something that is guiding the thought process
dialoguing about the problem. If their theory of and behavior of the therapist while with a client.
practice says problems derive from a person’s As Minuchin (1974) asserted, “the scope of the
irrational thoughts that drive problematic behav- family therapist and the techniques he uses to
ior, the therapist will work toward helping them pursue his goals are determined by his theoretical
have more rational thoughts. If their theory of framework” (p. 14). And furthermore, "it must be
practice says that problems are a result in how recognized that techniques are designs or contriv-
people relate to their problems and with each ances which implement a rationale of therapy"
other, they will attempt to help them relate differ- (Framo 1965, p. 149). And, the therapist’s episte-
ently to their problems and each other. If the mology is an accumulation of learned ideas that
clinician believes symptoms are a result of disease can derive from many places from science to
or chemical imbalance, they may refer them to a graduate education to culture to personal
medical doctor for medication and decide there is experience.
nothing they can do to help them. There are at least two ways this can be poten-
Each philosophy guides how the therapist will tially detrimental or dangerous: if the therapist
view everything, what direction they will take, cannot, does not, or refuses to recognize the pre-
what questions they ask, who and what they mises and epistemology they enter the room with
focus on, and how they will use themselves in and/or they rigidly adopt one position without
the therapy room. This view will determine their variance. Both of these positions are limiting and
intentions for their interaction with the client(s). can limit the possible avenues and directions a
Every therapist is intentional about how they therapist may take. A therapist may not ask a
approach clients, enter the room, utilize the ses- vital question or use a potentially helpful tool
sion time, and interact with the people they are in because it does not fit within their epistemological
the room with. While these may not be concrete framework. Anytime someone is focused in one
steps, some type of organizing thought guides the direction, there are also many things they
person’s intentions when entering the therapy may not be seeing that fall outside of that
room. This too cannot be escaped. Intentionality epistemological view.
is built into a therapist’s working philosophy And the client’s epistemology is relevant to
about what they are doing, the purpose for them how they will interpret and respond to the thera-
being there, and what it means to be a therapist. pist and their approach. This dynamic give-and-
Whether a therapist is trying to provoke change, take shape therapy, the nature of the therapeutic
eliminate symptoms, help the system function relationship, how therapy progresses over time or
better, change the dialogue and conversations doesn’t, how the client and therapist treat each
people have, help people communicate better, other and relate to one another and the outcome
elicit an experience that sparks growth, open up of therapy. When therapy is successful, the thera-
space for new possibilities to emerge, assist with pist and client have created a shared epistemology
new ways of thinking about things, or interacting that works to meet the needs of that context.
with others etc., the therapist has in their mind the
purpose of being in that room and charging that
person for that session. The therapist has an inten- Clinical Example
tion just by being a therapist whether that is to
make some money, help people, or sit and have a Within this clinical example, we provide a
conversation with someone for an hour, there is vignette case example and illustrate both a sys-
purpose and intent implicit within the use of the temic and a lineal epistemology. This example
space and time as well as the role of being a will demonstrate how two different epistemol-
“therapist.” ogies can influence the conceptualization of
therapy, approach to treatment and the client, this path, he could end up a junkie, in jail and is
which can lead therapy in two different directions. likely to never finish school. You stress the impor-
tance of him attending the Alcoholics Anonymous
Vignette Case Example group he was ordered to attend by the court in
Jose, a 25-year-old Mexican-American man, finds addition to your therapy so he can get back on the
himself in your therapy office after his 5th DWI. right track. You begin your therapy by setting
From his intake paperwork, you know that he has goals for him to change his people, places, and
previously been diagnosed with bipolar disorder, things. His first homework assignment is to end
after being hospitalized a couple years ago, and his friendships with the “friends” getting him into
takes medication on and off for this. He is on the trouble, many of which work at the restaurant
E
verge of failing out of college, but indicates a where he works. You recommend that he should
desire to finish so he can be the first in his family start looking for another job as well.
to earn a college degree. In addition to going to
college, he works part-time at a restaurant. He Systemic Epistemology
reveals that the latest DWI resulted from taking You begin your work with Jose by trying to learn
pills at a “pill party.” more about how he views his situation, his atten-
dance in therapy, and his perspective. You listen to
Lineal Epistemology the words he uses, how he describes his experi-
You begin your work with Jose by asking him a ences and how he makes sense of them, in addi-
series of questions to understand the etiology of tion to observing any nonverbal communication
his substance abuse, with a hunch that it may be cues. You begin to wonder how does it make sense
related to not taking the medications for his bipo- that Jose finds himself in this situation? What is
lar disorder. This seems to be confirmed when he happening in Jose’s life and context that he would
states that he hates having to take that “awful be hospitalized, receive a diagnosis of Bipolar
medication” they prescribed him that makes him Disorder, not consistently take the medication
“feel like a zombie.” Through your questions, you prescribed, attend a “pill party,” take pills, have
discover that he copes with pressure and failure by 5 DWI’s, be failing college, but is still attending,
drinking and after he failed a major examination is still able to work part-time and still have a goal
and therefore an important class, he drank too of finishing his degree? You find out his first DWI
much and got his first DWI. was after he failed a final for one of his major
You begin to explore what he is thinking when courses, had couple of drinks and drove home.
he is experiencing pressure that leads him to cope This occurred a few months before he was hospi-
by drinking. He says the pressure makes it hard for talized for “attempting suicide.” He reveals that he
him to concentrate and then he just knows he’s hates having to take that “awful medication” they
going to fail because he cannot think clearly. You prescribed him that makes him “feel like a
begin to educate him on the problem with this way zombie.”
of thinking and how that contributes to him fail- As he talks about this, he hangs his head and
ing. You explore with him how he could think says that he promised himself he’d never be like
different thoughts when he is feeling pressured so his abusive alcoholic father. You probe further and
that he could see the pressure differently. You also ask him about his relationship with his father. He
educate him on his substance abuse problem. You shares that he comes from a very traditional Mex-
tell him that many people use substances to self- ican family and his father embodies the stereotyp-
medicate mental illness when they don’t take their ical “machismo” role. Jose discloses it would get
medications as prescribed. You begin to reiterate worse after his father would drink and would often
the importance of taking his medication and that take out his frustrations by yelling and hitting his
should make it less likely he would feel the need mom, himself, and younger siblings from having
to medicate himself through alcohol or abusing to work two physically laborious jobs. Jose says
pills. You let him know that if he keeps going on he set out to attend college and be successful so
that he wouldn’t have to work two jobs like his participates in that dynamic. You also want to help
father and to help take care of his mom and youn- him work toward his goals of being loyal to his
ger siblings, but now he is failing and can’t deal family, while not having to be just like them, and
with the thought of ending up like his father. You finishing school. Together with Jose, you both
ask him more about what was going on in his life explore ways to work toward these goals where
that he attempted suicide. He answers by saying drugs and alcohol are no longer problematic for
the night before his final exam that he failed, he him and discuss the possibility of inviting his
was eating dinner at home with his family and family to therapy.
“things blew up.” His father became enraged at
Jose saying he needed to help them more and quit
school so he could be a man and help provide for Cross-References
his family. Jose says he was so upset by what
happened the night before, he couldn’t concen- ▶ Bateson, Gregory
trate and failed a major exam that was in a class he ▶ Circular Causality in Family Systems Theory
had to pass. ▶ Communication Theory
He said after the first DWI things have been ▶ Context in Family Systems Theory
down-hill ever since. He states he just couldn’t ▶ Hoffman, Lynn
take the pressure from his family, from school, ▶ Keeney, Bradford
from work and then with the court he’d find any- ▶ Linear Causality in Family Systems Theory
thing to feel free from that. Drinking with his ▶ Postmodernism in Couple and Family Therapy
buddies seemed to help and then one night his ▶ Punctuation in Family Systems Theory
friend offered him a Xanax. This is how he ended ▶ Second-Order Cybernetics in Family Systems
up with a second DWI. After the third, he was Theory
hospitalized when he took three Xanax and drank
too much. When the psychiatrist evaluated him
prior to release, she determined that he was References
attempting suicide due to the amount of sub-
stances he had taken and involuntarily hospital- Bateson, G. (1972). Steps to an ecology of mind.
ized him. He says the only things keeping him New York: Ballantine.
Bateson, G. (1979). Mind and nature. New York: Dutton.
going are his job, knowing he has to work to Becvar, D. S., & Becvar, R. J. (1999). Systems theory and
survive, and the hope that one day he will get his family therapy: A primer (2nd ed.). Lanham, MD:
degree so that he could have a better life. He says University Press of America.
he’s never talked about any of this with anyone Becvar, D. S., & Becvar, R. J. (2013). Family therapy:
A systemic integration (8th ed.). New York: Pearson.
and it feels good to be able share what’s going on Framo, J. (1965). Rationale and techniques of intensive
him with someone who gets it. family therapy. In I. Boszormenyi-Nagy & J. Framo
You begin to see how much his family means (Eds.), Intensive family therapy: Theoretical and prac-
to him and despite the difficulties in their relation- tical aspects (pp. 143–212). New York: Harper & Row.
Goolishian, H., & Anderson, H. (1987). Language systems
ships he says it’s important for him to be loyal to and therapy: An evolving idea. Psychotherapy, 24(35),
them. You begin to have some ideas about the 529–538.
relational context where Jose’s behavior makes Hammond, D. (2003). The science of synthesis: Exploring
sense. Through his story, you see that Jose is the social implications of general systems theory. Boul-
der: University Press of Colorado.
doing the best he can in very difficult circum- Hoffman, L. (1985). Beyond power and control: Toward
stances. It becomes clear that the concerns for a “second-order” family systems therapy. Family Sys-
and about his family, his culture, and epistemol- tems Medicine, 3(4), 381–396.
ogy have something to do with the situation he Keeney, B. (1979). Ecosystemic epistemology: An alter-
native paradigm for diagnosis. Family Process, 18(2),
finds himself in. You begin to focus your ques- 117–129.
tions and work around the interactional context Keeney, B. (1982). Not pragmatics, not aesthetics. Family
between Jose and his family, as well as how he Process, 21(4), 429–434.
Epstein, Nathan 923
Keeney, B. (1983). Aesthetics of change. New York: understanding, assessing, and diagnosing family
Guilford Press. functioning. Using the MMFF as a foundation,
Keeney, B., & Sprenkle, D. (1982). Ecosystemic epistemol-
ogy: Critical implications for the aesthetics and pragmat- Dr. Epstein created a treatment model called the
ics of family therapy. Family Process, 21, 1–19. problem-centered systems therapy of the family
Kerr, M., & Bowen, M. (1988). Family evaluation: (PCSTF), a therapeutic approach that focuses pri-
An approach based on Bowen theory. New York: marily on the overall stages of therapy rather than
W.W. Norton.
Minuchin, S. (1974). Families and family therapy. specific interventions and strategies. Together, the
Cambridge, MA: Harvard University Press. MMFF and PCSTF constitute the McMaster
Minuchin, S., & Nichols, M. P. (1993). Family healing: approach to family therapy. In addition,
Strategies for hope and understanding. New York: Free Dr. Epstein helped create instruments and a struc-
Press. E
Ray, W. A., & Borer, M. (2007). Tracking talk in therapy- tured interview used in the practice of the
12 useful maps. Journal of Brief, Strategic Therapies, McMaster approach.
1(1), 69–84.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., &
Prata, G. (1978). Paradox and counterparadox:
A new model in the therapy of the family in schizo- Career
phrenic transaction. New York: Jason Aronson.
Simmons, B. S. (2010). Family therapy legacies and the In 1948, Dr. Epstein received his M.D. at the
patterns that connect: Transcending the modern/post- Dalhousie University Faculty of Medicine in
modern dichotomy in family therapy. Retrieved from
ProQuest Dissertations & Theses A&I. (3446927). Canada. He completed his internship at Boston
Watzlawick, P., Beavin Bavelas, J. H., & Jackson, D. D. University Medical Center and residency in psy-
(1967). Pragmatics of human communication: A study chiatry at the Columbia University School of Pub-
of interactional patterns, pathologies, and paradoxes. lic Health. While at Columbia University,
New York: W.W. Norton & Company.
Watzlawick, P. (Ed.). (1984). The invented reality: How do Dr. Epstein trained with Dr. Nathan Ackerman,
we know what we believe we know? (contributions to another pioneer in the field of family therapy.
constructivism). New York: W.W. Norton. Following his training at Columbia University,
Whitaker, C. (1989). Midnight musings of a family thera- Dr. Epstein and his colleagues at McGill Univer-
pist. New York: W.W. Norton.
sity in Montreal, Canada, began research in the
area of family studies. His research lab was moved
to McMaster University in Ontario, Canada, in
1966, where he became a founding chair of the
Epstein, Nathan Department of Psychiatry, and held that position
until 1975. In 1980, Dr. Epstein and his col-
Kamran K. Eshtehardi and Molly F. Gasbarrini
leagues, Dr. Duane Bishop and Dr. Gabor Keitner,
moved their research to Brown University in
Alliant International University, Los Angeles,
Providence, Rhode Island, where he created the
CA, USA
Brown University Family Research Program.
Name of Person
Contributions to the Profession
Dr. Nathan B. Epstein
Dr. Epstein is recognized as the primary developer
of the McMaster model of family functioning
(MMFF), a comprehensive and normative family
Introduction model that integrates validated assessment instru-
ments and an evidence-based family treatment
Dr. Nathan B. Epstein is the primary originator of process. Dr. Epstein began development of the
the McMaster model of family functioning model in the mid-1950s at McGill University.
(MMFF). The MMFF is a theoretical basis for During this time, Epstein and his colleagues
924 Epstein, Norman
sought to describe various dimensions of family Dr. Epstein and his colleagues as an alternate
life and developed a classification system called means of producing an MCRS score in situations
the Family Category Schema. It was after Epstein where the interviewer is clinically inexperienced
moved to McMaster University that the Family or unfamiliar with the McMaster approach. In
Category Schema evolved into the MMFF. Sub- addition, the McSiff is used by therapists to gain
sequently, at Brown University, Epstein and his experience in interviewing, to learn therapeutic
colleagues continued to refine and build upon structure, and as a teaching tool for learning the
the MMFF. McMaster approach.
In 1981, Drs. Epstein and Bishop published a
model for conducting therapy based on the
MMFF called the Problem centered systems ther- Cross-References
apy of the family (PCSTF). The PCSTF approach
shifted the focus from subtle interventions and ▶ Family Assessment Device
strategies to the overall stages of therapy as the ▶ McMaster Clinical Rating Scales
essential components of treatment. By utilizing ▶ McMaster Family Therapy
this structure, the PCSTF sought to facilitate
effective treatment by therapists of various styles
and levels of experience. Research findings on the References
efficacy of the PCSTF have shown positive treat-
Epstein, N. B., & Bishop, D. S. (1981). Problem centered
ment outcomes for patients and families manag- systems therapy of the family. Journal of Marital and
ing depression and bipolar disorders. Family Therapy, 7(1), 23–31.
In 1982, Epstein and his colleagues Epstein, N. B., Bishop, D. S., & Levin, S. (1978). The
Dr. Lawrence Baldwin and Dr. Bishop published McMaster model of family functioning. Journal of
Marriage and Family Counseling, 4(4), 19–31.
an instrument based on the MMFF called the Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983).
McMaster family assessment device (FAD). The The McMaster family assessment device. Journal of
FAD, a self-report questionnaire used to gather Marital and Family Therapy, 9(2), 171–180.
measureable feedback from family members, Miller, I. W., Kabacoff, R. I., Epstein, N. B., Bishop, D. S.,
Keitner, G. I., Baldwin, L. M., & Van der Spuy, H. J.
assessed family functioning by incorporating (1994). The development of a clinical rating scale for
each of the family members’ perceptions of the the McMaster model of family functioning. Family
family’s functioning. The FAD has been used in a Process, 33(1), 53–69.
variety of settings and cultures and has been trans- Ryan, C. E., Epstein, N. B., Keitner, G. I., Miller, I. W., &
Bishop, D. S. (2005). Evaluation and treating families:
lated into over 20 different languages. The McMaster approach. New York: Routledge/Taylor
The McMaster clinical rating scale (MCRS) & Francis Group.
was also developed in 1982 by Epstein and his
colleagues. The MCRS evaluated family func-
tioning through a clinical interview conducted
by a therapist familiar with the MMFF. The Epstein, Norman
MCRS provided an objective summary of the
various dimensions that contributed to a family’s Mariana K. Falconier
functioning and acted as a guide that enabled a Virginia Polytechnic Institute and State
therapist to perform a thorough evaluation of the University, Falls Church, VA, USA
patient and family members. The MCRS was
designed to be flexible in that it could be tailored
to the needs of the family and the therapeutic Introduction
environment, and it correlated moderately with
the FAD. Dr. Norman Epstein is a clinical psychologist and
The McMaster structured interview of family marriage and family therapist, clinical and
functioning (McSiff) was developed in 1987 by research supervisor, teacher, and researcher
Epstein, Norman 925
focusing on cognitive-behavioral theory, assess- Washington Post, Baltimore Sun, Los Angeles
ment, and treatment of couples and families, with Times, and Wall Street Journal. He is an
a systemic lens and special attention to domestic approved supervisor of the American Associa-
violence and culturally sensitive treatment tion of Marriage and Family Therapy (AAMFT)
models. and is a clinical fellow of AAMFT, a fellow of
the American Psychological Association, a
member of the Association for Behavioral and
Career Cognitive Therapies, a member of the Groves
Conference on Marriage and the Family, a dip-
Dr. Epstein obtained his Bachelor of Arts, Mas- lomate of the American Board of Assessment
E
ter of Arts, and Doctoral degrees in psychology Psychology, and a founding fellow of the Acad-
from the University of California at Los Angeles emy of Cognitive Therapy. Dr. Epstein has been
in 1969, 1970, and 1974, respectively. He was the recipient of awards for his contributions in
first an assistant professor in the Department of community mental health and the prevention of
Psychology at the State University of New York domestic violence, and his research has been
at Buffalo and in Psychology in Psychiatry at funded by NIMH, SAMHSA, and the Henry
the School of Medicine at the University of M. Jackson Foundation for the Advancement
Pennsylvania. In 1983 he joined the Department of Military Medicine. He has been on the edito-
of Family Science (former Department of Fam- rial boards of the Journal of Cognitive Psycho-
ily Studies) at the University of Maryland, Col- therapy, Psychological Assessment, Behavior
lege Park as an assistant professor, and was Therapy, the Journal of Marital and Family
promoted to associate professor in 1986 and Therapy, Family Process, Cognitive and Behav-
professor in 1992. He has been director of the ioral Practice, Journal of Sex and Marital Ther-
department’s nationally accredited Couple and apy, Journal of Couple and Relationship
Family Therapy Program since 2003. He has Therapy, and International Journal of Cogni-
taught both graduate and undergraduate courses tive Therapy.
on theory and research on couple and family
relationships, couple and family therapy,
research methods, and human sexuality, has Contributions to Profession
provided clinical supervision to student thera-
pists, and directed over 85 master’s theses and Dr. Epstein’s main contributions lie in the area of
doctoral dissertations. He has held licenses as cognitive-behavioral theory, assessment, and
both a clinical psychologist and clinical mar- treatment of couples and families, including the
riage and family therapist in Maryland where area of domestic violence. He also has focused on
he has had a part-time private practice for over understanding and treating individual psychopa-
40 years. He has presented 120 research papers thology within the family context. Regarding
as well as 88 training workshops on couple and individual functioning and psychopathology,
family therapy at national and international pro- Dr. Epstein worked with Dr. Aaron Beck at the
fessional meetings. He has also authored Center for Cognitive Therapy in Philadelphia and
56 book chapters (at least 50 in cognitive theory contributed to the development and assessment of
and cognitive-behavioral family and couple the widely used Beck Anxiety Inventory (Beck
therapy) and 58 peer-reviewed journal articles. et al. 1988) and the Beck Self-Concept Test (Beck
He has coauthored two books on cognitive- et al. 1990). However, his research and clinical
behavioral therapy for couples and has edited work increasingly focused on couples and fami-
two more books. His work has received media lies. He published the first description of cognitive
attention through appearances in radio talk therapy with couples (Epstein 1982) and articles
shows and published interviews in newspapers describing the development of the first measure of
of wide circulation such as the New York Times, couple relationship cognitions, the Relationship
926 Epstein, Norman
Belief Inventory (Epstein and Eidelson 1981; involved in the implementation and evaluation of
Eidelson and Epstein 1982). Subsequently he a family psychoeducational intervention program
conducted an extensive collaboration with Donald for schizophrenia and an evaluation of effects on
Baucom, investigating the role of cognitions in family relationships of engaging military service
the functioning of intimate relationships. This members with posttraumatic stress disorder in
work led to their typology of cognitions, including training in service dogs for placement with phys-
assumptions, attributions, standards, expectan- ically disabled service members.
cies, and selective attention (Baucom
et al. 1989), their development of an instrument
to measure relationship standards, the Inventory
Cross-References
of Specific Relationship Standards (Baucom
et al. (1996), and two groundbreaking books on
▶ Baucom, Donald
cognitive-behavioral couple therapy (Baucom and
Epstein 1990; Epstein and Baucom 2002).
Dr. Epstein also developed the Marital Attitude
Survey with James Pretzer and Barbara Fleming
References
(Pretzer et al. 1991) that assesses attributions and
expectancies. Dr. Epstein played a major role in Baucom, D. H., Epstein, N., Rankin, L. A., & Burnett,
incorporating systemic concepts into cognitive- C. K. (1996). Assessing relationship standards: The
behavioral treatment by emphasizing the interplay inventory of specific relationship standards. Journal
of Family Psychology, 10, 72–88.
among partners’ cognitions, emotions, and behav-
Baucom, D. H., Epstein, N. B., Sayers, S., & Sher, T. G.
iors so that problematic patterns of interaction (1989). The role of cognitions in marital relationships:
could be better understood and changed. His Definitional, methodological, and conceptual issues.
work has been praised for its integration in assess- Journal of Consulting and Clinical Psychology, 57,
31–38.
ment and treatment of partners’ individual char-
Baucom, D. H., & Epstein, N. (1990). Cognitive behav-
acteristics and personal histories and their past and ioral marital therapy. New York: Brunner/Mazel.
present dyadic interactions. Dr. Epstein developed Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988).
a cognitive-behavioral intervention protocol to An inventory for measuring clinical anxiety: Psycho-
metric properties. Journal of Consulting and Clinical
safely treat couples experiencing psychological
and mild to moderate physical partner aggression Beck, A. T., Steer, R. A., Epstein, N., & Brown, G. (1990).
and conducted a clinical trial, the Couples Abuse Beck Self-Concept Test. Psychological Assessment: A
Prevention Program (CAPP), comparing it to Journal of Consulting and Clinical Psychology, 2(2),
191–197. https://doi.org/10.1037/1040-3590.2.2.191
other systemic models of couple therapy. In addi-
Eidelson, R. J., & Epstein, N. (l982). Cognitio n and
tion to his university teaching and research, relationship maladjustment: Development of a measure
Dr. Epstein has disseminated his cognitive- of dysfunctional relationship beliefs. Journal of Con-
behavioral treatments for couples and families sulting and Clinical Psychology, 50, 715–720.
Epstein, N., & Eidelson, R. J. (l98l). Unrealistic beliefs of
internationally, but he has especially provided
clinical couples: Their relationship to expectations,
extensive training in China regarding couple and goals, and satisfaction. American Journal of Family
family therapy models, contributing to the rapid Therapy, 9, 13–22.
growth of such treatment approaches there, and Epstein, N. (l982). Cognitive therapy with couples. American
has published articles on culturally sensitive adap-
tations of Western-derived therapy models in behavioral therapy for couples: A contextual approach.
China. He has also conducted several studies Washington, DC: American Psychological
with colleagues in China advancing knowledge Association.
Pretzer, J., Epstein, N., & Fleming, B. (1991). The marital
about couple and family relationships. Further- attitude survey: A measure of dysfunctional attribu-
more, consistent with his focus on psychopathol- tions and expectancies. Journal of Cognitive Psycho-
ogy in the family context, Dr. Epstein has been therapy: An International Quarterly, 5, 131–148.
Epston, David 927
Sociology & Anthropology at Auckland University

Epston, David (1969), he returned to Canada to study sociology at
the University of British Columbia, and then earned
Peggy Sax1, Kay Ingamells2, Dean Lobovits3 and a Diploma in Community Development from Edin-
Sasha McAllum Pilkington4 burgh University in 1971. He spent time in Australia
1
Re-authoring Teaching, Inc, Middlebury, VT, working for the Department of Aboriginal Welfare
USA in the Northern territory before returning in 1973 to
2
Narrative Apprenticeship, Auckland, New Zealand to work as a medical social worker. In
New Zealand the United Kingdom, he then studied Applied Social
3
Narrative Approaches, Berkeley, CA, USA Studies and Social Work at the University of War-
4 E
Hospice North Shore, Auckland, New Zealand wick. He rigorously researched the videotapes of
legendary family therapists at The Family Institute
in Cardiff, Wales. His studies established the influ-
Name ences of anthropology, social constructionism, Fou-
cault, and Milton Erickson.
David Epston. Returning to New Zealand, David worked as
a senior social worker in a Child and Adolescent
Mental Health Service and as a consultant fam-
Introduction ily therapist at the Leslie Centre in Auckland
(1981–1987). With Johnella Bird, he developed
David Epston is the co-creator of Narrative a teaching partnership and they became
Therapy – a collaborative and non- co-directors of The Family Therapy Centre in
pathologizing approach to family therapy, Auckland.
counseling, and community work that centers David has lectured extensively at home in
people as the experts of their own lives and New Zealand and through workshops and guest
identities. The intellectual partnership between lectures around the world. After Michael’s death,
David Epston and Michael White initiated in he continued a long-standing association with
1980 founded a narrative family therapy frame- The Dulwich Centre in Adelaide.
work infused with a spirit of adventure and From its inception in 1980 until 1990, David was
invention based on a shared political philoso- editor of Story Corner in the Australian and
phy. Narrative Therapy views problems New Zealand Journal of Family therapy. From
as separate from people and engages people in 2006–2017, he was editor of The Story Corner in
re-authoring the stories of their lives by devel- the Journal of Systemic Therapies. Together with
oping counter storylines that revive and vivify Tom Stone Carlson and Marcela Polanco, he is
hopeful, preferred ways of living and being in current co-editor of an online Journal of Narrative
relationships. David has disseminated this Family Therapy.
approach for 30 years through his teaching and In 1996, David was awarded an honorary
lively collaborations with partners in 19 coun- Doctor of Humane Letters (D.Litt.) by the
tries and has authored or co-authored ten books Graduate School of Professional Psychology,
that have been translated into many languages. John F. Kennedy University, in Orinda, Califor-
nia. He received a Special Award for Distin-
guished Contributions to Family Therapy from
Career the Australian and New Zealand Journal of Fam-
ily Therapy (2002) and from AFTA (American
David Epston was born in 1944 in Peterborough, Association of Family Therapy) in 2007 for Dis-
Ontario, Canada. At 19, he arrived by tramp steamer tinguished Contribution to Family Therapy The-
in New Zealand. After completing a BA degree in ory and Practice.
928 Epston, David
Contributions to the Profession Cross-References
David Epston’s collaboration with Michael White ▶ Deconstruction in Narrative Couple and Family
was founded on a shared commitment to creating Therapy
a partnership without competition. Together they ▶ Deconstructive Listening in Couple and Family
co-authored Narrative Means to Therapeutic Therapy
Ends – and developed much of the theory and ▶ Externalizing in Narrative Therapy with Cou-
practices of narrative therapy. ples and Families
David is known for bringing an ethnographic ▶ Narrative Couple Therapy
and auto-ethnographic approach to narrative ▶ Poststructuralism in Couple and Family
practice. Collecting a library of videotapes of Therapy
young people’s “asthma knowledges,” he coined ▶ Problem-Saturated Stories in Narrative Couple
the term “co-research” to signify a collective and Family Therapy
approach to narrative practice. Additional collec- ▶ Re-authoring Teaching
tive insider knowledge projects include: The Anti- ▶ White, Michael
anorexia League and the internet-based Archive ▶ Witnessing in Narrative Couple and Family
of Resistance: anti-anorexia/anti-bulimia. David Therapy
pioneered therapeutic letter writing as a
narrative therapy practice. He brought radical
and inventive approaches to such childhood prob- References
lems as intractable sibling disputes, chronic bed-
wetting, extreme temper tantrums, stealing, fears, Epston, D. (2008). In B. Bowen (Ed.), Down under and up
over: Travels with narrative therapy. London: Karnac
and responses to trauma. He has developed a
Books.
significant number of breakthrough books and Epston, D. (2016). Re-imagining narrative therapy:
website collaborations internationally. A history for the future. Journal of Systemic Therapies,
His innovations include creating and develop- 35(1), 79–87.
Epston, D., Maisel, R., & Borden, A. (2004). Biting the
ing: Story and Counter-story, Mapping the
hand that starves you: Inspiring resistance to anorexia/
Unmapped Practice, Stories as Pedagogy, Inter- bulimia. New York: Norton.
nalized Other Interviewing, and Insider Witness Epston, D., Marsten, D., & Markham, L. (2016). Narrative
Practices. Through his rigorous, careful, and play- therapy in wonderland: Connecting with Children’s
imaginative know-how. New York: Norton.
ful attention to therapeutic questions, he has Freeman, J., Epston, D., & Lobovits, D. (1997). Playful
invented genres of questions such as: Haunting approaches to serious problems: Narrative therapy
from the Future questions, Wonderfulness and with children and their families. New York: Norton.
Weird Abilities inquiries with children, and Niania, W., Bush, A., & Epston, D. (2017). Collaborative
and indigenous mental health therapy: Tātaihono –
Researching a Person’s Moral Character.
Stories of Maori healing and psychiatry. New York:
As Narrative Therapy develops throughout the Routledge.
world, David is fiercely committed to honoring local White, M., & Epston, D. (1990). Narrative means to ther-
knowledge and context, resisting the colonization of apeutic ends. New York: Norton.
White, M., & Epston, D. (1992). Experience, contradic-
cultural ideas, and imagining narrative therapy
tion, narrative and imagination: Selected papers of
within many cultural contexts and insider commu- David Epston & Michael White, 1989–1991. Adelaide:
nities. In his endeavors to create a history for the Dulwich Centre Publications.
future while supporting others to co-invent and
re-invent narrative therapy, he actively joins with
and supports partners in Mexico, Columbia, Chile,
Brazil, Scandinavia, Spain, France, Switzerland, Websites
http://www.journalnft.com
Belgium, the Netherlands, Britain, Canada, the http://www.narrativeapproaches.com
USA, Israel, South Africa, India, Korea, and Japan. http://www.reauthoringteaching.com
Equifinality in Family Systems Theory 929
Description
Equifinality in Family Systems
Theory Equifinality in family systems theory is the belief
that the use of different theoretical orientations and
Sarah K. Samman1 and Jessica M. Moreno2 interventions often results in a given end state, goal,
1
Alliant International University, San Diego, or outcome. This implies that in open systems,
CA, USA namely, social systems, clinicians have permission
2
California State University, Sacramento, to align with any specific theoretical or clinical
Sacramento, CA, USA modality with the understanding that the system
will largely effect similar changes and outcomes.
E
Name of Concept
Equifinality in family systems theory
Family Therapy
According to Kapsali (2009), in order to apply

Introduction
the concept of equifinality to an open or social
system such as that of a couple or family, a
Equifinality is both a term and concept adopted
therapist would (1) recognize there is more
across various disciplines including archaeol-
than one method to effect change and achieve
ogy, biology, business, and psychology. Propo-
outcomes, (2) commit to therapeutic flexibility
nents of the concept commonly believe that
within a chosen therapeutic modality during
various means and/or developmental paths lead
case conceptualizing and intervention imple-
to similar end states or outcomes. Within the
mentation, and (3) consider the match of client
discipline of couple and family therapy,
factors such as personality traits with different
equifinality refers to an open and flexible posi-
treatment modalities (Luborsky et al. 2002) as
tion and mindset by a therapist. This is based on
well as client strengths, commitment, participa-
the belief that different treatment modalities
tion, and alliances.
from various theoretical orientations possess
the same potential to yield similar results when
treating couples and families.
Clinical Example
Theoretical Context for Concept The Johnson family is a Native-American Sioux

family that lives together on a reservation in the
Hans Driesch, a German developmental biologist United States of America. The family is com-
and philosopher, coined the term equifinality as prised of Shelley Ska, a 40-year-old cisgender
well as established its meaning and concept from female; Martin Mato, a 38-year-old cisgender
his philosophy of potentials at the beginning of the male; Curtis Chaska, their biological 16-year-
twentieth Century (Sato 2011). Ludwig von old cisgender son; and Ska’s father and tribe
Bertalanffy, the founder of general systems theory, elder, Tom Takoda, a 68-year-old cisgender
later used and applied the concept of equifinality to male. The family reported Chaska’s school
open and closed systems such as social systems counselor referred them to family therapy
(Drack and Pouvreau 2015). When describing social because Chaska appears to struggle with symp-
systems, Driesch and von Bertalanffy preferred toms of depression and recent suicidal ideation
referring to the concept of equifinality rather than in response to bullying from seniors at his high
focusing on a specific end goal or state. school. Ska, Mato, and Takoda reported feeling
930 Erectile Disorder in Couple and Family Therapy
blessed to have access to family therapy and References

experienced positive outcomes for similar men-
tal health symptoms when Chaska was 8-years- Drack, M., & Pouvreau, D. (2015). On the history of
Ludwig von Bertalanffy’s “general systemology”, and
old. The family reported they previously
on its relationship to cybernetics – part III: Conver-
worked with an experiential therapist and Ska gences and divergences. International Journal of Gen-
and Mato were hopeful, yet cautious, that pur- eral Systems, 44(5), 523–571. https://doi.org/10.1080/
suing family therapy with a solution-focused 03081079.2014.1000642.
Kapsali, M. (2009). Comparing the application of closed
therapist would not yield similar results.
and open systems approaches in innovation project
The therapist assured the family that their management. The Systemist, 33, 31–46.
fears and concerns for the well-being of their Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P.,
family were valid. She also reflected that con- Berman, J. S., Levitt, J. T., et al. (2002). The dodo bird
verdict is alive and well – mostly. Clinical Psychology:
cerns were warranted considering their socio-
Science and Practice, 9(1), 2–12. https://doi.org/
cultural status as a Sioux family with limited 10.1093/clipsy.9.1.2.
financial and healthcare resources as well as Sato, T. (2011). Minding money: How understanding of
culturally appropriate caution in response to value is culturally promoted. Integrative Psychological
and Behavioral Science, 45(1), 116–131. https://doi.
educational and mental health services involve-
org/10.1007/s12124-010-9142-7.
ment. The therapist explained that contrary to
popular belief and despite therapists’ special-
ized training in various therapeutic modalities
and interventions, different modalities such as
experiential and solution focused have major
Erectile Disorder in Couple
components and elements in common that result
and Family Therapy
in insignificant differences in therapeutic out-
Barry McCarthy and Danielle Cohn
comes. The therapist, committed to cultural
American University, Washington, DC, USA
responsivity, requested permission to address
their concerns and reassure them that their con-
tributions significantly affect the therapeutic
experience. Once the family agreed, the thera-
Name of Concept
pist shared family strengths in responding to
Biopsychosocial model of assessment, treatment,
their child’s needs and well-being, seeking out
and relapse prevention
mental health services, demonstrating previous
and current commitment and participation in
therapy, and interest in building alliances with
the therapist to effect systemic change. The Introduction
therapist highlighted that these client factors in
addition to the concept of equifinality will most When Viagra (sildenafil) was introduced in 1998,
likely result in similar outcomes even when it was a common belief that a stand-alone medical
using a different therapeutic modality. intervention would resolve erectile disorder (ED).
ED is the major cause of secondary male hypo-
active sexual desire disorder (HSDD). The mis-
Cross-References taken assumption underlying this belief was that
male HSDD would dramatically be reduced with
▶ Common Factors in Couple and Family assured erectile function. Rather than solve ED,
Therapy many men felt like “Viagra failures” and gave up
▶ Systems Theory on couple sex, leading to a shockingly high Viagra
▶ von Bertalanffy, Ludwig dropout rate. Some clinicians believe that Viagra
Erectile Disorder in Couple and Family Therapy 931
has caused more nonsexual relationships since confidence by viewing sexuality as a “couple pro-
1998 than anything else in history (Metz and cess” with mutual giving and receiving of
McCarthy 2004). pleasure-oriented touch, rather than as an individ-
ual pass-fail test of erection and intercourse. This
framework involves two core concepts. First, sex-
Theoretical Context for Concept uality involves sensual, playful, and erotic touch
in addition to intercourse, which runs counter to
The great majority of men learn sexual response in the “sex equals intercourse” myth, which is com-
adolescence and young adulthood in an autono- monly believed and needs to be confronted. The
mous manner in which he experiences spontane- second concept is the replacement of the perfect
E
ous erections, transitions to intercourse, and performance model with the Good Enough Sex
orgasm on his first erection; consequently, sexual (GES) model (Metz and McCarthy 2012). GES
function is 100% predictable. A key factor in affirms that couple sexuality is variable and flex-
autonomous sex is that he needs nothing from ible in nature. The majority of sexual encounters
his partner in order to experience desire, erection, (85%) flow from comfort to pleasure to arousal to
and orgasm. Unfortunately, this conceptualization erotic flow to intercourse and orgasm. When sex
has become the typical model of male sex in the does not flow, the man comfortably transitions to a
media as well as among male peers and even sensual or erotic alternate scenario or asks for a
physicians. Over time, especially after age “rain check.” Apologizing or panicking is unnec-
40 and when in an intimate relationship, this essary and self-defeating. The healthy sexual
model can become oppressive and self-defeating. cycle is positive anticipation, pleasure-oriented
Erection and intercourse becomes an individual sexuality that flows to intercourse, and a regular
pass-fail performance test. With the introduction rhythm of sexual connection. The negative cycle
of Viagra, the biomedical community, driven by is anticipatory anxiety, tense performance-
ads and marketing, asserted that solely the “blue oriented intercourse, frustration, embarrassment,
pill” would return the man to the sex function of and sexual avoidance.
his youth.
Application of Concept in Couple

Description and Family Therapy
There is a growing consensus among mental A major cause of sexual problems when using
health professionals and sex therapists that a Viagra is that the man rushes to intercourse as
biopsychosocial model of assessment and treat- soon as he gets an erection because he fears losing
ment of ED is superior to the biomedical approach his erection. Erectile psychosexual skill exercises
(Rosen et al. 2014). McCarthy and Wald (2017) are utilized to increase erectile self-efficacy. First,
argue that the most important factor in a compre- the man does not transition to intercourse until
hensive approach to ED is psychological in nature subjective arousal is a “7” or “8” on a scale of
and thus advocate for a biopsychosocial model. 1–10, in which “10” is orgasm. During inter-
They also maintain that it is crucial to expand the course, he enhances erotic flow by utilizing mul-
definition of sexuality from one in which sex tiple forms of stimulation, including fantasies as
equates to intercourse to one in which sexuality well as giving and receiving erotic touch. Second,
involves sensual, playful, and erotic touch in addi- the couple uses the “wax and wane” erection
tion to intercourse. A new model of male sexuality exercise. This exercise involves using physical
(McCarthy and Metz 2008) emphasizes the relaxation and self-entrancement arousal for an
importance of building erectile comfort and “easy erection.” Once this is achieved, they stop
touching so that the erection wanes. The couple of the medication, but rather the ease of integrat-
remains mindful and open to sensual and playful ing the medication into the couple style of inti-
touch so the erection will wax again. They then macy, pleasuring, and eroticism; another
allow it to wane a second time, after which they important issue constitutes side effects. Viagra is
proceed to orgasm on his third erection. Although especially valuable for procrastinators and those
men do not enjoy this exercise, it increases aware- men who prefer structure, since it presents a 1–4 h
ness of the role of relaxation in sexual arousal and window of opportunity for sex. For many couples,
teaches them an anti-panic strategy. He learns not Cialis is the preferred medication because it pre-
to panic when his erection wanes as well as sents a window of opportunity that ranges from
increases his confidence that his erection will 30 min to 30 h, which promotes sexual freedom
return with relaxation and pleasuring. As the and choice. The daily low-dose Cialis can easily
physiological process underlying pro-erection become part of his routine.
medications is the relaxation of penile muscles The popularity of testosterone enhancement is
and subsequent enhancement of blood flow to driven by ads about “low T.” There is no doubt
the penis, this exercise is able to achieve more that for the man with very little or no testosterone,
by comparison. this form of treatment can be a valuable therapeu-
The biopsychosocial model of understanding, tic resource to enhance desire. Two major con-
assessing, and treating ED is compatible with the cerns include that it is very difficult to conduct an
couple/family therapy approach. Whether the pri- assessment of testosterone levels, and there is a
mary cause of ED is biomedical, psychological, tendency to overprescribe testosterone in ways
relational, or social, ED has a profound impact on that alarm endocrinologists. In addition, the effect
the man and couple. ED is best understood and of testosterone on erectile dysfunction is unclear
addressed within the context of the complexity of and quite complex. Using testosterone as a stand-
its meaning to the man, woman, and couple. ED alone intervention for ED has little empirical or
not only affects the man sexually but also the clinical support.
partner; furthermore, it can devitalize their rela- Penile injections are very effective in produc-
tionship and threaten relational security. Depres- ing reliable erections. However, they suffer from
sion, drug and alcohol abuse, shame, and an extremely high dropout rate. Typically, the
avoidance are all common reactions to ED. more intrusive the medical intervention is, the
more efficacious it is and the greater the challenge
Integrating Medical Interventions into is to integrate it into the couple sexual style. In
the Couple Sexual Style using penile injections, one important question is
The hope is that medical interventions will whether the man or the woman will administer the
become more efficacious and user-friendly in the injection. A second question is whether they will
future. At present, there are three major types of start with the injection or engage in sensual and
medical interventions for ED: pro-erection medi- playful touch to enhance subjective arousal before
cations, penile injections, and testosterone doing the injection. The core issue is learning to
enhancement. The most popular medications are integrate the penile injection with the couple style
Viagra (sildenafil) and Cialis (tadalafil). Although of intimacy, pleasuring, and eroticism. The
few men report the miracle cure promised by the woman may complain that his penis feels like a
ads, these medications are a valuable therapeutic dildo. He may have a hard time ejaculating
resource. Reports of efficacy vary from 65% to because he is not subjectively aroused. Both may
85% of encounters resulting in successful inter- report that it feels strange that he does not lose his
course. These rates are promising; however, there erection after ejaculation. Usually, it is men who
is a high dropout rate, which is caused by the stop using injections because they feel awkward
drug’s inability to return the man to totally pre- and antierotic. These problems are similar to com-
dictable, autonomous erections. In choosing plaints about the external penile pumps, the med-
Viagra versus Cialis, the core issue is not efficacy icated urethral system for erection (MUSE)
Erectile Disorder in Couple and Family Therapy 933
system, and the penile prosthesis. They focus so couple sexuality. If sexuality were about pre-
heavily on erectile performance that they reduce dictable erections and orgasms, men and
sexual desire, playfulness, subjective arousal, and women would masturbate rather than engage in
the couple’s feelings of being an intimate couple sex. Couple sexuality, by nature, is var-
sexual team. iable and flexible.
In treating ED, the context of desire/pleasure/ GES is relevant when using medical as well as
eroticism/satisfaction has a central role. The fatal psychosexual interventions. Although penile
flaw of the medical approach is that it requires the injections produce more reliable erections, they
medication or medical procedure to be the only do not return the man to autonomous, 100% pre-
solution. This builds performance anxiety and dictable erections. Men who use Viagra or Cialis
E
negates the concept of sexuality as an intimate experience successful intercourse less than 90%
sexual team process. By its nature, couple sexual- of the time. Hoping that the medical intervention
ity is variable and flexible with a number of roles, will do it all and enable the man to meet unrealistic
meanings, and outcomes. Sexuality is a team pro- performance standards is a common trap for phy-
cess of sharing pleasure. sicians and clients alike. For many men, the com-
Although the Good Enough Sex (GES) bination of vascular effects and the placebo effect
model is a challenge for men to adopt, it is a facilitates erectile confidence; however, this com-
core element in regaining self-efficacy with bination also puts the man in a vulnerable position
erectile function. The essence of GES is that in which he is one erectile failure from feeling
the couple’s approach is desire/pleasure/eroti- hopeless about ED.
cism/satisfaction. A guideline is that 85% of
sexual encounters should flow from pleasure to The Partner’s Role in Promoting GES
arousal to erection and then intercourse and GES receives little acceptance from male peers,
orgasm. Rather than panicking or apologizing physicians, or the media. In heterosexual couples,
when that sequence of events does not occur, the the woman’s support is crucial in enabling the
couple transitions to a sensual scenario or a man to embrace GES. When practicing GES, a
synchronous erotic scenario, though it is impor- therapist will instruct, “Traditional men stop being
tant to note that asynchronous scenarios are also sexual between ages 50 and 60, whereas ‘wise
positive (McCarthy 2015). The core of GES is men’ can be sexual in their 60s, 70s, and 80s.”
the recognition that couple sexuality can be Women find GES easier to accept because it is
positive without erection and intercourse. congruent with female sexual socialization and
Whether it occurs once a month, once every lived female sexual experiences. Men view GES
ten times, or once a year, it is normal to not as “settling,” “feminizing,” and “wimpy,” indicat-
have an erection sufficient for intercourse. This ing that he is not “man enough.” In fact, “wise
is true for the great majority of adult men, espe- men” are the ones who beat the odds and enjoy
cially those ages 50 and older. This is true of sexuality with aging. An important psychosexual
both gay and straight men; treatment of ED is of skill is for the man to learn how to “piggyback”
importance to gay couples as well. When the his arousal on his partner’s. With aging, many
man and couple believe that perfect intercourse women find arousal and orgasm easier than her
performance is the definition of male sex, they partner does. Men who welcome this experience
always feel vulnerable to ED. Healthy couple will continue to enjoy couple sexuality rather than
sexuality is anti-perfectionistic, and this is feel intimidated by this change.
important for individuals to keep in mind.
Lindau and colleagues (2007) examined sexual
function between ages 58 and 85 and found that Clinical Example
sexual satisfaction increases with aging. Funda-
mental to this satisfaction is the recognition of To illustrate these concepts, a couple who had
the multiple roles, meanings, and outcomes of been together since adolescence and who had
now been together for more than 55 years were in different model than that which uses medical
therapy. The woman said she enjoyed sex with interventions as a stand-alone approach to
him more now than she had during their first return the man to totally predictable erections
20 years. His feelings were initially hurt, leading and intercourse.
her to explain, “In the beginning, you had show-
up erections, and now you have grown-up erec- Summary
tions. You need me sexually, and our sex is more As the empirical and clinical study of ED con-
human, genuine, and interactive. I love the fact tinues to evolve, the hope is that the comprehen-
that we are now a genuine sexual team.” sive couple psychobiosocial model of assessment,
treatment, and relapse prevention will receive fur-
Psychobiosocial Model for Assessment, ther empirical and clinical validation. Rather than
Treatment, and Relapse Prevention of ED view sex as an individual performance for erec-
The comprehensive couple biopsychosocial tion and intercourse, a positive, realistic approach
model for ED is optimal (Metz et al. 2017). is variable, flexible male and couple sexuality
Important messages to convey to the man with with a focus on sharing pleasure. The hope is
ED include: he is not alone; all the pressure does that this formulation will become the dominant
not have to be on him and his penis; his partner therapeutic narrative. Subsequently, the mantra of
wants to understand and help him deal with the desire/pleasure/eroticism/satisfaction with desire
ED; she is his intimate and erotic ally; and they as the core factor will replace the secondary
will use all appropriate psychological, biomed- HSDD caused by ED.
ical, and social-relational resources to build sex- Psychologically, the focus is on using all appro-
ual desire, erectile comfort and confidence, and priate resources to build erectile self-efficacy with a
sexual satisfaction. The major strength of the foundation of comfort and confidence.
biopsychosocial model is that it honors the com- Biomedically, user-friendly medications and proce-
plexity of ED and approaches sexuality as a dures that can be integrated into the couple style of
couple issue. The GES model of sexual function intimacy, pleasuring, and eroticism will be the dom-
and satisfaction aims to be motivating and inant narrative, rather than the medical intervention
empowering for the man and couple. Setting as a stand-alone approach. The social-relational
positive, realistic goals is key for relapse pre- breakthrough for the man, woman, couple, and cul-
vention and decreases the likelihood that the ture is to define sexuality as involving sensual,
man will be chronically fearful of failure. The playful, and erotic touch in addition to intercourse.
realistic perspective is that whether erectile A core concept is that the man and woman function
problems occur once a month or once a year, it as intimate and erotic allies. Perhaps the most impor-
is normal to not have an erection sufficient for tant factor is the adoption of the Good Enough Sex
intercourse. This is true whether he uses Viagra, (GES) model, which encourages the couple to
Cialis, penile injections, or testosterone embrace the multiple roles, meanings, and outcomes
enhancement. GES is compatible with couple of couple sexuality.
sexuality, which is variable and flexible and
features a range of roles, meanings, and out-
comes. A crucial relationship skill is to stay Cross-References
involved with the partner, whether the sexual
experience is great, good, okay, mediocre, or ▶ Delayed Ejaculation in Couple and Family
dysfunctional. When sex does not flow to inter- Therapy
course, the encounter transitions to a sensual or ▶ Female Sexual Interest/Arousal Disorder in
erotic scenario rather than apologizing or pan- Couple and Family Therapy
icking. In couple sexuality, desire is the most ▶ Male Hypoactive Sexual Desire Disorder in
important dimension, with satisfaction the sec- Couple and Family Therapy
ond most important. This is a completely ▶ Sexuality in Couples
Erickson, Milton 935
References Madanes, and the Brief-Solution Focused team in

Milwaukee as well other prominent solution-
Lindau, S., Schumm, L., Laumann, E., Levinson, W., oriented clinicians such as Bill O’Hanlon and
O’Muircheataigh, C., & Waite, L. (2007). A study of
Michele Weiner-Davis. His indirect influence
sexuality and health among older adults in the United
States. New England Journal of Medicine, 357, spans almost everywhere in the field including the
762–774. Collaborative Language Systems approach of
McCarthy, B. (2015). Sex made simple. Eau Claire: Icai Harlene Anderson and Harry Goolishian in
Publication.
Houston-Galveston and Minuchin’s structural ther-
McCarthy, B., & Metz, M. (2008). Men’s sexual health.
New York: Routledge. apy. Echoes of his influence extend even to what is
now called the common factors movement and the
McCarthy, B., & Wald, L. (2017). The psychobiosocial
model of couple sex therapy. In Z. Peterson (Ed.),
E
idea of the empirically validated therapist.
Wiley-Blackwell handbook of sex therapy. New York:
Wiley-Blackwell.
Metz, M., & McCarthy, B. (2004). Coping with erectile Career
dysfunction. Oakland: New Harbinger.
Metz, M., & McCarthy, B. (2012). The Good Enough Sex
(GES) model. In P. Kleinplatz (Ed.), New directions in Erickson earned a masters degree in psychology and
sex therapy (2nd ed., pp. 213–230). New York: a medical degree from the University of Wisconsin
Routledge. at Madison. He worked as a medical doctor and
Metz, M., McCarthy, B., & Epstein, H. (2017). Cognitive-
behavioral couple sex therapy. New York: Routledge. psychiatrist in multiple hospitals until 1948 when
Rosen, R., Miner, M., & Wincze, J. (2014). Erectile dys- he was appointed Clinical Director at the Arizona
function: Integration of medical and psychological State Hospital. He left that assignment after a year in
approaches. In Y. Binik & K. Hall (Eds.), Principles order to focus on writing, teaching, and private
and practice of sex therapy (5th ed., pp. 61–85). New
York: Guilford. practice. Erickson contracted polio at age 17 and
endured a paralysis so severe doctors believed he
would die. He again experienced symptoms of polio
when he was near the age of 50, but it was later
Erickson, Milton determined that he had “post-polio syndrome.” It
was Erickson’s illness at an early age that gave him
Chris J. Gonzalez his introduction to hypnosis and the impetus for so
Department of Psychology, Counseling, and much of his inquiry. While recovering from polio as
Family Science, Lipscomb University, Nashville, a teenager, he learned how to listen to his own body,
TN, USA listen to and observe others, and to recognize the
discrepancies and congruencies between verbal and
nonverbal communication.
Name
Milton H. Erickson, M.D. (1901 –1980).
Erickson was an innovator on all levels. From the
clinical interactions he had with therapy clients
Introduction through hypnosis, storytelling, and interventions of
creative choice to how he taught and framed the
The influence of Milton Erickson spreads wide and field of hypnosis and psychotherapy to larger
deep across mental health professions including: audiences – his work was an endless source of
psychiatry, psychology, family therapy, and clinical innovation. Erickson essentially remade the field
hypnosis. In the field of couple and family therapy, of hypnosis in his own image. O’Hanlon highlights
Erickson’s direct influence is manifest in the work of many of these changes including: shifting from
the MRI group in Palo Alto, the Milan group in hypnotic suggestion to creative choice while in
Italy, the strategic work of Jay Haley and Cloe trance and from a directive and commanding
936 Erikson, Erik
posture to a permissive and collaborative engage- instrumental in founding the American Society
ment. His approach to hypnosis with clients was of Clinical Hypnosis and was their first president.
“with” clients not “applied to” clients. He was the He was also instrumental in launching the Amer-
first to highlight the importance and influence of ican Journal of Clinical Hypnosis and invested a
therapists’ words, tone of voice, and actions, thus decade into being editor. The first International
paving the way for a far more active therapy than Congress of Ericksonian Approaches and Psycho-
afforded within the assumptions of psychoanalysis. therapy was planned for December 1980 and he
Erickson’s unique approach did not resist anticipated attending. He never got the chance to
symptomology so much as leverage acceptance of attend as he died 8 months prior to the event. The
client symptoms and client resistance as useful Milton H. Erickson Foundation continues to host
information for creating unique and personalized conferences decades later for clinicians and
interventions (B. O’Hanlon, personal communica- researchers to further explore the genius of Milton
tion, December 2, 2016). This approach fascinated Erickson.
clinicians such as Jay Haley, who made considerable
efforts trying to solve the Erickson formula and
served to inspire all manner of paradoxical inter- Cross-References
ventions such as prescribing the symptom.
Erickson was also one of the first to disconnect ▶ Hypnosis in Couple and Family Therapy
the solution from the problem and thereby provid- ▶ O’Hanlon, William
ing inspiration to DeShazer, Berg, and colleagues ▶ Paradoxical Directive in Couple and Family
with one of the foundational assumptions of Therapy
solution-focused therapy. Erickson saw whole fam-
ilies in his office for therapy as early as 1948, a time
when such modality was not simply uncommon, References
but contraindicated due to the dominating assump-
tions of the prevailing model, psychoanalysis. Erickson, M. H., & Rossi, E. L. (1979). Hypnotherapy: An
exploratory casebook. New York: Irvington Publishers.
O’Hanlon reports Erickson being invited in the
Erickson, M. H., Rossi, E. L., & Rossi, S. I. (1977). Hypnotic
1950s by Gregory Bateson to the Macy Conference realities: The induction of clinical hypnosis and forms of
on cybernetics. At this conference, Erickson indirect suggestion. New York: Irvington Publishers.
reported a clinical case that was the first known Haley, J. (1986). Uncommon therapy. New York: Norton.
O’Hanlon, W. H., & Hexum, A. L. (2011). An uncommon
time the theory of cybernetics was actually
casebook: The complete clinical work of Milton
observed as being clinically relevant. In short, H. Erickson. New York: Norton.
Erickson brought cybernetics from theory to prac- Rosen, S. (1982). My voice will go with you. New York:
tice (B. O’Hanlon, personal communication, Norton.
Zeig, J. (1994). Ericksonian methods: The essence of story.
December 2, 2016).
New York: Brunner/Mazel.
Erickson assumed the unconscious mind knew
more than the conscious mind. His assumption that
clients already had what they needed in order to heal
was not merely encouraging talk, but rather a foun- Erikson, Erik
dational assumption that the client’s unconscious
mind knew better than anyone, even Erickson, Dawn L. Glover
how to heal. Erickson’s goal in therapy was to California School of Professional Psychology,
agree with the client’s unconscious mind. In so Alliant International University, Los Angeles,
doing, Erickson challenged the notion of “client CA, USA
resistance” and inspired what was later to be coined
the humbling concept of “therapist resistance.”
Erickson desired to make his thinking, his Name
approaches, and his stories available to as many
people as possible. Toward this end he was Erik Homburger Erikson.
Erikson, Erik 937
Introduction Novel to the field, Erikson’s work theorized

that children are not simply shaped by biological
Erik H. Erikson was a twentieth-century psycho- forces in isolation and that early childhood issues
analyst. His major contribution to the field was the may be resolved later in life. This framework of
concept that identity development extends across identity development was part of the shift in psy-
the lifespan and is rooted in a sociocultural con- choanalytic theory toward ego and self-
text. He is best known for the eight stages of psychology. Freud’s drive theory was based on
psychosocial development and the identity crisis. psychosexual stages, whereas Erikson’s theory
was broader and based in epigenetics.
Erikson’s psychosocial development theory
Career E
described the dialectical relationships between
the individual and cultural influences. Although
Erikson’s career was molded by multiple cultural Erikson focused primarily on individual develop-
influences. In 1902, Erikson was born to Danish ment, he acknowledged the contribution of the
parents, a Jewish mother and Protestant father. He family to development. Caregivers are cultural
was raised by his mother and stepfather in Ger- representatives who mold the child according to
many and attended a Jewish school where he did cultural values and needs. Cultural leaders are
not feel accepted due to his gentile appearance. quasiparents. As part of his work, Erikson
After wandering through Europe as an artist, in described not only childhood but also the structure
1927 Erikson moved to Vienna and began teach- and function of adulthood. He attempted to dis-
ing children. At this time, he began studying child tinguish between normal, psychopathological,
psychoanalytic theory and practice with Anna and socially acceptable development. He studied
Freud at Vienna Psychoanalytic Institute. nonmedical populations.
In 1933, during Hitler’s rise, he fled to the Erikson’s legacy, the eight stages of psychosocial
United States with his Canadian-born wife, Joan development, posited that across the lifespan, indi-
Serson. Serson collaborated with Erikson to write viduals face eight identity conflicts. Each stage rep-
his works in English. In the United States, Erikson resents a critical conflict: (1) Trust versus Mistrust
went on to teach at Harvard, Yale, and University takes place during infancy from birth to 12–18
of California, Berkley. He published over 14 books months (oral-sensory stage) when infants are fully
and won the Pulitzer Prize and the National Book dependent on caregivers. (2) Autonomy versus
Award. In studying the role of culture in develop- Shame and Doubt takes place from 18 months to
ment, he utilized a comparative cultural approach 3 years (muscular-anal stage) when children are
and spent time studying Yurok and Oglala Sioux learning to control their own body, bodily functions,
tribes in Northern California. He died in 1994. and beginning to make some choices. (3) Initiative
versus Guilt, takes places from 3 to 6 years
(locomotor period) during a time when children
Contribution to Profession are asserting themselves and taking control of play
and social interactions. (4) Industry versus Inferior-
Given Erikson’s translocation and various cultural ity takes place during ages 6 to 12 years (latency
experiences, it is not surprising that his work period) when children are learning new skills, taking
centered on the impact of sociocultural influences risks, and working toward goals. (5) Identity versus
on identity. His theories included the identity cri- Confusion takes place from 12 to 18 years
sis and a stage-based approach to core identity (adolescence) when children use cues from peers
conflicts. The eight stages of psychosocial devel- and personal exploration to develop a sense of iden-
opment, from his book Childhood and Society, tity around occupation, relationship role, sex role,
was a conceptual departure from Freudian theory politics, and religion. (6) Intimacy versus Isolation
in that it grounded the “self” within a social con- takes place from 19 years to 40 years (young adult-
text and expanded personality development hood) when individuals strive to develop
throughout adulthood. close, committed, and secure relationships.
938 Escudero, Valentin
(7) Generativity versus Stagnation takes place Introduction

between 40 years to 65 years when adults work
toward having a stable home and helping others, Valentín Escudero, Ph.D., is a professor of psy-
usually the next generation. (8) Integrity versus chology at the University of A Coruña and direc-
Despair takes place from 65 years until death tor of the Family Intervention and Care Research
(maturity). Resolving the conflict at each stage Unit (UIICF), a family therapy center at the
leads to virtues of hope, will, purpose, competency, Hospital Naval, where four prestigious programs
fidelity, love, care, and wisdom, respectively. An of family therapy research and family therapy
inability to resolve these conflicts results in stagna- training have been run since 1999. Escudero’s
tion, distress, and feelings of inadequacy. research and practice epitomizes a systemic
approach to family therapy founded on solid
observational study and careful theoretical con-
Cross-References ceptualization. His primary area of scholarship
concerns the development and maintenance of
▶ Children in Couple and Family Therapy therapeutic alliances with couples and families,
▶ Development in Couples and Families specifically using alliances to empower the ther-
▶ Personality in Couple and Family Therapy apeutic system (Escudero and Friedlander 2017).
▶ Social Constructionism in Couple and Family Escudero’s work is extraordinary in the field
Therapy of family therapy in Europe due to his balance
▶ Socialization Processes in Families in connecting research to therapist training
and clinical practice. Escudero has published
numerous journal articles and chapters and is the
References co-author of three books: Relational Communica-
tion, Therapeutic Alliances in Couple and Family
Erikson, E. H. (1950). Childhood and society. New York: Therapy: An Empirically-Informed Guide to
WW Norton & Co.
Practice, and Therapeutic Alliances with Fami-
Erikson, E. H. (1962). Young man Luther: A study in psy-
choanalysis and history. New York: WW Norton & Co. lies: Empowering Clients in Challenging Cases.
Erikson, E. H. (1968). Identity: youth and crisis. Oxford:
Norton & Co.
Erikson, E. H. (1977). Toys and reasons: Stages in the
ritualization of experience. WW Norton & Co.
Career
Erikson, E. H. (1980). Identity and the life cycle.
New York: WW Norton & Co. Dr. Escudero obtained his Ph.D. in Psychology
Erikson, E. H. (1985). The life cycle completed: A review. at the University of Santiago de Compostela,
New York: WW Norton & Co.
Erikson, E. H. (1993). Gandhi’s Truth: On the Origins of
Spain, and published his doctoral dissertation on
Militant Nonviolence. WW Norton & Co. relational communication in distressed couples
in treatment. After postdoctoral scholarship at the
University of Utah, his academic career spans over
25 years at the University of La Coruña, where he
Escudero, Valentin began as an assistant professor of psychology in
1990 and is a professor of the Department of Psy-
Myrna L. Friedlander chology, director of the master’s program in family
University at Albany/State University of therapy, and director of the prestigious Family Inter-
New York, Albany, NY, USA vention and Care Research Unit (UIICF). An
accredited psychotherapist and family therapist,
Escudero is also an adjunct clinical professor at the
Name University at Albany/State University of New York.
Additionally, he was a visiting professor for 3 years
Escudero, Valentín at Vrije Universiteit, in Brussels, Belgium
Ethics in Couple and Family Therapy 939
(2007–2011), and a visiting researcher at the Centre Psychotherapy, Psychotherapy Research, and the
for Family Policy and Child Welfare, at the Univer- Journal of Counseling Psychology. His treatment
sity of Bristol, UK (2006–2007). manuals and intervention guides for alliance-
empowering mental health care are widely used
by social services professionals in Spain and in
Contributions to Profession several other Spanish-speaking countries.
From the beginning of his career, Escudero’s work

focused on exploring the process of change in fam- Cross-References
ily systems distinct from more traditional
▶ European Family Therapy Association E
psychopathology, relying instead on the concept of
relational communication. His doctoral dissertation ▶ Therapeutic Alliance in Couple and Family
used observational techniques for the microanalysis Therapy
of conflictual interactions of clinical couples. This
framework of research and practice led to collabo-
ration on the creation of the SOFTA (System for References
Observing Family Therapy Alliances; Friedlander
Escudero, V., & Friedlander, M. L. (2017). Therapeutic
et al. 2006), a conceptual model and set of instru- alliances with families: Empowering clients in chal-
ments designed to conceptualize, operationalize, lenging cases. New York: Springer. https://doi.org/
and study therapeutic alliances in the context of 10.1007/978-3-319-59369-2.
couple and family therapy. This line of research, in Escudero, V., Friedlander, M. L., Varela, N., & Abascal,
A. (2008). Observing the therapeutic alliance in
collaboration with Friedlander and Heatherington, family therapy: Associations with participants’ per-
now comprises a range of studies on the process of ceptions and therapeutic outcomes. Journal of Family
building and maintaining alliances in family therapy Therapy, 30, 194–214. https://doi.org/10.1111/j.1467-
and their power to predict therapeutic outcomes. 6427.2008.00425.x.
Escudero, V., Boogmans, E., Loots, G., & Friedlander,
Because of its reliability and systemic assumptions, M. L. (2012). Alliance rupture and repair in conjoint
the SOFTA is one of the major instruments used to family therapy: An exploratory study. Psychotherapy,
evaluate the alliance in couple and family therapy, 49, 26–37. https://doi.org/10.1037/a0026747.
having been translated into six languages. Friedlander, M. L., Escudero, V., & Heatherington, L. (2006).
Therapeutic alliances with couples and families: An
Aside from his profile as a researcher, Professor empirically-informed guide to practice (Vol. 53, p. 214).
Escudero identifies as a “systemic therapist.” Cur- Washington, DC: American Psychological Association.
rently, he directs the Therapy Program for Vulner- https://doi.org/10.1037/0022-0167.53.2.214.
able Children and Families, which is the primary
mental health treatment program for the Child Pro-
tective Services of the Galician Regional Govern-
ment in Spain. The main focus of Escudero’s Ethics in Couple and Family
work – systemic family therapy in the context of Therapy
social services and child protection – are the con-
texts in which establishing a strong working alli- Colleen M. Peterson1 and Marj Castronova2
1
ance is a challenge as well as a critical process. In University of Nevada, Las Vegas, NV, USA
2
this line, he trains, supervises, and consults for Relational Wellness Institute, Las Vegas,
several public family intervention programs in NV, USA
Spain, Portugal, England, Belgium, and Poland.
Professor Escudero is International Associate
Editor of the Journal of Family Therapy and has Introduction
also published his research in numerous other
refereed journals, including Family Process, the Ethics in couple and family therapy is based on
Journal of Marital and Family Therapy, the long-held understanding that the therapeutic
940 Ethics in Couple and Family Therapy
relationship between client and therapist is one of characteristics for which a therapist should aspire
safety and trust, with therapists bearing the rather than on the ethical dilemma per
responsibility for ensuring that they are protecting se. Principle ethics asks “Is this situation
that relationship and acting in the client’s best unethical?” whereas virtue ethics asks “Am
interest. A successful therapeutic relationship I doing what is best for my client?” Ideally, couple
depends on clients being able to openly and hon- and family therapists integrate both principle and
estly discuss things that are very personal and virtue ethics.
private, putting them in an extremely vulnerable Underlying ethical decision-making are six
position. The safety and protection of clients moral principles: autonomy, nonmaleficence,
engaged in therapy are so vital that very specific beneficence, justice, and fidelity. Autonomy is an
expectations and requirements for therapist pro- individual’s right to self-determination and mak-
fessional conduct have been developed in the ing his/her own choices. Therapists support
form of professional Codes of Ethics and laws autonomy by acknowledging and encouraging
regulating the practice of licensed therapists. clients’ freedom of choice and respecting their
Unique to the ethics in couple and family therapy wishes. Nonmaleficence is avoiding doing harm
is the notion of the family or couple system; or the risk of doing harm. Therapists are obligated
everyone is impacted both individually and rela- to practice in ways that prevent harming or the
tionally. At times this creates ethical dilemmas in potential of harming clients. Beneficence is pro-
that what is best for the individual may not be best moting the good of others. Therapists act in ways
for the couple or family system. that support clients’ growth, development, and
well-being. Justice is being fair through equality.
Clients are entitled to equal access to therapy
Theoretical Context for Ethics in Couple services, regardless of age, sex, race, ethnicity,
and Family Therapy socioeconomic status, cultural background, reli-
gion, sexual orientation, or disability. Fidelity is
The expectations for ethical therapist conduct are being true to one’s word – to making and keeping
deeply rooted in ethics and moral principles which promises. Therapists maintain their responsibility
are thoroughly reviewed and explored during of trust in the therapeutic relationship by keeping
therapist education and training in ethical and their commitments to clients. These moral princi-
legal issues (Corey et al. 2011; Heckler 2010; ples are at the core of all therapeutic
Wilcoxon et al. 2012). In addition, ethics and relationships – putting client interests first and
moral principles are often reviewed during con- doing no harm. They are also at the root of expec-
tinuing education required for licensed therapists. tations for therapists that are spelled out in Ethical
This core knowledge of ethical and legal issues Codes (AAMFT 2015) and laws regulating their
includes the aspects and differences between man- clinical practices.
datory and aspirational ethics, with mandatory While there are some things related to the
ethics being the minimal standards of ethics and practice of couple and family therapy that are
aspirational ethics being the more lofty and ideal clearly spelled out in black and white (i.e., sexual
standards for which a therapist should strive. intimacy with current or former client or known
The core ethical knowledge of couple and fam- members of the clients’ family system), there are
ily therapists includes understanding and applying others that are less specific and require that thera-
principle and virtue ethics. Principle ethics pists use their best professional judgment to oper-
focuses on moral issues in solving an ethical ate within ethical and legal bounds (i.e., not
dilemma or type of dilemma. Principle ethics exploiting clients with unavoidable multiple rela-
involves making choices and taking action in tionships). When therapists encounter ethical
answering the question “What shall I do?” in a dilemmas, it is vital that they engage in an ethical
way that is historically and socially acceptable. decision-making process that demonstrates the
Virtue ethics focuses on the qualities and use of sound professional judgment in
determining a course of action. While some ther- other biological parent still have access to the
apists utilize specific models of ethical decision, file? If the client is viewed as the family system,
most include identifying what the ethical dilemma the child is no longer an individual client.
is, consulting pertinent ethical codes and state/
federal laws, exploring the pros and cons of poten- Person of the Therapist A strong ethical stance
tial actions and corresponding outcomes, consult- in couple and family therapy ethics flows from the
ing with supervisors or colleagues, exploring person of the therapist. Therapists hold their own
what would be considered a professional standard values and morals which influence how they view
of practice, documenting the decision-making the world. These values and morals are heavily
process, and then acting on the choice that appears influenced by the social contextual issues that
E
most appropriate given all the considerations. The surround them. Therapists also hold implicit bias
exploration of pros and cons often encompasses that influences their preconceived ideas and influ-
the moral principles discussed above. ences how they respond to their clients. It is
incumbent upon therapists to conscientiously
maintain self-awareness and self-monitoring so
Description of Important Aspects of as to avoid negative impacts upon clients.
Ethics in Couple and Family Therapy
Diversity and Social Contextual Issues When a
There are several important perspectives and con- therapist is working with a family or couple sys-
structs that warrant consideration when working tem, there is an acute awareness that several
with couples and families. These perspectives and underlying dynamics and other systems are
constructs can influence how a therapist works impacting work with couple and families. These
with a case, and when they go unnoticed or can be referred to as the Social GRRAACCEESS
unchecked, ethical violations can occur. While (Burnham et al. 2008): gender, race, religion, abil-
the therapist may not have been maleficent in ity, age, culture, class, education, ethnicity, spiri-
their intention, the standard of care when working tuality, and sexuality. The Code of Ethics that
with a couple and or family involves a deeper and guides couple and family therapy clearly states
broader consideration of a plethora of systems. that therapists are to provide therapy without dis-
crimination on the basis of race, age, ethnicity,
Who Is the Client? The first thing to consider is socioeconomic status, disability, gender, health
“who is the client?” The way a therapist answers status, religion, national origin, sexual orientation,
this question in terms of the couple or the family gender identity, or relationship status. This
he/she is working with influences the kinds of requires awareness that each person involved in
legal and ethical considerations the therapist the therapy process, the client(s), the therapist,
must make. If the therapist sees only one spouse and the potential supervisor all are being
as the client because of his/her diagnosis and the influenced by their own Social GRRAACCEESS
spouse is brought into therapy as a support, the and the values that they hold in reference to each
ethical implications may defer to the spouse with one of them.
the diagnosis. However, if the therapist sees the
couple as the client, regardless of the diagnosis, Client Rights All therapists working with clients
then the ethical implications are considered in are obligated to obtain written client consent prior
terms of the relationship. In a blended family, to initiating therapy and to uphold client confiden-
“who is the client?” is also an important ethical tiality which is at the core of establishing a safe
consideration. When a child enters therapy and therapeutic relationship. The therapists working
the biological parents are divorced and have with the couples and families must consider addi-
joint legal custody, typically both parents sign tional information when obtaining informed con-
the consent and have access to the file; however, sent due to multiple people being involved in
when a blended family starts therapy, does the therapy and/or being present in the therapy
room. Best practice is for therapists to obtain Another aspect of client rights that needs to be
written consent from each person involved in the considered is how information obtained while
treatment prior to seeing them. Having more than seeing one part of the system alone without the
one person involved in the therapy also impacts other member present will be managed within
confidentiality and privacy, as the therapist can- couples’ therapy. How will the therapist manage
not guarantee the confidentiality of what partici- confidentiality of what is disclosed in individual
pants may tell others. State laws differ with regard sessions if/when it has a significant impact on the
to handling confidentiality in couple and family couple relationship? For instance, what does a
therapy. Some states may legally require only one therapist do with the information if one partner
person to sign a release of information, whereas discloses having an affair in individual therapy
other states may clearly require all participants to and the partner isn’t present and doesn’t know
sign a release of information. Still other state laws about the affair? The danger in these situations is
are not explicit as to who can release the informa- the other partner feeling betrayed by the therapist
tion when more than one person is in the room. for aligning with the partner in not sharing the
While the legal implications must be considered, information. This kind of triangulation has the
the ethical implications are also important, and potential to impede couple’s therapy work. Unless
this goes back to the question of “who is the the therapist has preemptively addressed this kind
client?” When therapists are clear about who of situation by informing the couple of a no
their client is, they are clearer as to who needs to secrets policy, the therapist’s hands are tied with
sign the release. If the client is the family system regard to addressing the affair in the couples’
or the couple system, then all involved parties therapy (maintaining individual confidentiality)
need to sign; however, if the therapist is viewing until the affair partner discloses it to the partner.
the couple and family as individuals, they may Attending to this aspect of confidentiality between
determine only one person needs to sign a release the two parties in the system from the onset of the
(unless prohibited by certain state statutes). Best couple, therapy is crucial.
practice with regard to releases of information is Client rights of confidentiality are also
to have each person involved in the therapy sign a impacted by therapists’ legal obligations with
release of information. regard to their duty to protect and duty to warn.
Therapists are required by law to report threats of
Another challenge often faced by therapists suicide or threats of physical harm to another to
working with families with children is obtaining the appropriate authorities. In a couple or family
proper consent. Of course, all therapists should where one of the individuals dealing with a long-
obtain written parental consent prior to treating term chronical illness decides that they want to
minors; however, sometimes this can become stop taking their medications that have been keep-
complicated when parents are separated, ing them alive: Is this suicide or is this the right of
divorced, or hold different views/perspectives a patient, as in a living will? How does the thera-
on child involvement with therapy. State law pist work with the couple and family to consider
varies on this, and the couple and family thera- ethical options? When working with a couple, this
pists are obligated to know and practice within can become especially complicated when dealing
the regulations of the state in which they are with the issues of intimate partner abuse. States
practicing. It is generally accepted that the best differ in terms of the laws in handling these types
practice is to make sure that parents are aware of of situations. This becomes even more compli-
any child in therapy and to obtain written con- cated when one considers child abuse and neglect
sent from both parents. It is also advisable that and whether or not a state considers the child
therapists request and review copies of court witnessing an act of domestic violence as child
documents related to child custody and adhere neglect. In regard to therapists’ duty to report
to the conditions for medical treatment specified abuse and neglect of a minor, elderly person, or
therein. a dependent adult, state law differs surrounding
these issues with regard to suspicion verses rea- Technology-Assisted Therapy With the ever-
sonable suspicion. Again, it is incumbent upon increasing prevalence technology-assisted therapy
therapists to be knowledgeable about and adhere and research supporting its benefits and effective-
to the state laws that regulate their practice. ness, it is important that couple and family thera-
Central to client rights and safety in the therapists understand the ethical and legal ramifications
peutic relationship is the therapist attending to and of conducting technology-assisted therapy. When
keeping her influential position (power) in check. providing services through electronic means, ther-
Doing so requires therapists to monitor and main- apists are obligated to ensure that they comply with
tain boundaries and avoid exploiting client trust laws that pertain to the delivery of those services.
and dependency. To this end, therapists are In addition, those engaging in these types of ser-
E
expressly directed in the AAMFT Code of Ethics vices should only do so after receiving appropriate
to avoid conditions and multiple relationships education, training, and/or supervised experience
with clients that could impair professional judg- in the use of such technology to deliver therapy
ment or exploit clients. Perspectives on multiple services. Furthermore, it is requisite that therapists
relationships vary across the continuum from give careful consideration to and assessment for
avoiding them at all costs on one end to embracing the appropriateness of the use of the technology-
the complexity of relationships and interacting assisted services, thoroughly advise clients on the
with clients in a less hierarchical and more equal potential risks and benefits, obtain written consent,
manner on the other end. It is generally accepted and follow the same ethical and legal obligations
that there are some situations/circumstances in of in-person therapy. Laws pertaining to the deliv-
which multiple relationships are unavoidable ery of technology-assisted therapy vary from state
(rural communities and smaller populations to state, and it is vital that therapists utilizing this
where clients prefer therapists with insider knowl- delivery method thoroughly investigate and com-
edge of their specific population). In those circum- ply with those laws.
stances, therapists bear the responsibility of taking
precautions to minimize the risk of impairment or Professional Competence and Integrity Ther-
exploitation and of documenting the appropriate apists working with couples and families are
precautions taken. obligated to maintain high standards of profes-
sional competence and integrity. Inherent in this
Record Keeping Ethically and legally, all ther- obligation is therapists obtaining and
apists are required to document client treatment. maintaining competence in therapy through
When working with couples and families, it is education, training, and/or supervised clinical
imperative therapist specifies in documentation experience throughout the course of their ther-
who is present in sessions. State law typically apy careers. It also includes staying abreast of
dictates the length of time that records must be new developments in the field as well as pursu-
kept after treatment has ended (usually a mini- ing requisite consultation and training as it per-
mum of 5 years) and most specifically address tains to pertinent laws, ethics, and professional
the keeping of records for minors (usually at standards. It is incumbent upon therapists to
least until they reach the age of 18). Therapists practice only within the bounds of their compe-
are responsible for making sure that those tencies and to exercise caution in representing
records are kept safe and protect client confi- themselves and their competencies and their
dentiality, whether in hard copy or electronic professional opinions and doing so with integ-
form, in accordance with applicable ethical and rity and honesty. Therapists are obligated to
legal obligations as set forth in codes of ethics, represent themselves, their background, educa-
state law, and federal law (such as the Health tion, training, affiliations, etc., honestly and
Insurance Portability and Accountability accurately and to correct, wherever possible,
Act – HIPAA). This applies to both clinical false misleading or inaccurate information or
and financial records. representations. Therapists who are impaired
in any way, with regard to work performance or spirituality, our geography, and our gender
clinical judgment, are expected to seek assis- norms. The therapist and the couple or family
tance and take the steps necessary to correct are all influenced in various ways, and the ethical
the impairment. therapist must be cognizant of these intersections.
The various Codes of Ethics that clinicians
follow emphasize therapists valuing their client’s
Application of Ethics in Couple and autonomy, but a therapist working with a couple
Family Therapy or family must also consider the ethical consider-
ations of the unit as a whole – what is best for an
The application of ethics in couple and family individual may not be the best for a couple or
therapy are ever present issues in the course of family and vice versa. For instance, when a
therapy, from the very first session to termination family’s system intersects around culture, sexual-
and often times issues that arise later on, such as ity, and religion, there are potential life and death
when one person from a family requests a release consequences that must be considered. An indi-
of records long after therapy has terminated. vidual may be left with the decision of having to
States vary in the length of time that therapists forfeit their family, culture, and religion in order to
need to hold on to their medical records, and often live out their sexual preference; however, if he/she
there is an exception when children under 18 are a is living in a country where a person can still be
part of the therapy process. This means that if you stoned to death for not being heterosexual, the
worked with a family and the child was 12, you ethical stakes take on a whole new level for the
would need to retain these records for a set num- therapist to consider when working with a family
ber of years after the child turned 18. system.
Teenagers and young adults who are exploring Working with various multicultural Social
careers in the military, law enforcement, or high GRRAACCEESS of race, ethnicity, culture, and
security clearance-type jobs are often asked if they gender also needs ethical consideration. When a
have had mental health counseling. If the appli- therapist is working with a couple of a different
cant had family counseling due to either a parents race or is working with an interracial marriage,
divorce or early at-risk adolescent behavior, there are many things the therapist may not know
should these records be released? When the fam- or many things the therapist may assume. Thera-
ily was the client, the couple and family therapist pists need to be aware of their own implicit bias
needs to consider the reality of more than one and privilege that may be influencing their work
person signing a release for records. In addition, with a couple or family and have the potential to
this means that the job requesting the information take them down an unethical path.
has the file for the whole family. It also means that
if the records aren’t released, it could jeopardize
the former client’s potential employment. Clinical Example of Ethics in Couple and
When looking at the social graces of sexuality, Family Therapy
the values and beliefs regarding premarital sex,
casual sex, extramarital sex, open marriages, sex- Sarah Ahmed is a 17-year-old client who will be
ual orientation, heterosexuality, homosexuality, turning 18 in 3 months. Her parents have brought
polygamy, and sexuality in adolescence or as her into therapy because she has been withdrawn
older adults create a plethora of potential ethical and her grades have been dropping. Sarah and her
issues that may come into play with the couple or parents describe their family as very close. Sarah’s
the family. When one adds culture to the consid- family immigrated to the United States when she
eration of the social grace of sexuality, the idea of was 12 from Yemen. Sarah’s parents had previ-
intersectionality creates more complexity. Culture ously lived stateside when her dad was in medical
plays out in many ways. We have culture in terms school. During this time, Sarah’s parents had
of our ethnicity and race, our religion and converted from Muslim to Christianity after
doing medical rotation with a Christian organiza- Social GRRAACCEESS are impacting her work
tion that did short-term medical mission work. and wants to know Sarah’s perspectives: how it is
The Ahmed family moved back to Yemen after different being a female in Yemen verses in the
the father finished medical school and worked for states; what is it like to be Arab in a primarily
several years; however, when Sarah turned white school; what does she notice about the
12, they were concerned about Islamic law and differences in her freedom level as a teenager
the possibility that it might be expected that Sarah verses her peers; do the cultural customs of Mus-
marry so they immigrated to the states. The major- lim verses Christianity impact things for her at
ity of the Ahmed extended family is still in Yemen home, etc. When the therapist starts having con-
and still is Muslim. The therapist provides the versations with Sarah about the differences
E
family with paperwork where the parents sign between American culture and Muslim culture
consent for their child under 18 to be seen. The on how she interacts with boys, Sarah expresses
therapist tells Sarah and her parents that the state that it is a nonissue for her. When the therapist
statutes give Sarah’s parent’s access to her medi- asks her why, Sarah reveals to her that she is
cal records until she is 18 and wants to know if attracted to females.
Sarah’s parents are willing to respect the idea of The therapist is left with an intersection of a
confidentiality and the idea that confidentiality is complex ethical dilemma on many levels. First, it
only broken when there is a threat to life or a is against the law in the state Sarah lives in to do
reasonable suspicion of abuse to a child, older conversion therapy of a minor, and Sarah is still
adult, or a person with a disability. The therapist under the age of 18. Her parents also have legal
also tells them that when Sarah turns 18, this will access to the file, so what she puts in her notes and
no longer be the case, and they will need to close what she doesn’t put in her notes are critical. Sarah
her file out and open a new one if she is still in and her family still have strong ties back in Yemen
therapy. The parents ask to speak with the thera- with extended family. In researching the therapist
pist alone for a few minutes. After Sarah leaves discovers that consensual lesbian acts in Yemen
the room, the father tells the therapist that they are punishable by 3 years in prison. While her
suspect that their daughter is wrestling with same- family is part of a fundamentalist Christian church
sex attraction, and if this is the case, they want the and there is an assumption that this would be
therapist to fix this as it is against everything they viewed as a sin, the therapist has also worked
believe culturally and religiously. with several different evangelical pastors and
In that moment the therapist considers telling knows that this belief system is being challenged.
the parents that conversion therapy is against the Sarah also has limited support systems outside of
law but changes her mind as she feels this will her immediate family. The therapist considers all
scare the parents away from having their daughter of these complexities with the ethical idea of
in therapy. If this is indeed the case for Sarah, the autonomy of the client and also considers the
therapist wants her to have a safe place to process ethical code of helping a client to explore the
what she is thinking and feeling. The therapist risks and benefits of decisions.
makes this decision based on the premise that Since Sarah is almost 18, the therapist decides
her client is Sarah. to talk with Sarah about all the complexities and
As the therapist works with Sarah, she dis- how difficult this must be for her. As the therapist
covers that Sarah’s family is very strict and some- begins to bring up the contradictions, Sarah starts
times it feels like they are still following Sharia crying and says for the first time she feels like
law. For example, she has not been permitted to someone finally understands. Sarah and her ther-
get her driver’s license. The family has been a part apist first consider what it means to have conver-
of what would be considered a fundamentalist sations about this while she is still under 18 and
Christian church and school that has many rules her parents have access to her medical records.
and beliefs about right and wrong. As the therapist They intentionally decide to focus on the other
is working with Sarah, she considers how the contradictions surrounding her sexuality, such as
946 Ethnic Minorities in Couple and Family Therapy
what she values in her culture that she wants to Synonyms

embrace and the view of females in her race and
religion. Sarah believes this will be a good starting AAPI; African American; Alaskan Natives;
place for her to deal with complexities, and once Asian; Asian American; Black; Cultural minori-
she is 18, she and the therapist can begin to ties; Hispanic; Latino; Minority communities;
explore her sexuality. Minority populations; Native American; Pacific
Islanders; People of color; Race; Racial groups;
Racial minorities
Cross-References
Introduction
▶ Code of Ethics in Couple and Family Therapy
▶ Supervising Ethical Issues in Couple and Fam-
“Ethnicity, the concept of a group’s ‘peoplehood’
ily Therapy
refers to a group’s commonality of ancestry and
▶ Supervising Legal Issues in Couple and Family
history, through which people have evolved
Therapy
shared values and customs over the centuries”
(McGoldrick et al. 2005, p. 2). In every part of
the world, some ethnicities make up the majority
References
and other ethnicities are in the minority. It is
American Association for Marriage and Family Therapy. important to note that while the terms “race” and
(2015). AAMFT code of ethics. Alexandria: Author. “ethnicity” are used interchangeably in everyday
Burnham, J., Palma, D. A., & Whitehouse, L. (2008). language, they have distinctly different meanings.
Learning as a context for differences and differences The former refers to an erroneous notion of bio-
as a context for learning. Journal of Family Therapy,
30, 529–542. logical differences between subgroups of people
Corey, G., Corey, M. S., & Callanan, P. (2011). Issues and based on external appearance. However, this sim-
ethics in the helping professions. Belmont: Thomson plified way of classifying and ranking people has
Brooks/Cole. little basis in science (McGoldrick et al. 2005,
Hecker, L. (Ed.). (2010). Ethics and professional issues in
couple and family therapy. New York: Routledge. pp. 16–17).
Wilcoxon, S. A., Remley, T. P., & Gladdin, S. T. (2012). In the United States, White Americans
Ethical, legal, and professional issues in the practice of constitute the ethnic majority, thereby defining
marriage and family therapy. Upper Saddle River: ethnic minorities as people of color. While White
Pearson.
Americans have a rich history and ethnic heritage
with ancestry from Europe, North Africa, and
the Middle East, much of that history has been
dissolved into being “American,” since identify-
Ethnic Minorities in Couple ing ethnically was seen as a lowering of status.
and Family Therapy This idea as passing for being “regular” (i.e.,
White; McGoldrick et al. 2005) was significant,
Jessica ChenFeng1 and Mudita Rastogi2 and this created the “other,” or that which was not
1
California State University – Northridge, “regular,” i.e., ethnic minorities. The White ethnic
Northridge, CA, USA majority was established not only due to it is
2
Illinois School of Professional Psychology, representing the largest percentage of the popula-
Argosy University, Schaumburg, IL, USA tion, but also by the way that this majority group
influences all other groups and how it sets stan-
dards to which all other ethnicities are compared.
Name of Your Entry To recognize diverse ethnic minority experi-
ences is to understand that they are by no means
Ethnic Minorities in Couple and Family Therapy homogeneous (Rastogi and Wieling 2005, p. 2).
Ethnic Minorities in Couple and Family Therapy 947
Furthermore, the field of mental health is not merely historical occurrences but translate
enriched by the multitude of ways in which ethnic into present systemic injustices with disparities
minorities interact and respond to a legacy of in health, income, home ownership, poverty
white supremacy, colonialism, and other domi- levels, education, job promotion rates, incarcera-
nant discourses while contributing unique histo- tion rates, and experiences of violence/death.
ries, immigration stories, religious differences, This day-to-day reality of personal and systemic
socioeconomic status, and cultural values. An oppression shapes the identities and relationships
appreciation of the intersectionality of between of ethnic minorities.
and within group differences adds to a more In addition to racism and oppression, ethnic
enriched understanding of ethnicity. When we minorities carry the burden of responding to a
E
consider ethnic minorities in the field of couple society and an environment that is shaped by
and family therapy, we think about the clients and values held by mainstream White American cul-
communities served as well as the therapists, ture. These values often focus on human control
supervisors, and professors who contribute to of nature and environment, individual autonomy,
shaping the field. future-oriented growth, and capitalism. Many eth-
nic minorities come from cultures that may not
prize such values, but rather they might esteem
Description harmony with nature, collectivism, and being
reflective of the past or present-focused (Sue and
Discussion around ethnic minorities tends to Sue 2016, p. 42). Many ethnic minorities feel that
focus on their otherness, “emphasizing their def- being conflicted about holding on to one’s own
icits, rather than their adaptive strengths or their heritage and ethnic values while trying to adapt to
place in the larger society” (McGoldrick et al. dominant middle-class White discourses in the
2005, p. 2). This happens because of mistaken USA adds to their daily stressors.
but often deeply ingrained views that privilege Members of the ethnic minorities frequently
and value the majority culture over diversity, develop a bicultural identity because they often
as well as the assumption that ethnic minority participate in two cultural systems, which require
families have unchanging traditional cultural two sets of behavior (Ho et al. 2004). Different
values devoid of contextual influence (Rastogi contexts demand different expectations and so
and Thomas 2009, p. 6). The experience of ethnic consciously or not, they adapt to the changing
minorities and families must be understood environments. This can create spaces where indi-
with the larger American social context in mind. viduals feel a sense of safety and connection in
Ho et al. (2004) offer a helpful framework from being more authentic and other spaces where they
which to understand ethnic minority identitites. must adapt to the rules and expectations of the
A few variables from their framework are dominant culture.
highlighted here: (a) ethnic minority experiences There are also differences in status and hierar-
with racism and oppression, (b) impact of external chy between ethnic minority groups. It is impor-
systems of minority cultures, (c) biculturalism, tant to understand US history and the relationship
and (d) ethnic differences in minority status. within the USA among different ethnic groups
Racism, poverty, and oppression are founda- to grasp the ways that status is given or taken.
tional to the ethnic minority experience in the Sociopolitical issues, often relegating ethnic
USA. The history of the United States is filled minority groups to at least second-class citizen-
with the subjugation of ethnic minorities: African ship or worse, the objects of brutality and hate
Americans with slavery and second-class citizen- crimes, influence these “statuses” (Ho et al. 2004).
ship, genocide of indigenous peoples, the Chinese The insidious nature of White supremacy has
Exclusion Act and “anti-oriental” sentiment, resulted in countless lost lives, and violence
internment of Japanese Americans, Islamophobia towards ethnic (and religious) minorities, including
in the post-9/11 era, and countless more. These are African American, Asian, Latino, Muslim, Sikh,
948 Ethnic Minorities in Couple and Family Therapy
and Arab Americans. Indigenous people have to beginning cultural descriptors, but it is important
prove and qualify their indigenous identity and to seek out the local and personal knowledge
refugees from places such as Syria, Africa, or presented by each client/family.
Southeast Asian countries encounter multiple layers This ethnic specific cultural information also
of trauma and loss, not to mention outright hostility needs to be understood in context, otherwise ther-
in some cases, which make it difficult to create a apists can unintentionally essentialize and further
new life in the USA (Mirkin and Kamya 2008). disempower clients. More recent couple and
family therapy theories such as Socio-Emotional
Relationship Therapy (SERT; Knudson-Martin
Relevant Research et al. 2014) explicitly and intentionally integrate
the larger sociopolitical and historical context to
In the field of CFT European Americans are be able to recognize and interrupt power imbal-
significantly overrepresented, while only 2% of ances in the therapy room. For example, when
MFTs are African-American, 4% Hispanic, 1% therapists work with clients of Asian heritage,
Asian, and 1% Native American or Alaskan they may bring in unexamined assumptions about
Native (Northey and Harrington 2003). However, Asian Americans perpetuated by dominant dis-
we now have more research (Sprenkle 2012) that courses and stereotypes, such as Asian Americans
focuses on or includes ethnic minorities than the as a model minority, being forever foreigners, or
previously stated figure of 4.4% minority-focused the submissiveness of Asian American women
research articles (Bean and Crane 1996), and (ChenFeng et al. 2016). Therapists must examine
important gaps in this regard that were pointed their own biases so that clinical work does not
out by Sprenkle (2003). Previously, training in perpetuate the hurtful consequences of systemic
ethnic minority issues primarily focused on clini- issues of oppression, power, and privilege, and
cal interventions specific to minority client supervision of MFT trainees must necessarily
populations. We know now that ethnic minority encourage the exploration of self-of-therapist issues
issues go beyond how to treat clients in therapy, related to identity development. When therapists
to understanding the impact of the larger social critically engage by attuning to clients’ multiple
context (ChenFeng et al. 2016), as well as cultural worlds as embedded in sociopolitical real-
the experiences of ethnic minority therapists ities, empowering clients becomes a possibility.
(Wieling and Rastogi 2003) and students/super- The research reflects growing interest in the
visees (Hernández et al. 2009). experiences of ethnic minority therapists and
While ethnic specific articles based on case supervisees; these studies help to shape how
studies and specific populations can be helpful CFT training and supervision can be done to
for clinical practice, family therapists should use better serve students and clients. Some ethnic
“cultural descriptors as starting points and not minority therapists express having inadequate
definitive descriptors for a specific cultural group” clinical training in teaching, multicultural diver-
(Bermudez et al. 2010, p. 170). Researchers sought sity, and diverse learning environments (Rastogi
the feedback of Latino participants by asking the and Wieling 2005; Wieling and Rastogi 2003).
degree to which they agree with statements They strongly identify with their ethnic minority
describing Latino families found in marriage and identities and see this as having great value while
family therapy literature. Participants agreed with hoping for organizational and educational change
statements pertaining to Latino values of familism so that their experiences become less peripheral in
and personalism; however, there were mixed the field. Ethnic minority supervisees have at
results in regard to other Latino values presented times also “felt that their supervisors conducted
such as fatalism and spiritualism. This study supervision from a Eurocentric perspective that
reminds us that clients are better served when denied their identities and social locations.”
therapists are flexible and curious in their cultural Further, there are supervisee reports of supervi-
perceptions; articles and research can provide sors misusing power and engaging in overt
Ethnic Minorities in Couple and Family Therapy 949
racism in supervision (Hernández et al. 2009, Cross-References

p. 97). Training across all levels of CFT work
can benefit from the decentering of Eurocentric, ▶ African Americans in Couple and Family
White-dominant realities. Therapy
▶ Asian Americans in Couple and Family
Therapy
Special Considerations for Couple and ▶ Black Men in Couples and Families
Family Therapy ▶ Black Women in Couples and Families
Given this research, the field of couple and family ▶ Cultural Values in Couples and Families
E
therapy would benefit from responding thoughtfully ▶ Latino/Latinas in Couple and Family Therapy
to ethnic minority experiences. The hope is that in
the therapy room, or in supervision/teaching, MFTs
are not contributing to more spaces where clients
and students feel unsafe and further marginalized. References
We know that it is important to address issues
related to ethnic identity in therapy (Utsey et al. Bean, R., & Crane, D. R. (1996). Marriage and family
therapy research with ethnic minorities: Current status.
2002) and in supervision (Hird et al. 2004; Todd The American Journal of Family Therapy, 24(1), 3–8.
and Rastogi 2014). An article by Hird et al. (2004) https://doi.org/10.1080/01926189508251011.
on supervision that also applies to teaching and Bermudez, J., Kirkpatrick, D., Hecker, L., Torres-Robles,
clinical work states that the onus of responsibility C. (2010). Describing Latino families and their help-
seeking attitudes: Challenging the family therapy liter-
to initiate such conversations falls on the person ature. Contemporary Family Therapy, 32(2), 155–172.
who holds power in the relationship, whether this ChenFeng, J., Kim, L., Wu, Y., & Knudson-Martin, C.
is the therapist, supervisor, or instructor. When (2016). Addressing culture, gender, and power with
dialogue about culture and ethnicity is not part Asian American couples: Application of socio-
emotional relationship therapy. Family Process, 56,
of the process, supervisees (clients or students) 558. https://doi.org/10.1111/famp.12251.
are more likely to self-silence because it may Glosoff, H. L., & Durham, J. C. (2010). Using supervision
not feel safe for them to initiate conversation to prepare social justice counseling advocates.
even if it is on their mind (Hird et al. 2004). Counselor Education and Supervision, 50(2),
116–129. https://doi.org/10.1002/j.1556-6978.2010.tb
When supervisors model attending to issues of 00113.x.
power, oppression, and privilege in the supervi- Hernández, P., Taylor, B. A., & McDowell, T. (2009).
sory relationship, it enables supervisees to do the Listening to ethnic minority AAMFT approved super-
same with clients (Glosoff and Durham 2010). visors: Reflections on their experiences as supervisees.
Journal of Systemic Therapies, 28(1), 88–100. https://
Watts-Jones (2010) models how a therapist can doi.org/10.1521/jsyt.2009.28.1.88.
initiate conversation about the therapist’s own Hird, J. S., Tao, K. W., & Gloria, A. M. (2004). Examining
self-location. It is the therapist’s responsibility to supervisors’ multicultural competence in racially similar
have a sufficient base of knowledge, a conceptual and different supervision dyads. The Clinical Supervisor,
23(2), 107–122. https://doi.org/10.1300/j001v23 n02_07.
framework around ethnicity, culture, identity, Ho, M. K., Rasheed, J. M., & Rasheed, M. (2004). Family
power, and oppression discourses (Pandit et al. therapy with ethnic minorities (2nd ed.). Thousand
2014), to engage in conversations with clients Oaks: Sage.
around the issue of ethnic identity. This contrib- Knudson-Martin, C., Huenergardt, D., Lafontant, K.,
Bishop, L., Schaepper, J., & Wells, M. (2014). Compe-
utes to the creation of a safe space in therapy for tencies for addressing gender and power in couple
clients to be able to dialogue about their own therapy: A socio emotional approach. Journal of Mar-
ethnic minority or majority identities. This pro- ital and Family Therapy, 41(2), 205–220.
cess hopefully leads to greater awareness regard- McGoldrick, M., Giordano, J., & Garcia-Preto, N. (2005).
Ethnicity and family therapy. New York: Guilford
ing ethnic minority experiences and issues so that Press.
the CFT field can better serve and empower ethnic Mirkin, M. P., & Kamya, H. (2008). Working with immi-
minority clients, students, and supervisees. grant and refugee families. In M. McGoldrick &
950 Ethnicity in Couples and Families
K. V. Hardy (Eds.), Re-visioning family therapy Introduction

(2nd ed., pp. 311–326). New York: Guilford Press.
Northey, W. F., Jr., & Harrington, M. (2003). 2002
AAMFT member survey of clinical practices and Ethnicity, the concept of a group’s “peoplehood,”
approaches to substance abuse. Alexandria: The refers to a group’s common ancestry and history,
American Association for Marriage and Family through which people have evolved shared values
Therapy. and customs over the centuries. Based on a com-
Rastogi, M., & Thomas, V. (2009). Multicultural couple
therapy. Thousand Oaks: Sage. bination of race, religion, geography, political, and
Rastogi, M., & Wieling, E. (2005). Voices of color. cultural history, ethnicity is retained, whether or
Thousand Oaks: Sage. not members realize their commonalities with one
Sprenkle, D. H. (2003). Effectiveness research in another. Its values are transmitted over generations
marriage and family therapy: An introduction. Journal
of Marital and Family Therapy, 29(1), 85–96. by the family and reinforced by the surrounding
Sprenkle, D. H. (2012). Intervention research in couple community. Ethnicity is a powerful influence in
and family therapy. Journal of Marital and Family determining identity. It patterns our thinking, feel-
Therapy, 38(1), 3–29. ing, and behavior in both obvious and subtle ways,
Sue, D. W., & Sue, D. (2016). Counseling the culturally
diverse. Hoboken: Wiley. although generally we are not aware of it. It plays a
Todd, T. C., & Rastogi, M. (2014). Listening to supervisees major role in determining how we eat, work, cele-
about problems in systemic supervision. In T. C. Todd brate, make love, and die (McGoldrick et al. 2005).
& C. L. Storm (Eds.), The complete systemic supervi- Ethnicity is not, however, the only dimension
sor: Philosophy, context and pragmatics (2nd ed.,
pp. 314–334). Chichester: Wiley. of culture, and to understand it, we must pay
Utsey, S. O., Chae, M. H., Brown, C. F., & Kelly, D. attention to its intersection with race, social
(2002). Effect of ethnic group membership on ethnic class, gender identity, sexual orientation, religion,
identity, race-related stress and quality of life. Cul- geography, immigration, and family dynamics.
tural Diversity & Ethnic Minority Psychology, 8(4),
366–377. https://doi.org/10.1037/1099- Such factors affect the way individuals may feel
9809.8.4.367. about their cultural heritage, how they relate to
Watts-Jones, T. D. (2010). Location of self: Opening the others in their cultural group, and their interest in
door to dialogue on intersectionality in the therapy preserving cultural traditions. They also influence
process. Family Process, 49(3), 405–420. https://doi.
org/10.1111/j.1545-5300.2010.01330.x. people’s social location, their access to resources,
Wieling, E., & Rastogi, M. (2003). Voices of marriage and their sense of belonging to this society, and the
family therapists of color. Journal of Feminist Family extent to which they are privileged or oppressed.
Therapy, 15(1), 1–20. https://doi.org/10.1300/j086v15 The continuing rise of immigrants to the
n01_01.
United States from Asia, Latin America, and the
Middle East during recent decades has contrib-
uted to high rates of cultural intermarriage. These
changes have also brought more attention to the
Ethnicity in Couples and existence of marked disparities in mental health
Families services for racial and ethnic minorities in this
country (Sue et al. 2009). The fact that
Nydia Garcia Preto1 and Monica McGoldrick1,2 non-dominant ethnic groups face many barriers
1
Multicultural Family Institute, Highland Park, in accessibility, an use of high-quality care has
NJ, USA prompted mental health professionals to give
2
Psychiatry Department, Rutgers University, greater consideration to the underlying cultural
Robert Wood Johnson Medical School, Highland assumptions in therapeutic models and to question
Park, NJ, USA their universality for clinical work with couples
and families. Ethnicity offers a lens through which
marriage and family therapists can better under-
Synonyms stand the influence of cultural values and beliefs
on clients’ experience of physical and emotional
Cultural identity problems and their patterns of help seeking.
Ethnicity in Couples and Families 951
Description over group values, tending to avoid discussion of

group characteristics altogether, in favor of indi-
The consciousness of ethnic identity varies vidual characteristics, maintaining, for example,
greatly within groups and from one group to “I prefer to think of each individual as a unique
another. When we ask people to identify them- human being rather than pigeonholing individuals
selves ethnically, we are really asking them to in group categories.” Of course we all prefer to be
oversimplify, to highlight a part of their identity treated as unique human beings, but such assump-
in order to make certain themes of cultural conti- tions prevent acknowledging the influence of cul-
nuity more apparent. Many people in the United tural and group history on every person’s
States grow up not even knowing their ethnicity or experience. Some in our society have the privilege
E
having descended from multiple ethnic back- to belong, with access to society’s resources and
grounds. But everyone has a culture. Clinical the ability to trust that society’s institutions will
work may often entail helping clients locate them- work for them. Others are disqualified at
selves culturally so that they can overcome their every turn.
sense of mystification, invalidation, or alienation The values, beliefs, status, and privileges of
that comes from not being able to feel culturally at families in our society are profoundly influenced
home in our society. by their socioeconomic and cultural location,
Our clients’ personal contexts are strongly making these issues essential to our clinical
shaped by their ethnic cultures. As therapists, an assessment and intervention. Discussing cultural
important part of our work has been to help clients generalizations or stereotypes is as important as
clarify the multiple facets of their identity to discussing any other norms of behavior.
increase their flexibility to adapt to the multicul- It is almost impossible to understand the mean-
tural society in the United States. We help them ing of behavior unless one knows something of
appreciate and value the complex web of connec- the cultural values of a family. Even the definition
tions within which their identities are formed and of “family” differs greatly from group to group.
which cushion them as they move through life. The dominant mainstream definition in the United
Ethnically respectful clinical work helps people States (McGill and Pearce 2005) tends to empha-
evolve a sense of who they belong to. Thus ther- size the intact nuclear family, whereas for Italians
apy involves helping people clarify their self- (Giordano et al. 2005), there tends to be no such
identity in relation to family, community, and thing as the “nuclear” family. To them, family
their ancestors, while also adapting to changing typically means a strong, tightly knit three- or
circumstances as they move forward in time. four-generational kinship network, which also
While generalizing about groups has often includes godparents and old friends. African-
been used to reinforce prejudices, one cannot dis- American families typically focus on an even
cuss ethnic cultures without generalizing, since wider network of kin and community (Kelly and
the very definition of ethnicity or culture pertains Hudson 2016; Moore Hines and Boyd-Franklin
to group values, patterns, and traditions. The only 2005). And some Asian families include all their
alternative to generalizing about culture is deny its ancestors going all the way back to the beginning
relevance and ignore the analysis of group pat- of time and all descendants, or at least male ances-
terns, which is likely to disqualify the experience tors and descendants, reflecting a sense of time
of groups at the margins, perpetuating mystifica- that is almost inconceivable to most Americans
tion and covert negative stereotyping. Our field’s (Suzuki et al. 2016; Lee and Mock 2005).
diagnostic scheme, for example, whether the Ethnic groups’ distinctive problems are often
ICD-10 or the DSM V, does not require the the result of cultural traits that are conspicuous
slightest reference to any person’s cultural back- strengths in other contexts. For example, the opti-
ground or location in order to make a diagnosis or mism of those of British ancestry may lead to
to provide treatment (Regier et al. 2013). The confidence and flexibility in taking initiative. But
dominant culture privileges individual values the same preference for being upbeat may also
lead to the inability to cope with tragedy or to the dominant American pattern, while adoles-
engage in mourning (McGill and Pearce 2005). cence is shorter and leads more quickly into adult-
Historically, the British have perhaps had much hood than in the dominant American structure,
reason to feel fortunate as a people. But optimism where courtship is generally longer, and middle
often becomes a vulnerability when people must age extends into what Americans generally think
contend with major losses. They may have few of as older age.
philosophical or expressive ways to deal with Ethnic groups vary in what they view as prob-
situations in which optimism, rationality, and lematic behavior. Anglos (McGill and Pearce
belief in individual efficacy are insufficient. 2005) may be uncomfortable with dependency
Thus they may feel lost when dependence on the or emotionality; the Irish are distressed by a fam-
group is the only way to ensure survival. ily member “making a scene”, Italians about dis-
Families from different ethnic groups may loyalty to the family (McGoldrick et al. 2005),
experience diverse types of intergenerational Greeks (Killian and Agathangelou 2005) about
struggles. British-American (McGill and Pearce any insult to their pride or filotimo, Jews (Rosen
2005) families are likely to feel that they have and Weltman 2005) about their children not being
failed if their children do not move away from “successful”, Puerto Ricans (Garcia Preto 2005)
the family and become independent, whereas Ital- about their children not showing respect, and
ians (Giordano et al. 2005) generally believe they Arabs (Abudabbeh 2005) about their daughters’
have failed if their children do move away. Jewish virginity. For Chinese families, harmony is a key
families often foster a relatively democratic atmo- dimension (Lee and Mock 2005), while for Afri-
sphere in which children are free to challenge can Americans, the concept of bearing witness
parents and discuss their feelings openly (Rosen and testifying about their suffering is a central
and Weltman 2005). Greek (Killian and concept (Moore Hines and Boyd-Franklin 2005).
Agathangelou 2005) or Chinese families, in con- Of course, families also vary in how they
trast, do not generally expect or desire open com- respond to problems. Anglos (families of British
munication between generations and would ancestry) may see work, reason, and stoicism as
disapprove of a therapist getting everyone the best response, whereas Jews often consult
together to discuss and “resolve” their conflicts. doctors and therapists to gain understanding and
Children are expected to respect parental author- insight. Until recently, the Irish responded to
ity, which is reinforced by the distance parents problems by going to the priest for confession,
maintain from their children (Lee and Mock “offering up” their suffering in prayers, or, espe-
2005). cially for men, seeking solace through drink
Cultural groups vary greatly in the emphasis (McGoldrick et al. 2005). Italians may prefer to
they place on various life transitions. Irish and rely on family support, eating, and expressing
African Americans have always considered themselves. West Indians may see hard work,
death the most important life cycle transition thrift, or consulting with their elders as the solu-
(McGoldrick et al. 2004). Italians, Asian Indians, tion (Brice-Baker 2005), and Norwegians might
and Poles tend to emphasize weddings, whereas prefer fresh air or exercise (Erickson 2005). Asian
Jews often pay particular attention to the bar or bat Indians might focus on sacrifice or purity and the
mitzvah and Puerto Ricans to the Quinceanera Chinese on food or prayer.
(15th birthday), celebrating transitions from child- Groups also differ in attitudes toward seeking
hood that other groups hardly mark at all. Fami- help. In general, Italians rely primarily on the
lies’ ways of celebrating these events differ also. family and turn to an outsider only as a last resort.
The Irish tend to celebrate weddings (and every African Americans have long mistrusted the help
other occasion) by drinking, Poles by dancing, they can receive from traditional institutions
Italians by eating, and Jews by eating and talking. except the church, the only institution they could
Mexican Americans (Falicov 2005) may see early consider “theirs.” Puerto Ricans and Chinese may
and middle childhood as extending longer than somatize when under stress and seek medical
rather than mental health services. Norwegians, Italians may seek solace in food or in emotionally
too, often convert emotional tensions into physi- and dramatically expressing their feelings, and
cal symptoms, which they consider more accept- Asians may become very silent, fearing loss of
able, thus, their preference for doctors over face. Members of these groups sometimes per-
psychotherapists. Likewise, Iranians (Jalali ceive each other’s reactions as offensive or insen-
2005) may view medication and vitamins as a sitive, although, within each group’s ethnic
necessary part of treating symptoms. And some norms, such reactions make perfect sense. Much
groups tend to see their problems as the result of of therapy involves helping family members rec-
their own sin, action, or inadequacy (Irish, African ognize each other’s behavior as largely a reaction
Americans, Norwegians) or someone else’s from a different frame of reference.
E
(Greeks, Iranians, Puerto Ricans). Consider an Anglo (British American)-Italian
The degree of ethnic intermarriage in the fam- couple in which the husband takes literally the dra-
ily also plays a role in the evolution of cultural matic expressiveness of the Italian wife, while she
patterns (McGoldrick and Garcia Preto 1984; finds his emotional distancing intolerable. The hus-
Crohn 1995; Root 2001; Kennedy 2003; Killian band may label the Italian “hysterical” or “crazy”
2013; Karis and Killian 2009; Rastogi and and in return be labeled “cold” or “catatonic.”
Thomas 2009; Brunsma and Porow 2016). Knowledge about differences in cultural belief sys-
Although as a nation we have a long history of tems can help spouses who take each other’s behav-
intercultural relationships, until The Loving ior too personally to be less reactive. Couples may
vs. Virginia court ruling in 1967 (Newbeck and experience great relief when they can come to see
Wolfe 2015), our society explicitly forbade racial the spouse’s behavior fitting into a larger ethnic
intermarriage and discouraged cultural intermar- context rather than as a personal attack. Yet cultural
riage. But traditional ethnic and racial categories traits may also be used as an excuse for not taking
are now increasingly being challenged by the responsibility in a relationship: “I’m Italian. I can’t
cultural and racial mixing that has long been a help it” (i.e., the yelling, abusive language, impul-
submerged part of our history. Intimate relation- siveness), or “I'm a WASP. It is just the way I am”
ships between people of different ethnic, reli- (the lack of emotional response, rationalization, and
gious, and racial backgrounds offer convincing workaholism).
evidence that Americans’ tolerance of cultural
differences may be much higher than most people
think (Pew Research Center 2012; Killian 2013; Relevant Research
Crohn 1995; McGoldrick and Garcia-Preto 1984).
Intermarriage can also complicate issues that most Studies on ethnicity in the United States have
partners face. The greater the cultural difference fluctuated depending on social factors and poli-
between spouses, the more trouble they may have tics. Sociologists such as Glazer and Moynihan
in adjusting to marriage. Knowledge about ethnic/ (1963, 1975), and Greeley (1974) made numerous
cultural differences can be helpful to spouses who early contributions that raised awareness about the
take each other’s behavior too personally. Typi- important role families play in groups maintaining
cally, we tolerate differences when we are not their ethnic identity. Glazer and Moynihan (1963)
under stress. We may even find them appealing. in their influential book Beyond the Melting Pot
However, when stress occurs, tolerance for differ- presented their analysis of five specific ethnic
ences diminishes. Not to be understood in ways groups in New York City: Irish, Italians, Jewish,
that conform with our wishes and expectations African Americans, and Puerto Ricans. They saw
frustrates us. For example, when upset, Anglos the family as the most important factor in keeping
(Americans of British ancestry) tend to move ethnic groups from losing their national identities
toward stoical isolation to mobilize their powers as they struggled to adapt to a new culture and
of reason. In contrast, Jews may seek to analyze offered some protection from adversity in the
their experience by talking things out together. dominant culture.
The US Census tracking of race and ethnic (Fischer et al. 2016), the Family Interventions
ancestry provides statistics that help researchers for Schizophrenia and the Psychosis model
to measure growth or decline of certain ethnic (McFarland 2016), and the Multidimensional
groups and to compare many trends in the popu- Family Therapy model (Liddle 2016), have
lation. In the 1970s and 1980s, there was a surge given some consideration to the influence of eth-
of literature and studies that alerted the govern- nicity in shaping couple and family relationships
ment and public about the alarming disparities in and have noted that acknowledging cultural
the provision and quality of services and care that beliefs and attitudes of the target population
some racial and ethnic minority groups receive. seems to increase the participation of ethnic
Many of these studies called for the need to inte- minorities. But, the only group that has actually
grate cultural awareness particularly in the deliv- acknowledged that their lack of studies on ethnic
ery of health and mental health services (Sue minority groups is a limitation of their model were
1998; Sue et al.1982; Sue and Zane 1987, 2006; the authors of Alcohol-Focused Behavioral Cou-
Kleinman 1980; Hall 1987). Since then, many ple Therapy (McCrady et al. 2016). More com-
studies have reported positive results about the monly, if the researchers even refer to culture at
efficacy of integrating cultural competent inter- all, it is not embedded in their work in any mean-
ventions when working with ethnic minorities ingful way. For example, Busby and Holman
(Rosello et al. 1999; Bernal and Saez-Santiago (2009) refer in a study based on John Gottman’s
2006; Santisteban et al. 1997, 2003, 2012). How- work, to the importance of understanding back-
ever, in the field of marriage and family therapy, ground variables including ethnicity and religion
there continues to be a lack of such research. in order to understand a couple’s relationship
Increasingly over the past 25 years, research in style. However, they give no idea how these issues
the field has been focused more narrowly on would be assessed or integrated into clinical
developing empirically supported evidence- understanding.
based treatment models, rather than exploring Only two models, The Oregon Model of Parent
the vast untapped potential of system concepts to Management Training (Forgatch and Kjobli 2016;
bring about change for the diverse population of Parra-Cardona et al. 2016) and The Brief Strategic
our nation. These treatment models have rarely Family Therapy Model (Szapocznik et al. 1978;
been tested on the diverse populations of our Santisteban et al. 2006) seem to really understand
country. Yet increasingly, they are becoming the that cultural perspectives are at the core of human
only models one can teach at Marriage and Family relationships. The Oregon group, following Stan-
Graduate Schools. Research evidence is primarily ley Sue’s model for cultural competence (Sue
based on studies conducted by white middle-class 1998), integrates cultural assumptions within the
researchers on white European Americans, and very core of their structure. Impressively, all those
the instruments they use reflect the dominant involved in the training are encouraged to learn
white culture. The lack of research on ethnically, about their own culture as well as other cultures
racially, and/or socioeconomically diverse groups and to increase their cultural competence. The
raises obvious questions about the general appli- model has been translated and developed in dif-
cability of these models (Bernal and Scharron- ferent languages, modifying their examples to be
Del-Rio 2001; Hall 2001; Sue 1998). For exam- culturally relevant in each version. The Brief Stra-
ple, the Emotionally Focused Couple Therapy tegic Family Therapy model is unique in having
model (Weibe and Johnson 2016) has rarely been designed to fit the cultural values of Cuban
even mentioned cultural dimensions of experi- immigrant families in Miami who presented with
ence and has conducted no trials with adolescent behavioral problems and
non-dominant cultural groups, yet the data gener- intergenerational conflicts (Szapocznik et al.
ated tends to be viewed as universally applicable. 1978). The model has evolved, applying strategies
A few evidence-based models, such as the that were initially tailored for engaging Latinos
cognitive behavioral couple therapy model into work with African Americans and
interventions with white European populations their own families of origin, developing cultural
(Santisteban et al. 2006). competence and cultural responsiveness requires
Overall, the consideration of ethnicity in mar- coming to terms with one’s own ethnic identity.
riage and family therapy has remained a “special Ideally, therapists would no longer be “triggered”
issue,” mostly ignored in research, taught at the by ethnic characteristics they may have regarded
periphery of psychotherapy training and rarely negatively or caught in the ethnocentric view that
written about or recognized as crucial by or for their own cultural values are more “right” or
therapists of European origin (Rastogi and “true” than those of others. Ethnically self-aware
Thomas 2009; Murry et al. 2001; Chambless therapists achieve a multiethnic perspective,
et al. 1996). which opens them to understanding values that
E
differ from their own, so that they neither need
to convert others to their view nor to give up their
Special Considerations for Marriage and own values. David McGill (McGill and Pearce
Family Therapy 2005) has suggested that the best training for
family therapists might be to live in another cul-
In the past few years there has been a greater ture and learn a foreign language and that experi-
commitment by professional organizations such ence might best help the clinician achieve the
as the American Association for Marriage and humility necessary for respectful cultural interac-
Family Therapy to integrate requirements for cul- tions that are based on more than one way of
tural awareness and sensitivity into their profes- defining normality, truth, and wisdom. Thus, the
sional codes of ethics and into their curricula. For best cultural training for marriage and family ther-
example, The Commission on Accreditation for apists might be to experience what it is like not to
Marriage and Family Therapy Education be part of the dominant culture.
(COAMFTE) Accreditation Standards (2015)
has called for “ Marriage and family training pro-
grams to demonstrate a commitment to diversity References
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53(4), 440–448. intent to understand individuals through their
958 Ethnography in Relation to Couple and Family Therapy
social and cultural arrangements. Ethnography considered to be the first researchers to use ethno-
attempts to define cultural realities by interpreting, graphic methods to assess the experience of cli-
analyzing, and documenting detailed descriptions ents participating in family therapy. Through their
of patterns, events, contexts, and conversations to work, these researchers demonstrated how obser-
better comprehend how culture influences human vations of both the client and the therapist can be
behavior in everyday environment (Tubbs and effectively utilized to improve the therapeutic
Burton 2005). process.
Ethnography has been widely used to enhance In recent times, Monica McGoldrick, cofounder
the understanding of the practical and theoretical and director of the Multicultural Family Institute
domains of family therapy and its applicability in in Highland Park, New Jersey, has contributed
the client’s real world. In the field of couple significantly through her writings on the inclusion
and family therapy, the use of ethnographic inter- of race, culture, and gender in family therapy
views began as an initiative to create more client- practices. Her work has provided recommenda-
based descriptions of family therapy sessions. tions for culturally sensitive and culturally aware
This approach was a shift away from the existing assessments, treatment considerations, and clini-
literature that primarily focused on the therapist’s cal training efforts for diverse groups of couple
perspective. Since then, ethnographic interviews and family therapists.
have been continually used to gather feedback
from the clients regarding the direction of the
therapeutic process. This approach has also been Description
utilized in exploring the therapeutic relationship
to determine fit between client and therapist The validity of ethnographic interviewing can
variables, formulating effective treatment plans, be better understood by expanding on the
and delivering high-quality services. In couple idea that research concepts can be effectively
and family therapy, ethnographic debriefing has combined with counseling techniques. The ethno-
also been found to significantly benefit in graphic interview questions also serve the purpose
repairing ruptures in the therapeutic alliance and of pursuing cultural meaning that is translated
addressing dissatisfaction expressed by the clients and understood differently by different people.
regarding the therapeutic process. Thus, it is imperative to become familiar with
One of the unique features of ethnographic the different kinds of questions that therapists
research is to focus on hypothesis development, can ask their clients to better understand their
rather than testing, based on the analysis of the cultural context and how the clients’ cultural
gathered data. In lieu of forming questions to upbringing may have influenced their current life-
elicit predetermined responses, ethnography aids styles. A further discussion will follow regarding
in formulating hypotheses based on an individual’s a number of ethnographic questions including,
description of their sociocultural experiences. example questions, structural and descriptive
questions, native-language questions, and the eth-
nographic mapping task.
Prominent Associated Figures Ethnographic descriptive questions (Banister
1996) are a series of questions asked by therapists
Gregory Bateson is noted as one of the pioneers to elicit details about specific events, people, or
in the field who first introduced ethnographic behaviors and how it may have impacted the
approaches to incorporate systems into cultural client’s presenting problem and formed the
behavior. Bateson fostered cross-cultural under- problem sequence. For example, “I see that this
standing of various ethnic groups through his was the first time you celebrated Thanksgiving
proposed theory – ecology of the mind. in America. Can you please tell me what exactly
Additionally, Bruce Kuehl and his colleagues happened during the Thanksgiving dinner
Neal Newfield and Harvey Joanning, are with your partner’s parents that upset you?”
A subcategory of descriptive questions is mini- effective technique called mapping tasks. In

tour questions (Spradley 1979). which refers to using the mapping task technique, clients are
placing the context of the content in practice for asked to map out a particular event, feeling,
the client (Bruner 1990). For example, “if I were experience, relationship, or a situation through
to observe you and your son praying at the a diagram. This technique can be helpful in
mosque, what would I see?” breaking down the event that is being considered
Another category of ethnographic questions and also providing an opportunity to the individ-
includes example questions (Banister 1996), which ual client to fill in the blanks for other significant
are most commonly used to comprehend the client’s people involved in the event. This technique is
narrative about a particular event, person, or situa- similar to mapping a problem sequence in Inte-
E
tion. For instance, “can you give me an example of grative Systemic Therapy (IST) that aids in visu-
what ‘gets on your nerves’ when you are with your alizing a typical repetitive and recursive pattern
partner?” (Pinsof et al., 2018).
Therapists can also ask ethnographic struct- The different types of ethnographic questioning
ural questions that help in exploring the client’s techniques have also been found to be effective in
responses to the descriptive questions and how eliciting details about the client’s history in a way
they organize this information in everyday life. that promotes an organic flow of conversation and
For example, if a client frequently mentions that maintenance of therapeutic alliance. Different
he feels burned-out when he spends time with his 3- kinds of questions serve different purposes and
year-old child, the therapist can ask different types assist in facilitating a smooth interview. Therefore,
of structural questions in order to identify if any the ethnographic questioning technique is relevant
significant relationship exists between different to any form of therapy, especially couple and fam-
variables of the presenting problem. This will ily therapy, as it can be efficiently used by therapists
also serve to assist the therapist in testing the evolv- to combine the experiences of each member in the
ing hypotheses. For example, “What are some of family for a more thorough conceptualization of
the things you do with your child that contribute to the presenting problems.
you feeling burned-out? Is your partner’s insistence
of sending your child to daycare stressing you out?
Are there other family members to help you Relevance to Couple and Family Therapy
throughout the day? What is the first thought that
comes to your mind when you are with your child?” Recent statistics indicate that interracial mar-
Ethnographic native-language questions riages in the United States have been on the
(Spradley 1979), are asked when clients use a rise – from 3% in 1967 to 17% in 2015 (Pew
specific term or phrase (which could be in their Research Center, 2017). According to
native language) to describe their presenting McGoldrick (2006), interracial marriages in the
problem, an event, or a person. The important United States have increased as a consequence
thing for the therapist to do is to use the same of sociocultural, political, and economic factors
term or phrase that the client has used and present that in turn continually impact marital and
it in another context or experience. This in turn familial relationships. As such, the utilization
may help the client create new meanings and of ethnographic techniques in the context of
interpretations of the given situation. For exam- therapy provides a more in-depth cultural obser-
ple, “What are some other situations that make vation, which is crucial in formulating effective
you want to pass the buck?” Or “can you think of solution sequences and identifying potential
other terms or phrases to describe why you tend to constraints that may have unknowingly been
pass the buck in crucial times?” brought into the relationship by the partners.
In order to obtain accurate information about Consideration of all the given cultural factors
the clients’ experiences of their presenting helps the therapist to better understand how peo-
problems, Banister (1996) also suggested an ple preserve their cultural heritage and traditions
960 Ethnography in Relation to Couple and Family Therapy
and the ways in which it surfaces in different relationship. Clinicians can also coach family
contexts of their relationships. members to differentiate between deeply held
McGoldrick aptly highlights the importance beliefs from values that reinforce dysfunction in
of observing how cultural groups differ in under- the relationship. For clinicians to effectively under-
standing what is problematic behavior, how stand their clients’ familial problems in a cultural
they respond to given problems, and how they context, the following basic assumptions have been
seek help to address these issues. For example, outlined to guide them through the process
individuals from West Indies may prefer to (Giordano and Carini-Giordano 1995; McGoldrick
consult the elders in their family, while Norwegians 1998):
may see physical exercise regimens such as run-
ning and hiking as a beneficial means to solve
• Assume that no one can completely under-
distress. Similarly, Iranians, Puerto Ricans, and
stand other cultures, but one must have cultural
Chinese individuals may seek medical help rather
humility, sensitivity, and awareness of one’s
than mental health services to find solutions for
own values and biases.
their marital or familial problems.
• Assume that a person’s awareness about the
According to McGoldrick (1998), the greater
positive aspects of his or her cultural heritage
the cultural difference between spouses, the
and family of origin history contributes toward
more likely they are to have difficulty in
his or her mental health and well-being.
adjusting to the relationship. For example, East
• Assume that individuals and families from
Asian tend to become silent during conflict, in
marginalized cultures have possibly internal-
part due to the fear of losing their dignity, while
ized shame and prejudice toward themselves.
Italians may turn toward food or a major dra-
This internalized shame and prejudice may be
matic display of emotional venting to comfort
due to interactions within the larger society by
themselves. Hence, ethnographic techniques in
those from the dominant cultures who may
couple and family therapy can be immensely
have most likely internalized their superiority
helpful for partners to gain more knowledge
and privileges.
about their ethnic differences. Also, couples in
• Assume that negative cultural attitude, or lack
interracial marriages are continuously trying to
of awareness about one’s own heritage, can be
rebalance their own cultural characteristics by
a result of oppression, cutoffs, or traumatic
moving away from some of the values from
experiences of being suppressed throughout
their culture of origin while moving toward cul-
history.
tural values that they are adapting (McGoldrick
2006). This process of identifying one’s own
ethnic identity and cultural values may poten- Clinical Example of Application of
tially create friction in marriages and blended Theory in Couples and Families
multiracial families. As such, adopting an ethno-
graphic therapeutic approach to treat families Reiko is a 33-year-old Japanese woman who has
may shed insight, for both the clients and the been married for 2 years to Mateo, a 36-year-old
clinicians, uncovering the complexities in the Mexican-American man. The couple met when
presenting problems. Mateo traveled to Japan for a work-related confer-
As elaborated in the previous section, ence. They legally married after dating for 2 years.
therapists can ask different types of ethnographic Prior to their union, Mateo lived with his father and
questions to understand the implications of the stepmother due to financial constraints. When
clients’ sociocultural background and resolve Reiko moved to the United States, she agreed to
deeply embedded negative cultural attitudes as live with her in-laws for a brief period of time before
well as conflicts within the family system. Thera- the couple could afford their own place.
pists can do this by identifying and choosing the The first few months of their marriage were
values that the clients wish to retain in the difficult as Reiko was still adjusting to the culture
of a new country, learning a new language, as It will be crucial to ask direct questions about
well as making efforts to get along with Mateo’s religious and spiritual beliefs, social class and
Mexican-American family. During this same how it is stratified in their respective societies.
time period, Mateo was struggling to find Furthermore, it would be necessary to learn
sponsors for his project and he often felt about Reiko's migration and how it has impacted
exhausted being the mediator between Reiko and them individually and their relationship. Often-
his parents as minor relational conflicts arose. times sharing their individual views on their per-
Some of these conflicts came about when Mateo’s sonal history, and hearing the narrative of the
parents, who were described by the couple as other partner, brings to light significant insight
emotionally expressive, respectively expressed a and creates a safe space to share feelings or con-
E
desire to spend more time with Mateo and cerns that the couple may not have shared before.
Reiko. Mateo’s parents’ emotional expressiveness This therapeutic approach was helpful for the
was described by Reiko as suffocating and she couple as they learned different things about one
experienced it as crossing boundaries. Upon another and had the opportunity to express curi-
further questioning about Reiko’s family of osity and understanding in the process.
origin, Reiko indicated that she was raised in a With Reiko and Mateo, asking example ques-
family that was more stoic in nature, not emotion- tions also provided clarity in terms of pinning the
ally expressive, and encouraged independence exact issues and making suggestions accordingly.
and personal space. Thus, Reiko was able to Remaining mindful that Reiko is not fluent in
explain why the everyday family dinners and out- the native English language, it is essential for the
ings with Mateo’s parents became overwhelming therapist to provide examples of situations or
for her. Mateo indicated understanding Reiko’s events as a means to simplify the communication
concerns, but he expressed not being able to between the couple. In such instances, Banister’s
convey Reiko’s needs to his family due to the (1996) mapping task techniques can be useful
fear of hurting his parents’ feelings and creating in breaking down an event or behavior. This can
friction by disrespecting their intentions. As such, be accomplished by drawing a diagram and iden-
living with Mateo’s parents while belonging tifying and tracking each partners’ respective
to vastly different cultural backgrounds and moment-by-moment thoughts and feelings within
having different experiences with their respective the session. As their couple therapist, it will be
families, began to strain Reiko and Mateo’s significant to ask questions about how they both
romantic and sexual relationship. The residual cope and process their conflict while identifying
tension further contributed to the dyadic the defensive strategies they tend to use. Being
emotional distancing. Reiko and Mateo sought mindful of the general cultural context of each
couple therapy to address communication issues, partner’s background, the therapist may choose
lack of intimacy, and understanding of one to ask ethnographic structural questions, as a
another’s needs. way to explore how they describe and organize
For a multiculturally aware therapist, ethno- information in their daily interactions. Utilizing
graphic questioning techniques can be beneficial this method of questioning may expose any
in getting familiar with each of the partner’s underlying inner conflicts for the couple. “Reiko,
backgrounds – how they were raised, their family would you say that Mateo not speaking out to his
histories, family cultures and traditions, dynamic parents to give you both some space, has contrib-
between different family members, etc. Families uted to your lack of desire for him in any way?”
belonging to different ethnic groups experience The therapist must also ask direct questions about
unique intergenerational struggles that shape the the couple’s personal beliefs and values, and if
future generations (McGoldrick 2006). Therefore, they are willing to accept each other’s differences
the therapist may benefit from starting the initial in this regard. Another critical theme to explore
assessment by extracting relevant details about with the couple is understanding what they con-
each of the partner’s respective families of origin. sider as a workable solution in a given situation.
962 Ethno-systemic Narrative Approach
Reiko and Mateo’s responses could possibly dif- Pew Research Center. (2017). Intermarriage in the US:
fer due to their different upbringings. In such 50 years after loving v. Virginia. Retrieved from:
http://www.pewsocialtrends.org/2017/05/18/1-trends-
situations, the therapist must act as a mediator, and-patterns-in-intermarriage/.
helping Reiko and Mateo to identify their own Pinsof, W., Breunlin, D., Russell, W., Lebow, J., Rampage,
ethnic values and to resolve clashes that grow C., & Chambers, A. (2018). Integrative systemic
out of dissimilar opinions and experiences. therapy: Metaframeworks for problem solving with
individuals, couples, and families. Washington, DC:
These ethnographic questioning techniques American Psychological Association.
can be valuable in analyzing the cultural con- Spradley, J. (1979). The ethnographic interview. New
straints that are contributing to Reiko and York: Holt, Rinehart and Winston.
Mateo’s problem sequences and in providing a Tubbs, C., & Burton, L. (2005). Bridging research: Using
ethnography to inform clinical practice. In D. Sprenkle
series of adaptive solution sequences, as they & F. Piercy (Eds.), Research methods in family therapy
explore what is keeping them from successfully (pp. 136–154). New York: Guilford Press.
moving toward agency. Respectful clinical
work in such cases involves assisting clients to
understand their ethnic identity better and how
to make sense of it in the context of marital and Ethno-systemic Narrative
familial relationships. Approach
Natale Losi and Carol Djeddah

Cross-References Ethno-Systemic Narrative School of
Psychotherapy, Rome, Italy
Therapy Introduction
▶ Cultural Values in Couples and Families The Ethno-Systemic Narrative (ESN) approach
▶ Culture in Couple and Family Therapy (Losi 2006) has been developed after years of
▶ Family of Origin experiences, in conflict and war-affected areas,
▶ Integrative Systemic Therapy with displaced persons and refugees enduring
▶ McGoldrick, Monica severe traumatic experiences. Many of them flee
▶ Qualitative Research in Couple and Family to escape danger or persecution. They have
Therapy witnessed or directly experienced violence and
▶ Socioculturally Attuned Family Therapy traumatic events, for example, death or disappear-
ance of family members. ESN therapy focuses
on individuals, their families, often divided by
References the migration and their contexts. It also considers
their social memory, key to understanding the
Banister, E. (1996). Spradley’s ethnographic questioning:
An invitation for healing. Journal of Constructivist
causes of their suffering and treats its conse-
Psychology, 9(3), 213–224. quences, thus avoiding medicalization or
Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard psychiatrization. Narratives coming from social
University Press. memory alleviate war-affected trauma and can
Giordano, J., & Carini-Giordano, M. (1995). Ethnic
boost transformations in refugees and their fami-
dimensions in family treatment (pp. 347–356). Ameri-
can Psychological Association. lies. The challenge is to construct, enrich, and
McGoldrick, M. (1998). Re-visioning family therapy: Race, apply a model that takes into consideration
culture, and gender in clinical practice. New York: the individual, his/her family, ethnicity, culture,
Guilford Press.
McGoldrick, M. (2006). In M. McGoldrick, J. Giordano, &
religion, geopolitical context, and co-construct,
N. Garcia-Preto (Eds.), Ethnicity and family therapy within a therapeutic setting, a new healing
(3rd ed.). New York: Guilford Press. narrative.
Ethno-systemic Narrative Approach 963
Theoretical Framework axis through which a therapeutic narrative can be

performed: the relationship between generations;
The ESN approach builds on strengths of earlier the relationship between women and men (or the
ethno-psychotherapeutic models developed by gender dimension); the relationship between the
Tobie Nathan (1993) and by capitalizing on the humble and the powerful; and the relationship
systemic therapy as well as the narrative therapy. between the visible and the invisible world, with
In his therapeutic approach, Nathan adopts a a particular focus on the link between the world of
pluricultural approach. His therapeutic group is living and that of the dead. During the therapeutic
made up of different therapists of different sessions, the floating objects and the narrative
national or ethnic origins. The presence of many method in family therapy such as the systemic
E
therapists, one of whom is the primary therapist tale is used (Caillé and Rey 2004).
and the others co-therapists, brings the patients The adoption of the Ethno, Systemic, and Nar-
into the framework of a group where they can rative components has important theoretical con-
bring their problems and be understood. The sequences on the therapeutic interventions:
ESN approach is the dynamic result of three
different components: ethnicity, system, and nar-
• The Diagnostic and Statistical Manual of Mental
rative. The term “ethnicity” originally refers to
Disorders (DSM) interprets symptoms in a linear
a community-based human group or to the strong
perspective: from symptoms to individualistic
affinity of somatic, cultural, linguistic, historical,
diagnosis. Following the ESN perspective,
and social characters. Among these similar char-
symptoms are viewed as “texts without context”
acters, there is the definition of illness, and the
(Nathan 1988, p. 137). It means that the thera-
ways of interpreting and healing it.
peutic process is the search of contexts/narratives
The term systemic refers to an integrated
giving sense and meaning to the symptoms. This
model in family or systemic therapy, here in
is especially true when, depending on his/her
particular the Milan approach (Selvini Palazzoli
culture, the patient brings into their story the
et al. 1985) and the contextual therapy
worlds inhabited by different types of forces
(Boszormenyi-Nagy and Spark 1984). Within
and spirits, of gods and of evil.
the ESN therapeutic group, the relationship
• Linear approaches position the therapist with
between patient, therapist, co-therapists, and cul-
the power to define the patient as normal or
tural mediator is important, in order to understand
pathologic, whereas in the ESN approach the
the causes of the suffering and co-construct its
therapist together with the therapeutic group
meaning and its healing process.
co-constructs a relationship with the patient
The introduction of a cultural mediator within
and his/her system (second order cybernetics),
the therapeutic group has a decisive value.
thus stimulating the patient with an active and
A cultural mediator translates from the patient’s
conscious position in confronting his or her
language and allows the therapeutic group to
own suffering.
understand the meaning that a certain thing has
within the respective mother tongues. Thus,
a situation is created in which the patient links Rationale for the Strategy or
up and can “crystallize” his or her own symptom Intervention
within one of the meanings proposed within the
group, the one that allows the patient to identify The psychosocial stress accompanied by trau-
him- or herself better and to understand more matic events in the refugees’ country of origin is
easily how, why, and what the reason might be often labeled by the dominant western approach
for that “thing” that makes him or her feel so with a psychiatric diagnosis or as posttraumatic
badly. stress disorder (PTSD). These diagnoses are
The term narrative reinforces the concept of called “narrative of the destiny” as it gives no
co-construction and is based on four fundamental chance to the patients to exit from their destiny.
964 Ethno-systemic Narrative Approach
The ESN approach legitimates the narratives of injustice suffered and the despair that leads to a
patients coming from different cultural worlds and self-destructive spiral and victim’s attitudes grad-
co-constructs therapeutic stories on the causes, ually gives space to the ability to make a consis-
interpretations, and treatment of the patient’s dis- tent and probable story of selves.
tress. This change of perspective, called also “nar- Furthermore, ESN considers the multiple con-
rative of the project,” can help the patients to nections between the patients’ narratives and the
re-organize their lives, often blocked or broken visible and invisible worlds. In order to explain
(Losi 2015). The person’s passage from a terrify- the origin of their symptoms, African patients may
ing destiny to narrative project changes the patient refer for example to a marabout, a diviner/healer
and therapist’s mutual positioning. The latter is no who holds and exercises magical powers on them.
longer the holder of the definition of “normality,” The therapeutic process provides the possibility of
nor a “diagnostic dispenser.” using ritual as a method to establish a vital narra-
tive within the patient/family social and cultural
world. Therapeutic rituals function as a way of
Description of the Strategy or “integration,” between a past and a “fractured”
Intervention present.
Another support to connect the family with the
In the ESN approach, the healing process draws therapeutic group, and therefore of their belong-
on the patient/family’s story as well as all the ing and identity, comes from the use of prescrip-
hypotheses brought by the ESN setting within tions. The prescriptions are done principally
the session. Each of these different narratives pre- to link the patient with important people who
sents the four-theme axis of the ESN model (the have been left behind, in the country of origin,
relationship between generations, gender, the in the village, those who have died and those
humble and powerful, the visible world, and who are living. Prescriptions are always directed
the invisible world) as constant. The etiology of at supporting the patient in moving towards fam-
the distress can be explained by the presence of a ily and relations that are not set and were left
fracture of one or more of these axes. The therapist on hold in the course of the migration. Finally,
will reconnect the fractures, through the links with their family history here and in the
co-construction of new narratives, using other country of origin through their genogram allow
possible meanings of the symptoms to disentangle an exploration of family dynamics and traumatic
the patient and his family from a destructive nar- events endured by the family.
rative. This will be made possible through an open ESN therapeutic setting: It refers to the setting
conversation between the therapist, co-therapists, and the rules through which the ESN therapy is
and cultural mediator, as they will facilitate the performed. This implies two rooms audio-visually
passage from the focus on individual experience/ interconnected. In the first, the patient/family and
memory, to a social/historical/cultural memory. the therapist, the co-therapists, and the cultural
In this way, the therapy allows for a mediator are sitting and conversing. In the second
co-construction of the external causes of violence room, a “reflecting team” is observing and giving
in the migration path, avoiding the remem- feedback. During the sessions, the rule to be
bering of the traumatic event per se (Losi and respected is that only the therapist speaks directly
Papadopoulos 2004). The therapy allows the with the patient/family and the co-therapists can
patient and his/her family to rethink the uprooting talk among them or with the therapist.
and the consequences of what he or she endured
within a secure setting rather than in isolation.
The therapeutic process considers the multiple Case Example
connections of meaning that bind personal and
cultural worlds, in the country of arrival and The R. family, an Alevi Turkish family, fled from
in the country of origin. In this process, the Southeastern Turkey. The Alevis have a long
Ethno-systemic Narrative Approach 965
history of persecution, massacres, and marginali- sessions. The reflecting team followed the session
zation (Issa 2017). Both parents have been diag- from the second room.
nosed with depression in Turkey and are under The setting structure, the communication
pharmacological treatment. The request for psy- between the participants and their way of pre-
chotherapy in the clinical ESN Centre in Rome senting the therapeutic group coming from differ-
(http://www.etnopsi.it/it/) has been asked for ent backgrounds, and the characteristics of the
because of the suffering expressed by the whole consultation room, that is, colorful and full of
family and their concern for the imminent objects on the shelves enabled the coming
appointment with the government commission together and the family narration.
for the recognition of international protection. In the first session, the family looked very
E
Akin and Fatma are both 40 years old. Akin scared and worried, tight – even physically –
discovered his religious affiliation, when he was around the mother, designated as the symptomatic
12, and decided to be a good believer, despite the member. The therapeutic work at this first stage
risks of discrimination he was aware of. In Italy he consisted of the positive connotation of Fatma’s
is suffering from insomnia despite the drugs he is symptoms and its subsequent de-structuring. Dur-
taking, his nights are tormented by bad thoughts ing the second session, the group highlighted how
that make him sweat and tremble. Fatma suffers with her symptoms Fatma activates Akin’s deci-
from “strange” fainting since she was 18 years sion to flee. The symptoms became a “smart
old, which were aggravated by the birth of Esra, symptom” that allowed the family to escape
a girl, who is now 10 years old. Fatma sees the from the on-going persecutions of the Alevis.
dead, three women who are busy sitting by her A new narrative was developed and Fatma, the
side during the day and frightening her. Metin, the depressed and psychiatric patient, was seen as the
eldest son is 13 years old, always together with his “rescuer” of her family. From the body language
father in affirming and sustaining their religious of the family members, this new narrative was
affiliation. Just as Akin, in Turkey, he was often immediately perceived as more vital leading to
attacked and beaten by fundamentalist groups and new perspectives. In that case, she did not need
has been repeatedly subjected to harassment and any longer the depression, as they were now safe
aggression even at school. Together with his and protected.
father, he began studying bağlama, a used string The de-construction of the symptom was also
instrument in the Cem ceremony, the central Alevi possible using symbolic objects. Esra was invited
worship service, during which prayers are accom- by the therapist to choose an object from the
panied by songs and rituals (Samāh) performed by shelves of the consultation room and then to give
men and women together. this to her mother in order that she may start a new
Metin cries often during the sessions when path, without the need for symptoms and drugs.
discussions touch on painful and distressing epi- Esra chose a mirror and explained, crying, to her
sodes from their past such as the Alevis persecu- mother that she can now take care of herself in a
tions and Esra suffers from nightmares. Fatma’s place where she no longer needs to faint and can
fainting is getting worse in Italy, and during the ask for help and be protected.
first session Akin and Fatma express their fear that Likewise, working on the axis of the visible
this situation could generate suspicion and com- and invisible world, and the vision of the dead
promise the outcome of the asylum application to that Fatma has experienced for the past 20 years,
the government commission. has revealed the painful family bonds abruptly
interrupted by the migration. The work done in
The Therapeutic Path this first phase has allowed an important
The ESN therapeutic group consisted of a princi- improvement in Fatma’s symptoms and of the
pal therapist, two co-therapists, the psychologist whole family, which after few weeks meant they
of the refugee center and a Kurdish cultural medi- were able to face the asylum seeker commis-
ator. The Turkish language was used during the sion, successfully.
966 European Family Therapy Association
Bad thoughts and the maternal symptoms

represented the cohesive energy of the family European Family Therapy
and played an important protective function Association
from fears and terror. However, the objective
of the therapy is to move from a destructive Maria Borcsa
narrative to a healing narrative. Therefore, the University of Applied Sciences Nordhausen,
second phase of therapy has centered on their Nordhausen, Germany
identity of being Alevis, according to a dynamic
vision of culture that recognizes and integrates
identity and belonging. The therapeutic space Introduction
has allowed giving a voice to those hidden
aspects of their religion that forced them to The European Family Therapy Association (EFTA)
practice taqiyya, a precautionary dissimulation was established in 1990 and is an international asso-
of religious belief and practice in the face of ciation dedicated to scientific purposes. It is an inde-
persecution. Being able to declare openly the pendent and strictly nonprofit-making association.
persecutions suffered or witnessed, but also At present (2016), EFTA has members from 32 Euro-
describing the Samāh that accompanied the joy- pean nations (plus so called “foreign members” from
ful moments of sharing and prayer, has allowed Canada, Brazil, Chile, Israel, Senegal, and the USA).
all members of the family to be recognized and EFTA has a tripartite structure and is made up
accepted in a protected environment. During the of three chambers:
last session Metin was given a bağlama with the
prescription of resuming to play for and with his • EFTA-CIM: The Chamber of Individual Mem-
family, with the aim of re-starting from the deep bers (CIM) gathers a wide range of professionals
sound of this instrument the interrupted narra- (social workers, nurses, medical doctors, psychi-
tive of their story and identity. atrists, psychologists, occupational therapists,
and other health professionals) who have fin-
ished a minimum of 4 years of training in family
therapy/systemic approach and are working with
References
families, couples, and larger systems.
Boszormenyi-Nagy, I., & Spark, G. (1984). Invisible loy-
• EFTA-NFTO: The Chamber of National Fam-
alties: Reciprocity in intergenerational family therapy. ily Therapy Organizations (NFTO) unites
London: Routledge. national associations/federations representing
Caillé, P., & Rey, Y. (2004). Les objets flottants, family therapists and/or promoting the sys-
méthodologie systémique de la relation d’aide. Paris:
Fabert.
temic approach and family therapy in any
Issa, T. (2017). Alevis in Europe: Voices of migration, country in Europe and Israel.
culture and identity. London: Routledge. • EFTA-TIC: The Training Institutes Chamber
Losi, N. (2006). Lives elsewhere, migration and psychic (TIC) connects training institutes and facilitates
malaise. London: Karnac.
Losi, N. (2015). Guérir la Guerre. Des récits qui soignent
networking, exchanges, and joint learning
les blessures de l’â me. Paris: l’Harmattan. between trainers based on the guidelines of min-
Losi, N., & Papadopoulos, R. (2004). Post-conflict con- imum training standards (http://efta-tic.eu/
stellations of violence and the psychosocial approach of minimum-training-standards).
the International Organization for Migration. In
Harvard book of good practices. Rome: Harvard
Program in Refugee Trauma. A common code of ethics is binding on every
Nathan, T. (1988). Le sperme du diable. Paris: Puf. member and should be read in conjunction with the
Nathan, T. (1993). Principes d’ethnopsychanalyse. code of ethics of relevant national associations and
Grenoble: La Pensée Sauvage.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G.
professional body(s). (http://www.europeanfami
(1985). Paradox and counterparadox. New York: lytherapy.eu/code-of-ethics-of-the-european-family-
Aronson. therapy-association)
European Family Therapy Association 967
Location Eric Louis, Elspeth McAdam, Jacques Miermont,

Luigi Onnis, Renos Papadopoulos, Roberto
Brussels, Belgium Pereira, Mina Polemi-Todoulou, Kyriaki Poly-
chroni, Yveline Rey, Jaakko Seikkula, Mara
Selvini-Palazzoli, Daniel Stern, Helm Stierlin,
Peter Stratton, Vasso Vassiliou, George Vassiliou
and Arlene Vetere
Official founding members (Moniteur Belge
1992):
Contributions
Mony Elkaïm (Belgium) E
Alia Samara (Greece) • Linking and coordinating European national
Maurizio Andolfi (Italy) organizations, institutes, and individuals in the
Hugh Jenkins (UK) field of family therapy and systemic practice
Edith Goldbeter-Merinfeld (Belgium) • Promoting the highest level of competence and
Elida Romano (France) quality in practice, research, supervision, and
Paul Igodt (Belgium) teaching in family therapy and allied fields
Jorma Piha (Finland) • Enhancing the training of systemic profes-
Camillo Loriedo (Italy) sionals and family therapists at regional,
Esther Wanschura (Austria) national, and European levels by organizing
Luigi Onnis (Italy) and facilitating exchanges between individ-
Jacques Pluymaekers (Belgium) uals as well as professional centers
Theo Compernolle (Netherlands) • Implementing committee work related to the
Rick Pluut (Netherlands) aims of EFTA such as research, training stan-
Gianfranco Cecchin (Italy) dards, ethics, and external relations
• Spreading information about family therapy
EFTA’s honorary presidents: and systemic approaches throughout Europe
to individuals, institutions, and organizations
Luigi Onnis (deceased) concerned with the health and development of
Jacques Pluymaekers families and human systems. Promoting
research, conferences, publications, audiovi-
EFTA’s presidents: sual tools and other scientific material in this
field through:
Rodolfo de Bernart (2016–2019) – Annual meetings of NFTOs: updating on
Maria Borcsa (2013–2016) the developments of family therapy and
Kyriaki Polychroni (2010–2013) systemic practice with regard to legislation
Arlene Vetere (2004–2010) and sociopolitical changes influencing the
Juan Luis Linares (2001–2004) health system in different countries
Mony Elkaïm (1990–2001) – Annual meetings of trainers: fostering net-
working among training institutes,
EFTA awardees: exchanging training methods (workshops),
Jean-Claude Benoît, Petr Bos, Ivan and developments in curricula
Böszörmenyi-Nagy, Bela Buda, John Byng-Hall, – Triennial international congress for health
Philippe Caillé, Luigi Cancrini, Alan Carr, Pat professionals and trainees with ca. 1000
Crittenden, Boris Cyrulnik, Mony Elkaïm, participants: Sorrento, 1991; Athens, 1994;
Elisabeth Fivaz, Janos Füredi, Edith Goldbeter, Barcelona, 1997; Budapest, 2001; Berlin,
Per Jensen, Barbara Kohnstamm, Miklos Kovacs, 2004; Glasgow, 2007; Paris, 2010; Istanbul
Annette Kreuz, Peter Lang, Juan Luis Linares, 2013; Athens 2016
968 Exception Question in Couple and Family Therapy
– Publication of a book series with rele- Theoretical Framework

vant topics for the field (founding edi-
tors: M. Borcsa and P. Stratton) (Borcsa Exception questions are among the main tech-
& Stratton 2016, Tilden & Wampold niques of solution-focused brief therapy (SFBT).
2017) The SFBT treatment model is supported by over
• Creating links with other organizations having 30 years of theoretical development and empirical
common or compatible aims worldwide research (De Jong and Berg 2012). Built upon
the foundation of social constructivism, SFBT
emphasizes the collaboration between the thera-
References pist and the client. The therapist is interested in
listening to what clients want and what is impor-
Borcsa, M. & Stratton, P. (Eds.) (2016). Origins and tant to them. The therapist pays special attention
Originality in Family Therapy and Systemic Prac-
to clients’ use of words and the meaning behind
tice. EFTA Book Series Volume 1. Springer
International. them. The focus is on understanding the clients’
http://www.europeanfamilytherapy.eu/ preferences. Through adopting clients’ language,
Tilden, T. & Wampold, B.E. (Eds.) (2017). Routine Out- asking solution-driven questions, the therapist and
come Monitoring in Couple and Family Therapy. The
client co-construct a new desired future. The ther-
Empirically Informed Therapist. EFTA Book Series
Volume 2. Springer International. apist is viewed as a consultant and facilitator. The
client is given full authority in deciding what areas
need to be changed (McGee et al. 2005).
Exception Question in Couple

and Family Therapy Rationale for Using Exception Questions
Fangzhou Yu No problem exists all the time (Trepper et al.

Counseling Department, The Family Institute at 2010). For couples and families, there are times
Northwestern University, Evanston, IL, USA when conflicts were prevented or did not happen
at all. These exceptions provide valuable
resources for the therapist and the clients to
Name of Strategy or Intervention co-construct solutions. One of the assumptions
that support exception questions is that solution
Exception Question in Couple and Family behaviors are already there for couples and fami-
Therapy lies (Trepper et al. 2010). Some couples and fam-
ilies can clearly identify the solutions they tried
before and were successful. If a couple or family
does not have a previous solution that can be
Introduction
repeated, discussing the situations when the prob-
lem did not exist can lead to a solution. In other
Exception questions are an intervention used to
words, the solution was there but the family was
uncover exceptions to the current problem in the
just not aware of it (Berg 1994).
client’s life. These kinds of questions encourage
competency-based conversations. They allow
the therapist to discover clients’ previous suc-
cesses and amplify the clients’ strengths Description of Exception Question
(Trepper et al. 2010). If miracle questions help
to identify the treatment goals, exception ques- Exception questions focus on the conditions that
tions provide the possible pathways to achieve helped the exception happen. The therapist is not
these goals. interested in knowing why but more focused on
Exception Question in Couple and Family Therapy 969
the where, when, who, and what of the exception. whole household of people who are not Chi-
Here are some examples of exception questions: nese. Maybe it is not so much about lacking
confidence, as it is about her cultural root.
Huang: That is exactly right. Whenever he does
• Was there a time you were able to calmly acknowledge my culture either intentionally or
express your needs without being aggressive unintentionally, it always makes me feel good,
towards your spouse? If so, could you describe and accepted as a whole.
Therapist: Really? Tell me about those times.
it for me? Huang: Like when we were dating, he learned how
• Tell me about a moment when you and your to write my name and “I love you” in Mandarin
dad were enjoying each other’s company. on a birthday card. That was so sweet. I still
• How did you end that argument with your have the card.
James: I did do that. E
mom without escalating it to the next level Therapist: Wow, that was so romantic, James! Any
like you used to? other times that he made you feel that way?
• How was that experience different from other Huang: I did not tell him this, but my father-in-law
fights with your spouse? got him a Rosetta Stone software to learn Chi-
nese. So whenever he practices, I like to listen. It
always gives me very warm and fuzzy feeling.
James: That is why you always stop doing what you
Case Example were doing and curl up next to me when
I practice?
Huang and James have been married for 3 years, Huang: Yes, but you do not do it very often now.
they don’t have children. Huang is Chinese, a first Therapist: Maybe we should make it happen again.
What do you say, James?
generation immigrant. James is American, born
James: I guess so. I like to make her happy. Learn-
and raised in the south. Huang and James met in ing Chinese is very hard though. My work has
college. They travel to China to visit Huang’s side kept me really busy lately, but I need to go back
family at least once a year. They came to therapy to my practice. Maybe I can also take you out to
a local Chinese restaurant sometime this week.
for marital issues.
We have not done that for a while.
Huang: We have not done that for months. Yes, it
Huang: I do not think he understands my loneliness. would be great.
James: She just tends to be overly dramatic about Therapist: If you and James do these activities
small things. often, will you feel less lonely and more
Therapist: Let’s listen to Huang and let her tell us accepted?
the details. Huang: Yes.
Huang: It is the Chinese New Year now, the most
important festival in my culture. Nobody around
here celebrates it. All my family is in China. In this case example, the therapist accomplished
Even though I do not talk about it all the time, several tasks. First, she listened carefully about
I miss them terribly. There are certain dishes we the presenting issues and accurately reflected the
cook for this celebration. Since we live with his
parents, I could not cook them in the kitchen.
wife’s feelings. Second, she seized the moment
I am afraid that they may not like the smell. I feel when one exception was mentioned. The therapist
like I have to hide part of my identity in that emphasized the importance of the exceptions by
house. repeatedly asking questions and getting more
James: You can cook it in the kitchen. My parents
would not mind at all. I think that is her own
information that can become a resource. Finally,
insecurity, which has nothing to do with others. the therapist connected the goal with the excep-
Huang: You just do not understand. I feel like my tions and received positive confirmation from the
Chinese heritage is invisible to you, but it is part clients.
of me.
James: I do understand, but we were talking about
cooking the dish. They are two different things.
You are exaggerating again. Cross-References
Therapist: James, I think Huang is trying to tell us
that they are all connected: food, festival, cul-
ture and her. Her concern and discomfort is real, ▶ Miracle Question in Couple and Family
since she is the only Chinese person living in a Therapy
970 Exiles in Internal Family Systems Therapy
References subpersonalities, each is “a discrete and auton-

omous system that has a range of emotions, style
Berg, I. K. (1994). Family-based services: A solution- of expression, and a set of abilities, intentions
focused approach. New York: Norton.
and/or functions” (Schwartz 1987, p. 3). The
De Jong, P., & Berg, I. K. (2012). Interviewing for solu-
tions (4th ed.). Belmont: Thomson BrooksCole. Internal Family System model posits that the
McGee, D. R., Del Vento, A., & Bavelas, J. B. (2005). An intrapsychic world is governed by systemic
interactional model of questions as therapeutic inter- principles, and functions best when it is led by
ventions. Journal of Marital and Family Therapy, 31,
the Self. The Self, per Schwartz (2001), is sep-
371–384.
Trepper, T. S., McCollum, E. E., de Jong, P., Korman, H., arate from a person’s parts; it is the core of a
Gingerich, W., & Franklin, C. (2010). Solution person, which possesses qualities such as com-
Focused Therapy Treatment Manual for Working passion, curiosity, calm, and confidence.
with Individuals. Research Committee of the Solu-
tion Focused Brief Therapy Association. Retrieved
from http://www.so1ut.ionfocused.net/ treatment
manual.
Like a family system, the intrapsychic system has

Exiles in Internal Family an organizing structure. The structure of the Inter-
Systems Therapy nal Family System is defined by several subsys-
tems, named: managers, firefighters, exiles, and
Nancy Burgoyne the Self (Schwartz 1995, 2001).
The Family Institute at Northwestern University, Exiles represent a subsystem of parts that have
Evanston, IL, USA been sequestered within the system for their own
protection or to protect the system from them
(Schwartz 1992, 1995). The pain the exiles
Name of Concept carry, and the meaning the parts (and often cul-
ture) assign to their attributes, generates reactivity
Exiles in managers and firefighters who want to protect
the individual from the imagined damage that is
assumed would occur if an exile were to surface.
The patterned interactions that occur in an effort to
Introduction
keep the exiles off the intrapsychic and interper-
sonal “playing field” generate significant distress
Exiles is a concept found in the Internal Family
and dysfunction within and between people
System model (IFS), founded by Richard Carroll
(Schwartz 1992, 1995).
Schwartz (Schwartz 1987, 1989, 1995, 2001).
The Internal Family Systems Model of psycho-
therapy (IFS) brought family therapy theory and
technique to the intrapsychic worlds of clients. Description
IFS has become not only a school of family ther-
apy but also a major form of psychotherapy in Exiles hold thoughts, feelings, and memories that
general, with an extensive literature and training are considered unacceptable by the rest of the sys-
institutes throughout the world. tem. Often exiles are young parts that have been
The premise of the Internal Family Systems isolated in order to protect the individual from
model is that an individual’s intrapsychic world overwhelming affect or sensations. Parts who are
is not monolithic. Rather, the internal world is exiled are deprived of care and may become
made up of a plurality of “parts.” Parts are increasingly desperate to be known. Parts can be
Exiles in Internal Family Systems Therapy 971
triggered in the present day by experiences or Clinical Example

exposure to stimuli that activate a familiar felt
experience and set in motion an internal sequence An exiled part may, for example, interpret early
whereby mangers, firefighters, and/or parts of neglect from caregivers as evidence of their own
others in the interpersonal system work to banish unworthiness. The part would then carry both intol-
the exile once again (Schwartz 1995, 2001). erable shame associated with the belief they are
In addition to traumatic or intolerable expe- unworthy and a profound longing to be redeemed
riences, exiles carry what Schwartz has called from their unworthy state by being found loveable
our “everyday damage” (Schwartz 2001). The by another. When, in the present day, the individual
painful and contorting effects of racism, sexism, risks seeking love or attention from another, the
E
and homophobia and gender identity norms are protective parts (managers and firefighters) rally to
examples, as are idiosyncratic, often family of sequester the part, fearing that the part’s outsized
origin experiences and/or repeated shaming needs expose the person’s deficits and make them
attributions from larger systems. These lead an vulnerable to shame and rejection. To the extent the
individual to feel unworthy or in some way protective parts are successful in sequestering the
defective. exile, the individual continues to be deprived of
Schwartz has noted that exiles, given the tender- care, and their unmet needs, extreme beliefs, and
ness of their experience, also possess useful attri- pain grow. “The irony . . .” Schwartz explains, “...
butes. Sensitivity, vulnerability, and intimacy is that once you start the exiling process, it rein-
seeking are examples of resources exiles have that forces itself” (2001, p. 93).
are less accessible to managers and firefighters
whose job is to prevent the exiles from being seen
or felt (Schwartz 2001). Cross-References
▶ Firefighters in Internal Family Systems

Application of Concept in Couple and Therapy
Family Therapy ▶ Internal Family Systems in Family Therapy
▶ Managers in Internal Family Systems Therapy
An individual’s parts interact intrapsychically, ▶ Metaframeworks: Transcending the Models of
interpersonally, and with the larger systems they Family Therapy
come into contact with. A triggered exile is ▶ Schwartz, Richard C.
dysregulating to all levels of the system.
Intervention with an exile cannot be effec-
tively pursued until the managers have been References
collaborated with and the Self has been accessed
Schwartz, R. C. (1987). Our multiple selves. Family Ther-
to some degree. Thereafter, the goal vis-a-vis
apy Networker, 11, 24–31 & 80–83.
exiles is threefold. First is to provide a safe Schwartz, R. C. (1989). The internal family systems model:
interpersonal and intrapsychic context for the An expansion of systems thinking into the level of inter-
exiles to tell their stories and receive care. Sec- nal process. Family Therapy Case Studies, 3, 61–66.
Schwartz, R. C. (1992). Rescuing the exiles. Family Ther-
ond is to release the exiles from the burden of
apy Networker, 16, 33–37.
extreme beliefs that cause the individual pro- Schwartz, R. C. (1995). Internal family systems therapy.
found distress and generate reactivity in the New York: Guilford Publications.
internal system. Third is to identify nonextreme Schwartz, R. C. (2001). Introduction to the internal family
systems model. Oak Park: Trailheads Publications.
roles for these parts to have within the internal
Schwartz, R. C. (2008). You are the one you’ve been
system, so that their strengths can be a resource waiting for: Bringing courageous love to intimate rela-
to the individual (Schwartz 1992, 1995, 2008). tionships. Oak Park: Trailheads Publications.
972 Exosystem in Family Systems Theory
which impact an individual’s development and

Exosystem in Family Systems experiences (Bronfenbrenner 1986, 1977).
Theory
Amy D. Smith1,2 and Kelley Quirk2 Description

1
Marriage and Family Therapy/Applied
Developmental Science Program, Colorado State The exosystem is one of the first four levels of the
University, Fort Collins, CO, USA ecosystem (Bronfenbrenner 1977, 1986). This
2
Marriage and Family Therapy Program, Human system refers to the parts of the environment
Development and Family Studies, Colorado State which impact an individual’s development, even
University, Fort Collins, CO, USA though they do not directly interact with the indi-
vidual (Bronfenbrenner 1977, 1986). Examples of
the exosystem would include the work life of a
Name of Concept parent or partner impacting another member of the
family such as a partner or child, even though the
Exosystem in Family Systems Theory work life is not directly experienced by the indi-
vidual who is being impacted. In this way, the
experiences of one family member can have an
Introduction indirect impact on the experiences of other family
members (Bronfenbrenner 1986, 1977).
The exosystem is one of four primary levels of the
environment, or ecosystem, which are described in
the bioecological theory of human development
Family Therapy
(Bronfenbrenner 1986, 1977). Understanding the
different levels of the ecosystem, and how they can
The concept of the exosystem proposes that individ-
impact the development and experiences of indi-
uals are not only impacted by the environments that
viduals, can help therapists to better understand
they directly experience but also by the environ-
underlying causes to presenting problems, thus
ments that others in their family experience
enabling a more effecting and change-promoting
(Bronfenbrenner 1977, 1986; Lerner 2002). With
therapeutic process.
this understanding, it is important for a therapist to
explore how the experiences of other family mem-
bers may be indirectly impacting the presenting
Theoretical Context for the Concept
symptoms, especially in situations where the origin
of the presenting problem does not seem clear.
Family systems theory assumes that families operate
Through this exploration, the therapist may be able
as a system which cannot be fully understood by
to discover triggers for behaviors, thoughts, or emo-
looking at one individual without also including all
tions, in the extended environment which may in
of the other individuals which comprise the system,
turn be beneficial for progress and change to occur
or family (Cox and Paley 1997). The way in which
during the process of therapy.
different aspects of families and the environment
can influence the development and experiences of
the individual can be understood through the Clinical Example
bioecological systems theory (Bronfenbrenner
1977), which emphasizes the importance of the Jason, 35, and Kimberly, 34, recently started family
environment on development and experiences. In therapy with their daughter, Sarah, 5. The family has
this theory, Bronfenbrenner identifies four different decided to seek therapy because Sarah has recently
levels of the environment, the microsystem, the started to demonstrate new anxious behaviors
mesosystem, the macrosystem, and the exosystem, including not being able to sleep without a
Experiential Family Therapy 973
nightlight, crying when she is dropped off at school, Introduction

and worrying that her stuffed animals are “feeling
scared.” Jason reported that he is on active duty in Experiential Family Therapy is a humanistic
the Army and that he recently learned that he was approach to treating a variety of presenting prob-
leaving in 3 months for his second deployment since lems within families and couples. It values the “in
Sarah’s birth. In discussing this transition, Kimberly the moment” experiences of clients and centers on
reported that she first noticed Sarah’s changed authentic emotional expression. Experiential cli-
behaviors shortly after they had told Sarah that nicians use their unique self-of-the-therapist with
“Daddy has to go away again.” While Sarah does spontaneity and creativity to help clients experi-
not directly experience Jason’s work environment, ence in real time accurate self-expression
E
the time which he had to spend away due to his job (Baldwin and Satir 1987; Napier and Whitaker
seemed to be related to Sarah’s increased anxiety. 1978). The emphasis of clinicians being authenti-
With this understanding, the family was able to cally involved and to use their personhood indi-
work with the therapist to help ease Sarah’s fears cates that there are many different approaches to
about her father going away and increase her coping experiential therapy.
strategies for dealing with her anxiety. Experiential therapy is described as humanistic
based on the foundational assumptions that people
Cross-References possess the necessary resources for change
and are naturally drawn toward positive growth.
▶ Bronfenbrenner, Urie Further, experiential therapists believe that
▶ Ecosystem in Family Systems Theory change occurs as people experience honest self-
▶ Mesosystems in Family Systems Theory expressions from themselves as well as the
therapist. Along with other humanistic therapies,
experiential therapists believe in the value of
References self-actualization, the reaching of human poten-
tial, and in the natural ability and tendency of
Bronfenbrenner, U. (1977). Toward an experimental ecol- individuals to achieve it (Nichols 2013).
ogy of human development. American Psychologist, Consistent with other systemic approaches,
32, 513–531. experiential family therapists believe that the fam-
Bronfenbrenner, U. (1986). Ecology of the family as con-
text for human development. Research perspectives.
ily system is the preferred level of intervention.
Developmental Psychology, 22, 723–742. While other models typically focus on intervening
Cox, M. J., & Paley, B. (1997). Families as systems. with client behaviors, experiential therapists con-
Annual Review of Psychology, 48, 243–267. centrate the majority of their effort in addressing
Lerner, R. M. (2002). Concepts and theories of human devel-
opment (3rd ed.). Mahwah: Lawrence Erlbaum
the affective experience of the family (Gehardt
Associates. 2015).
Experiential Family Therapy Prominent Associated Figures
Todd Spencer, Trent Call and Nathan Hardy The origins of Experiential Family Therapy can
Oklahoma State University, Stillwater, OK, USA be directly tied to the work of Carl Whitaker
(1912–1995) and Virginia Satir (1916–1988).
Specifically, Whitaker developed the “symbolic-
Synonyms experiential” approach, which focuses on warmth
and confrontation, while Satir developed the
Satir’s experiential communications approach; Satir experiential communications approach, which
human growth model; Symbolic experiential family centers on expressions of warmth and empathy
therapy within families.
974 Experiential Family Therapy
Carl Whitaker. After graduating medical et al. 1991). The first two assumptions highlight
school and working at the University of Louisville the humanistic nature of experiential therapy; the
College of Medicine and the Oakridge Hospital, last two assumptions highlight the foundation in
Whitaker became interested in Psychiatry and family systems theory.
eventually became the Psychiatry department
chair at Emory University from 1946 to 1955. The Battle for Structure and the Battle for
Whitaker resigned from Emory University after Initiative
growing pressure for the department to become Whitaker discussed two different battles that cli-
more psychoanalytic in nature and formed the nicians need to be aware of: the battle for struc-
Atlanta Psychiatric Clinic. Under this new free- ture and the battle for initiative. Whitaker
dom, Whitaker was able to further develop his believed that it was crucial for clinicians to win
symbolic-experiential approach to therapy. the battle for structure by setting the boundaries
Virginia Satir. Satir was trained as a social and limits of therapy (Whitaker and Bumberry
worker and began her clinical work in 1951. 1988). Furthermore, Whitaker believed that clini-
She was invited to establish a training a program cians are responsible to ensure that the structure
at the Illinois State Psychiatric Institute in 1955. and program of treatment are in place in order to
Later in 1959 Satir was invited by Don Jackson to give clients an opportunity to express themselves.
join the MRI group in Palo Alto. She left the MRI Specifically, Whitaker believed that the therapist
group in 1966 to work as the director of the Esalen was responsible for making sure that the neces-
Institute located in the Central Coast of California. sary people attended session, therapy was fre-
Satir combined humanistic characteristics with quent enough to produce change, and session
principles of communication to develop the expe- content and processing could produce change
riential communication approach to working with (Gehart 2015).
families. Whitaker posited that the battle of initiative
Other figures. While Whitaker and Satir laid must be won by clients. In other words, clients
the foundation for experiential therapy, there are need to take accountability for the motivation to
also notable contemporary figures that have car- change and are responsible to be invested in the
ried on the humanistic-experiential tradition. therapeutic process. The assumption surrounding
Sue Johnson and Les Greenberg’s work on Emo- the battle of initiative is frequently summarized as
tionally Focused Couple Therapy (1985) has “clinicians should never work harder than their
received worldwide attention and is one of the clients” (Gehart 2015); the therapist is not respon-
leading evidence-based models of couple therapy. sible for a client’s motivation or intent to change,
Likewise, Richard Schwartz’s Internal Family except by providing the necessary structure for
Systems Model (Schwartz 1995) is a prominent client growth opportunities.
approach for helping people deal with internal
conflicting emotions. Core Concepts
Satir suggested that people protect themselves
through “survival stances” when they feel threat-
Theoretical Framework ened or vulnerable (Satir et al. 1991). She classi-
fied five different survival stances an individual
Assumptions can take: placater, blamer, super reasonable, irrel-
Satir described four core assumptions of her expe- evant, and congruence. With the exception of
riential communication approach: (1) People are congruence, these stances are based in low self-
naturally drawn towards positive growth, (2) peo- worth. Although individuals experience each
ple possess resources for growth, (3) circular stance in varying degrees during their life, Satir
reciprocity, and (4) therapy is a process of inter- believed family members tend to select comple-
actions between clients and therapist in which mentary stances to create homeostasis within the
each person is responsible for themselves (Satir family or relationship (Satir et al. 1991).
Placater. Placaters avoid conflict by putting and body language (Satir 1972). Satir believed
everyone else’s needs above their own at the that emotional suppression during communica-
expense of their self-worth. They tend to be peo- tion was at the root cause of conflict within
ple pleasers and deal with relational distress by relationships. As such, one of the primary goals
focusing on others. of treatment is to help families learn to communi-
Blamer. Opposite from the Placating stance, cate congruently. Congruent communication
Blamers will use their influence and power to shift means that individuals feel safe to authentically
responsibility to other family members. They express their emotions and to increase the syn-
identify others as the source of their problems chrony between what people are saying, feeling,
and avoid taking accountability for their own and their body language.
E
wellbeing. Self-worth. A second goal of experiential ther-
Super Reasonable. Individuals with a Super apy is to increase family members’ sense of self-
Reasonable survival stance exhibit overly rational worth. This is accomplished through acknowledg-
and logical punctuations of the source of the ing and celebrating differences that exist within
problems with minimal emotional expression. individual family members. Highlighting the
Super Reasonable clients tend to have difficulty uniqueness of each family member and creating
with multiple subjective realities and try to focus space for their individuality provides opportuni-
on what they can objectively measurable. ties for greater acceptance at the individual and
Irrelevant. An individual with an Irrelevant family level. Self-worth is manifest as individuals
survival stance tries to perpetuate the illusion take accountability and are proactive in making
that everything is okay and that the problems decisions in their life (Gehart and Tuttle 2003).
do not affect them. They may use humor as a Personal growth. The final goal of experien-
way to distract others and keep them at a distance. tial therapy is for individuals to experience per-
People with an irrelevant stance tend to have sonal growth. Satir posits that as family members
difficulty experiencing tension within relation- more authentically express their emotions that it
ships without providing a distraction away from opens greater possibility for personal growth
the core issues. (Satir 1991). Likewise, growth occurs as family
Congruence. Unlike the previous four sur- members acknowledge and accept differences
vival stances, congruence comes from a place of between family members.
self-worth. Congruence is the process in which
people balance the needs of self, others, and the
content of their context. Individuals with congru- Populations in Focus
ent communication demonstrate synchrony with
the emotions they are feeling, the words they use, Whitaker began seeing families in the 1940s.
and their body language. Satir was not far behind as she began working
with families in 1951 (Gehart 2015). Experiential
Goals for Treatment therapists typically attempt to see families
According to Satir, there are three overarching together. While they have similar beliefs as other
goals for treatment: congruent communication, systemic and intergenerational models about the
increased self-worth, and personal growth (Satir value of treating systemic patterns, experiential
1991). Similarly, there are three goals of treatment therapists are more likely than other models to
outlined by Whitaker: increased family cohesion, give specific attention to individual problems
promotion of personal growth, and expansion of and may treat them without intervening at the
the family’s symbolic world (Whitaker and relational or systemic level.
Bumberry 1988). Satir’s emphasis on congruent communication,
Congruent communication. Problems often authentic emotional expression, and vulnerability
arise as families experience a disconnect between has been demonstrated to be effective with most
what people are saying, the expressed emotion, groups of people. However, there are some
976 Experiential Family Therapy
important modifications a clinician may make A commonly held belief is that family problems
when working with certain clients. For example, are often rooted in emotional suppression.
the amount of vulnerability that experiential ther- As such, experiential therapists strive to prompt
apy prompts may not culturally fit ethnic groups clients toward emotional expression. This is often
who value less dramatic emotional expression accomplished by increasing the emotional intensity
(Wang 1994). In terms of gender, nontraditional in session. Whitaker called this process “emotional
female clients often report feeling misunderstood goading.” In order to create a new emotional expe-
because they do not fit into the stereotype of rience for clients, he would challenge in confronta-
traditional female emotional expression (Gehart tional ways to illicit a different emotional response
and Lyle 2001). As such it is important for the from clients if it would assist clients to be more
therapist to consider how emotional expression honest with themselves. Satir’s approach to increas-
and vulnerability are expressed within the culture ing the emotional intensity was to be honest in her
of their clients and modify the emotional intensity experience with clients and inviting clients into
within session appropriately. However, experien- greater emotional disclosure.
tial family therapy has been widely used with
LGBTQ clients due to the emphasis of authentic Play and Spontaneity
emotional expression and self-actualization A defining strategy and characteristic of experien-
(Davies and Neal 2000). Additionally, experiential therapy is the use of spontaneity and play.
tial therapy is often very threatening for mandated Experiential therapists use play as a way to
clients and may not be the best approach develop the therapeutic relationship that allows
(Gehart 2015). them to be honest and challenge clients directly
(Whitaker and Bumberry 1988). Additionally,
playfulness can be an effective tool in reframing
Strategies and Techniques Used in problems that family members have unrealisti-
Model cally magnified (Gehart 2015).
While Carl Whitaker is an influential figure in the Modeling Communication

development of Experiential Family Therapy, Satir describes how therapists model congruent
he was not interested in developing calculated inter- communication through three techniques: (1) the
ventions and techniques. Rather, he referred to therapist speaks in first person using I-statements,
his work as “therapy of the absurd.” Whitaker posits (2) the therapist expresses their own thoughts
that theory and technique are useful for beginning and feelings directly and avoids stating what
therapists but that the best clinical stance is other people are feeling, and (3) the therapist
for clinicians to be themselves (Whitaker 1975). is honest with others (Satir 1967). Modeling
Similarly, Virginia Satir preferred what she termed congruent communication should be present
“vehicles of change” over developing a set of during each phase of treatment and is part of
manualized techniques to be memorized. As such, every intervention.
the majority of the techniques and strategies associ-
ated with Experiential Family Therapy stem from Family Sculpting
Satir’s “vehicles of change” based on her commu- A family sculpt is accomplished by having family
nication approach. members take turns creating a living sculpture
where they get to position family members in a
Role of the Therapist way that represent the family. During this inter-
One of the hallmarks of experiential therapy is the vention, the members that are being sculpted are
role of the therapist. Experiential therapists not allowed to talk or influence how the sculptor
use warmth, empathy, and humor as way to chooses to position them. The sculptor may also
join with clients but are also direct and assertive include verbal statements representing each mem-
in confronting client’s maladaptive processes. ber who is sculpted. After the sculpture is
complete, the therapist then processes different relationship (Gehart 2015), which is strongly asso-
aspects of the sculpture (e.g., the proximity ciated with treatment outcomes (Lambert 1992).
between family members, sculpted body lan- Furthermore, research supports experiential thera-
guage). The goal is to identify roles and patterns pists’ assumptions that emotional expression is asso-
of communication within the family played out by ciated with wellbeing (Stanton and Low 2012).
its members and for families to experience alter- Other therapeutic models with humanistic-
native patterns of communication. experiential foundations – such as Emotionally
Focused Therapy (Johnson 2004) – have undergone
Self-mandala significant empirical testing and demonstrated effi-
The self-mandala technique is used to identify cli- cacy in producing positive client outcomes.
E
ents’ resources, highlight the interconnected nature
of our needs, and assess for balance across different
life domains. The self-mandala is a circle dived into Case Example
eight different pieces: physical, intellectual, emo-
tional, sensual, interactional, nutritional, contextual, Tony (46) and Martha (45) are seeking counseling
and spiritual (Satir et al. 1991). Clients identify their along with their sons David (9) and Jared (8). Their
needs within each domain and map out their level of youngest son Jared has been having behavioral
wellbeing in each domain. This allows clinicians to issues both at home and at school with the most
intervene in areas that are unfulfilling in the clients’ recent incident getting him suspended from school
lives and relationships. for hitting a peer. In session Martha mentioned that
everything they have tried has failed and she is
Co-therapy worried that if they do not get Jared help now he
Due to the necessity of implementing both might get into worse trouble later on. Tony sees that
warmth and confrontation, Whitaker was an advo- the behavior as a problem but believes it is just a
cate for involving co-therapists when doing phase and that Jared will grow out of it because he
Symbolic-Experiential Family Therapy (Napier too had behavioral issues that he grew out of it. The
and Whitaker 1978). He recommended that therapist has met with the whole family and has
co-therapists be able to model a collaborative identified Tony to have a placating survival stance.
co-parenting relationship for clients. Whitaker Martha has been identified as having a blamer stance
further explained that with co-therapy, one thera- where she blames Tony’s absence from the family as
pist is to provide a more supporting role, while the the root cause of Jared’s behavior.
other therapist would challenge the family. He The therapist decides to do a family sculpt as a
argues that a balanced approach to co-therapy means of intervention. The therapist asked Martha
would provide constant support for families as to sculpt how she sees each family member.
they encounter invitations to change (Napier and With help from the therapist, Martha positions
Whitaker 1978). Whitaker also believed that Tony standing in the middle of the room between
co-therapy was a way to safe guard against thera- her and their two children. She positions him facing
pist counter transference (Nichols 2013). the kids with a stern look on his face. She positions
the two boys sitting on the couch with their heads
down in their hands looking down at the ground.
Research About the Model Martha positions herself sitting on a chair across the
room because she feels that the three boys have their
There has, unfortunately, been little outcome relationship and she is the odd person out. Before
research on either Whitaker’s or Satir’s approach discussing each person’s perspective of Martha’s
to experiential therapy. There is, however, a body sculpt, each family member has the opportunity to
of common factor research that indicates that clini- sculpt the family. Tony positions his oldest son
cian’s humanistic ways of being (e.g., nonjudgmen- standing in the middle of the room with Jared stand-
tal, warm, and empathic) strengthen the therapeutic ing behind the other brother holding his shirt. Tony
978 Exposure in Couple and Family Therapy
positions Martha sitting on the couch facing away Johnson, S. M. (2004). The practice of emotionally focused
from the family with her phone in her hand. Tony marital therapy: Creating connection (2nd ed.).
New York: Brunner/Routledge.
positions himself sitting next to Martha with his arm Lambert, M. J. (1992). Psychotherapy outcome research:
around her but not touching her. Implications for integrative andeclectic therapists.
The therapist then processes with the family each In J. C. Norcross & M. R. Goldfried (Eds.), Handbook
person’s perspective on how each of them sculpted of psychotherapy integration (pp. 94–129). New York:
Wiley.
their family. The therapist assesses for anything that Napier, A. Y., & Whitaker, C. A. (1978). The family cruci-
stood out to the family. The therapist then asks each ble: The intense experience of family therapy.
family member to sculpt how they would like to see New York: Harper & Row.
their family. One by one each member of the family Nichols, M. P. (2013). Family therapy: Concepts and
methods (10th ed.). Jersey City: Pearson.
sculpts their desired outcome. Satir, V. (1967). Conjoint family therapy. Palo Alto:
Through the family sculpt the therapist is able Science and Behavior Books.
to identify in a visual way how each person in the Satir, V. (1972). Peoplemaking. Palo Alto: Science and
family system views their family. Through this Behavior Books.
Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991).
particular sculpt, the therapist is able to identify The Satir model: Family therapy and beyond. Palo
that David is perceived as the good child and that Alto: Science and Behavior Books.
Jared identifies as the bad child and Martha is Schwartz, R. C. (1995). Internal family systems theory.
often labeled as the bad parent. The therapist New York: Guilford.
Stanton, A. L., & Low, C. A. (2012). Expressing emotions
assesses what it is like to try openly communicate in stressful contexts. Current Directions in Psycholog-
from each of their identified roles. After pro- ical Science, 21(2), 124–128. https://doi.org/10.1177/
cessing the therapist invites each family member 0963721411434978.
to communicate from their desired role. The ther- Wang, L. (1994). Marriage and family therapy with people
from China. Contemporary Family Therapy, 16(1),
apist helps the family experience a more mean- 25–37. https://doi.org/10.1007/bf02197600.
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With a special emphasis on the psychotherapy of
aggression. Family Process, 14(1), 1–16. https://doi.
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Cross-References Whitaker, C. A., & Bumberry, W. M. (1988). Dancing with
the family. New York: Brunner/Mazel.
▶ Napier, Augustus
▶ Symbolic-Experiential Relationship Therapy
▶ Whitaker, Carl Exposure in Couple and
Family Therapy
References Alexander O. Crenshaw1 and

Brian R. W. Baucom2
Baldwin, M., & Satir, V. (1987). The use of self in therapy. 1
University of Utah, Salt Lake City, UT, USA
New York: Haworth Press. 2
Department of Psychology, University of Utah,
Davies, D. E., & Neal, C. E. (2000). Therapeutic perspec-
tives on working with lesbian, gay and bisexual clients. Salt Lake City, UT, USA
Maidenhead, BRK, England: Open University Press.
Gehart, D. R., & Lyle, R. R. (2001). Client experience of
gender in therapeutic relationships: An interpretive eth-
nography. Family process, 40(4), 443–458.
Introduction
Gehart, D. R. (2015). Theory and treatment planning in
family therapy: A competency-based approach. Exposure in couple and family therapy (C&FT)
Boston: Cengage Learning. draws on the same principles as exposure used in
Gehart, D. R., & Tuttle, A. R. (2003). Theory-based treat-
individual treatment of anxiety disorders. Based
ment planning for marriage and family therapists:
Integrating theory and practice. Belmont: Brooks/ on past learning, certain cues (e.g., an emotion
Cole Publishing. expressed by one partner) come to represent
Exposure in Couple and Family Therapy 979
some feared outcome (e.g., a relationship- or anxiety, which reliably reduces subsequent fear
threatening argument). In order to avoid the feared or anxiety in future encounters with the same
outcome, partners avoid the cues that are thought stimulus. The use of exposure in couple therapy
to precede the feared outcome. Through associa- is supported by research showing the efficacy of
tive learning, those cues come to represent the couple therapies that utilize the principle (e.g.,
feared outcome and are avoided with greater vig- Baucom et al. 2015). Two prominent theorized
ilance, growing the fear to be disproportionately cognitive-behavioral mechanisms of change for
larger than the actual likelihood of the event exposure have been proposed: habituation and
occurring. When fear cues inevitably arise in the inhibitory learning (Craske et al. 2014). The habit-
course of life, romantic partners may react with uation model states that exposure works to reduce
E
intense emotions, often leading to dysfunctional anxiety by helping an individual habituate to the
and destructive behaviors toward one another. feared situation. The inhibitory learning model
Exposure in C&FT, like in treatment for anxiety states that exposure works by learning that the
disorders, involves repeatedly facing such fear feared situation (e.g., anger of partner) usually
cues, learning to tolerate the intense emotions as does not produce the feared outcome (e.g., end
they arise, and learning that the specific cue does of relationship) through repeated trials.
not necessarily lead to the feared outcome. A key
difference between exposure for anxiety and in
C&FT, however, is that exposure in C&FT is Description of the Strategy or
typically done through interactions among part- Intervention
ners rather than to specific outside stimuli.
Exposure in C&FT, like couple and family ther-
apy in general, takes two forms: partner-assisted
Theoretical Framework exposure therapy and exposure as part of couple
therapy. In partner-assisted exposure therapy, a
Exposure in C&FT is utilized in most behavior- romantic partner assists in helping conduct expo-
ally and affectively based models. The unified sure exercises designed for his or her partner’s
protocol for couple therapy, a transtheoretical individual psychopathology, acting as a coach or
framework for couple therapy (Christensen source of encouragement. Exposure in
2010), suggests that exposure is a key intervention C&FT – the focus of this entry – is conducted in
technique because avoidance of relationship con- order to improve the relationship itself, and it
tent prevents couples from experiencing emo- typically involves exposure to frequently avoided
tional closeness and support with one another relational stimuli, such as intense negative emo-
around these difficult issues and prevents the cou- tions or undisclosed vulnerabilities.
ple from working together toward solutions. Carrying out exposure in C&FT involves primar-
ily eliciting avoided, relationship-relevant content
while preventing or interrupting subsequent destruc-
Rationale for the Strategy or tive interaction behaviors, and encouraging con-
Intervention structive communication and mutual disclosure of
avoided content. Like exposure therapy for anxiety
Decades of research support the effectiveness of disorders, in which exposures are carefully planned
exposure as an intervention when significant out based on a hierarchy of intensity, this process
avoidance is present (Foa and Kozak 1986). The involves a great deal of clinical judgment as to when
principle of exposure first gained support in the this avoided content is elicited and the depth at
treatment of anxiety disorders and serves as the which it is discussed. Also like exposure therapy
bedrock of cognitive-behavioral interventions for for anxiety disorders, the therapist typically exer-
anxiety disorders. Exposure therapy involves sys- cises more control over the process at the outset of
tematically confronting situations that elicit fear therapy compared with later.
980 Expressed Emotion in Families
Case Example Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T.,
& Vervliet, B. (2014). Maximizing exposure therapy:
An inhibitory learning approach. Behaviour Research
Eric and Cindy presented to therapy reporting and Therapy, 58, 10–23.
conflict related to the frequency of sexual contact Foa, E. B., & Kozak, M. J. (1986). Emotional processing of
they have. Cindy was satisfied, but Eric was not. fear: Exposure to corrective information. Psychological
Due to her history, Cindy was sensitive to feeling Bulletin, 99, 20.
that her autonomy was being encroached upon, so
she often felt her “walls” go up in response to
Eric’s attempts at establishing physical intimacy
and rebuffed his advances. Eric strongly wanted Expressed Emotion in Families
his relationship to be more than just an average
relationship, and he was vigilant for any sign that Hannah S. Myung and James L. Furrow
the relationship was less than great or in decline. Fuller Graduate School of Psychology, Pasadena,
When Cindy had disclosed emotions in the past CA, USA
related to feeling her sense of autonomy was
encroached upon, Eric interpreted these emotions
as signs that the relationship was in jeopardy and Name of Concept
responded with invalidation and anger, which
resulted in Cindy disclosing less in the future. Part Expressed Emotion in Families
of therapy for this couple involved eliciting this
important but avoided relationship content in a
safe, therapeutic context. Exposure to Cindy’s feel- Introduction
ings of having her autonomy encroached upon was
important both for Cindy to understand and express Expressed emotion (EE) was first identified
exactly what it felt like when Eric made sexual through studies of patients with schizophrenia
advances toward her and for Eric to hear this and their families. Researchers explored various
distressing content and learn over time that her factors contributing to patient relapse given high
response did not signal the end of the relationship. rates of hospital recidivism and decompensation
among patients diagnosed with schizophrenia.
A patient’s family environment and emotional
Cross-References ties were identified as key predictors of treatment
relapse and treatment outcomes. Over time EE has
▶ Cognitive Behavioral Couple Therapy been more generally recognized as a family-
▶ Cognitive-Behavioral Family Therapy specific influence effecting the course of treatment
▶ Emotionally Focused Couple Therapy for several psychological disorders. Although EE
▶ Extinction in Couple and Family Therapy studies initially focused on posttreatment out-
▶ Integrative Behavioral Couple Therapy comes, a series of family-based interventions
have been targeted to influence family environ-
ments and to address the core effects of EE.
References
Baucom, B. R., Sheng, E., Christensen, A., Georgiou, Theoretical Context for Concept
P. G., Narayanan, S. S., & Atkins, D. (2015).
Behaviorally-based couple therapies reduce emotional
arousal during couple conflict. Behaviour Research During the 1950s, George Brown was completing
and Therapy, 72, 49–55. his undergraduate study when he was offered a
Christensen, A. (2010). A unified protocol for couple ther- research position at the Maudsley Hospital in
apy. In K. Hahlweg, M. Grawe-Gerber, & D. H.
London to observe patients with schizophrenia.
Baucom (Eds.), Enhancing couples: The shape of cou-
ple therapy to come (pp. 33–46). Hogrefe Publishing: Increasing incidents involving patient readmission
Cambridge, MA. and symptom relapse prompted Brown and his
Expressed Emotion in Families 981
colleagues to examine patient experiences after models of depression suggest that depressed
they were discharged from treatment. Researchers people tend to internally attribute negative situ-
identified a link between patient readmission and ations. Critical relatives who attribute negative
the quality of the home environments to which they events to internal patient factors are likely to
were discharged (Brown 1959; Brown et al. 1958). reinforce patient sensitivity to these responses
Patients who returned to their parents or spouses especially for depressed patients (Wearden et al.
were showing higher readmission rates than those 2000). The potential influence of EE on depres-
who went on to live with their siblings, distant sion treatment is significant based on theoretical
relatives, or in new lodgings. Furthermore, if both and research grounds pointing to a positive rela-
the patient and a close relative, such as the mother, tionship between EE and relapse for both uni-
E
were unemployed and staying at home there was a polar and bipolar depression (Wearden et al.
higher risk for readmission and symptom relapse. 2000). Similar questions have been raised
This suggested that unavoidable and prolonged regarding EE’s influence on the course of treat-
contact to a close relative could be problematic ment for anorexia nervosa and bulimia nervosa
and that the close ties between a patient and family (Duclos et al. 2012), post-traumatic stress dis-
members needed further inquiry. Therefore, Brown order (Tarrier et al. 1999), and significant pre-
and his colleagues began examining the relation- dictor of time until relapse for patients with
ships between patients and their close relatives alcohol abuse problems (Fichter et al. 1997).
focusing on the emotional ties of hostility or affec- Summary efforts to establish a general role
tion that were often observed in these home for EE in predicting treatment outcomes for
environments. psychological disorder are challenged by the
In pursuing this, Brown recognized the need varied methodological approaches to the assess-
for reliable methods to measure the emotional ment and measurements of EE. For example,
quality in families and collaborated with establishing an agreed upon cutoff for critical
Michael Rutter, who was initially interested in comments to be considered as high EE has been
examining the emotional impact of neurotic par- problematic. The absence of a consensus criteria
ents on their children. Rutter had developed result limits the ability to estimate an overall EE
interview methods to assess the emotional qual- effect. Nevertheless, the breadth and scope of
ity of the familial relationships. Eventually, they findings among various psychological disorders
applied these methodologies to studying parents suggests that the influence of EE on course of
of patients with schizophrenia (Brown 1985). treatment should be considered well beyond the
The focus on the emotional aspect within the treatment of schizophrenia.
family interactions made Brown’s work distinc-
tive. His primary interest in emotional tone and
quality provided an innovative approach to Description
examining family environments including fam-
ily metacommunication and familial interac- EE is comprised of five components: criticism,
tions. For example, Brown and his colleagues hostility, emotional overinvolvement, positive
differentiated critical comments from state- remarks or regard, and warmth. Problematic
ments of dissatisfaction in the family based on levels of EE are generally characterized by
a person’s emotional tone and vocal quality. increased levels of criticism, hostility, or emo-
This distinction became important in determin- tional overinvolvement among the patient’s care-
ing EE which proved effective in predicting givers or close relatives, whereas low levels on
patient relapse. these dimensions are representative of low EE in a
Although the identification of EE was family setting. Although some studies have incor-
focused on the treatment of schizophrenia and porated the positive dimensions of EE along with
family environments, EE has also been shown to these negative dimensions, the negative EE fac-
be relevant to the treatment of other psycholog- tors are given greater consideration in predicting
ical disorders and problems overtime. Cognitive treatment outcomes.
Criticism Disparaging comments expressed in a overinvolved behaviors as parent assumes respon-

critical tone of voice is the defining feature of this sibility for the patient’s condition, and parental
dimension. Matter of fact statements without the self-blame and guilt increase as these efforts fail
presence of a critical tone would not be identified to abate the patient’s symptoms. Ironically, these
as criticism. Critical comments are indicative of parental behaviors often exacerbate the patient’s
disapproval or resentment about the patient’s symptoms and functioning since the patient is
behaviors. A family member often assumes that continually having to depend on the caregiver’s
he or she is helping the patient by being critical support. This undermines the patient’s agency as
and may complain about the patient’s inability to he or she is perceived as incapable of recovery
carry out what would be perceived as normal without the parent.
functioning, such as getting out of bed or taking
care of personal hygiene. These behaviors are Positive Remarks or Regard These statements
typically seen in patients exhibiting the negative are characterized by expressions of approval, sup-
symptoms of schizophrenia or other psychotic port, or appreciation toward the patient’s actions
disorders. and to his or her character.
Hostility Evidence of hostility is best character- Warmth The assessment of warmth in the family
ized by negative attitudes and critical remarks environment is characterized by expression of
made directly toward the patient. These remarks caregiver empathy and compassionate concern
are not only about the patient’s behavior but spe- for the patient. Similar to criticism, the caregiver’s
cific to the patient’s character as a person. For supportive tone is often the clearest marker for
example, not getting out of bed or refusing to level of warmth for families.
brush teeth by the patient is attributed to laziness
rather than manifestations related to the negative EE Measures Different measures have been
symptoms of the patient’s disorder. The caregiver developed to assess the level of EE in a patient’s
usually believes that the patient has control over family environment. The Camberwell Family
his or her mental illness, but is purposely not Interview (CFI; Leff and Vaughn 1985; Vaughn
willfully choosing to a course toward recovery. and Leff 1976) is a well-known conventional
Thus, the patient is often blamed for not taking measure that is administered to family members
control over the disorder, and many family prob- without the patient present. It includes semi-
lems are viewed as being caused by the patient structured questions to elicit discussions on every-
and his or her mental illness, although that may day features of family life and the patient’s condi-
not always be the case. The patient remains caught tion (e.g., onset of symptoms, worsening of
in a bind within the family since the mental illness symptoms, recent episodes, and the specific
is concluded to be both the cause and answer to events leading to hospitalization). The familial
most problems. interactions, levels of tension and irritability, and
daily routines are also noted. These discussions
Emotional Overinvolvement This EE compo- are recorded for later analyses and coding which
nent is identified based on a combination of the are done using rating scales developed based on
actions and beliefs of the family, typically the EE dimensions.
observed in a family interview. Parental and care- One drawback of the CFI is that the training,
giving behaviors are markedly beyond those nor- administration, and reliable scoring can be an
mally expected given the developmental level of arduous and time-consuming process. The Five-
the patient. These actions often include a care- Minute Speech Sample (FMSS; Magaña et al.
giver’s overprotection, intrusion, sacrifice of 1986) was proposed as a brief measure developed
own needs, and overidentification with the based on the CFI. The FMSS is comprised of the
patient. Parental guilt attributed to the patient’s ratings of the EE components, criticism and emo-
condition can motivate and heighten these tional overinvolvement, and is measured by
Expressed Emotion in Families 983
having family members independently discuss can also modify the question using the same scale
their relationship to the patient for 5 min. The to gather further information. For example, an
relative is asked to talk about his or her feelings interviewer may want to know about the patient’s
and thoughts regarding the patient, and describe own perceived criticism toward their relatives.
the emotional climate in the relationship. These
discussions are recorded and later coded based on
content and emotional tone. Application of Concept in Family
Other methods in assessing EE include self- Therapy
report measures. The Level of Expressed Emotion
Scale (LEE; Cole and Kazarian 1988) does not Research findings pointing to the negative influ-
E
require the presence of a close relative as in the ence of elevated EE and poor patient outcomes
CFI and FMSS. The LEE is a 60-item true or false led to the development of family-based inter-
measure, which is used to assess the relationship ventions targeting EE constructs. Psychoedu-
quality and emotional environment of the patient cational family interventions were initially
and close relatives across four dimensions: intru- developed with the primary goal of reducing
siveness, attitude toward illness, emotional negative components of EE and preventing
response, and tolerance and expectations. The relapse in patients. The intervention tasks
LEE, however, has been critiqued for being too focused on correcting misattributions related to
extensive for survey research and being limited to a patient’s illness and in turn help relatives
patients with schizophrenia. Furthermore, the become less critical toward the patient.
Family Emotional Involvement and Criticism Although psychoeducational programs have
Scale (FEICS; Shields et al. 1992) sought to achieved positive effects on outcomes, there
extend the EE concept and its measurement to has been a lack of consensus when it comes to
the broader field of family studies, and provide effects on EE levels. Findings suggest that inter-
an assessment that better supported survey ventions with the primary goal of reducing EE
research. The 14-item self-report FEICS provides have achieved only modest effects or limited
an assessment of the levels of familial criticism success, and that targeting EE as a core goal
and emotional overinvolvement consistent may be necessary, but not sufficient. Also, the
with EE. EE concept in the past has been criticized for
Other measures attempt to approximate impor- reinforcing views that pathologize and place
tant EE dimensions. The Family Attitude Scale blame on families. Recommendations to pro-
(FAS; Kavanagh et al. 1997) was initially devel- vide family strength-based approaches have
oped as an attempt to develop a questionnaire that drawn more attention as alternative strategies
could be administered to either patients or rela- for promoting a family’s strengths and resources
tives, would be sensitive in assessing criticism, in family interventions.
and would be correlated with the CFI. The FAS is Therefore, EE is better conceptualized as an
a 30-item scale that mainly focuses on the level of important factor in the treatment process, but
criticism, annoyance, and burden in the family. not a primary treatment method or outcome.
Patients or close relatives indicate on a scale One approach outlined by Barrowclough and
how often the given statement is true. Sample Tarrier (1997) is taking on a “needs-led”
statements include “I wish he were not here,” “I approach rather than an “EE-reduction”
shout at him,” and “I find myself saying nasty or approach for clinical practice. EE concepts and
sarcastic things to him.” Another quick and sim- dimensions can be used to guide therapists in
ple measure concentrated on the level of criticism their treatment formulation when obtaining
in EE is the Perceived Criticism (Hooley and clinically relevant information of the family’s
Teasdale 1989). On a 10-point scale respondents needs, evaluating coping strategies, and priori-
answer to the question, “How critical do you tizing change, but not a sole focus in treatment
consider your relative to be of you?” Interviewers (Barrowclough and Tarrier 1997).
Clinical Example areas where psychoeducation is needed. The ther-

apist kept in mind that Janice’s skepticism about
Janice (56) and Caleb (25) entered family therapy therapy was related to her attitude toward Caleb
after Caleb experienced a relapse in depression. He and his depression. The therapist provided Janice
expressed feelings of worthlessness and hopeless- information about depression and what she could
ness that persist through most of his day. Caleb expect as a result. At the same time the therapist
reported loss of interest and had little energy for gave recognition to her frustration that was asso-
daily activities. He described it being an “ordeal” ciated with her underlying desire to help Caleb
to get out of bed every morning. Caleb reported (since many relatives believe that they are helping
feeling helpless and incompetent in the everyday the patient by being critical although not
tasks he faced and would rather “sleep it through.” beneficial).
His mother, Janice, expressed frustration Additionally, the therapist listened and
regarding Caleb’s symptoms as much as she observed behaviors that involved emotional
feels guilt for feeling that way. In the beginning, overinvolvement and how these behaviors
she felt compassion for Caleb and his struggles, impacted Janice and Caleb’s well-being. The
but recently she is convinced that his problems are therapist assessed the extent to which Janice
from “laziness” and failing to take responsibility. felt pulled to “pick up” after Caleb and make
She believes that he uses his depression as an decisions on his behalf. The impact of Janice’s
excuse, since he has been in treatment for depres- behaviors was highlighted in relation to how her
sion previously and gained coping strategies, actions impacted Caleb’s feelings of helpless-
which he should have applied by now. She ness and dependence on his mother. Caleb iden-
expressed that much of Caleb’s issues stem from tified how that it was in these moments he
his indecisiveness to get a job, move out of the stopped trying and withdrew (e.g., sleeping or
home, and seek independence. Janice often finds refraining from making decisions), which in
herself having to pick up after Caleb and has taken turn activated Janice’s overinvolvement.
on the decision-making responsibility for him Identifying this sequence of misattributions
because she believes he is incapable of making and reactions helps the family and the therapist
even the most basic decision. At this point Janice target specific needs of family members and their
is skeptical entering into therapy again with Caleb responses when these needs are unacknowledged
as she doubts if anything will change, unless or dismissed. The therapist aids Janice and Caleb
Caleb is willing to change. in finding new strategies for coping. In addition,
Following a “needs-led” approach, the therapist recognizing positive and successful coping strat-
attuned to caregiver criticism and hostility that is egies and responses by each family member is
obvious in Janice’s manner and tone. The therapist pertinent to a strength-based approach to family
noted her reactions to Caleb’s behaviors and what therapy and in intervention planning as these
things he does or does not do, all the while paying strengths can be resources. Expressions of warmth
attention to how Janice coped with Caleb’s depres- and positive regard between family members can
sion, including the consequences that this recent also be noted in this process. Although Janice is
depressive episode has had upon the family. skeptical about therapy, she and Caleb seem to
The therapist asked Caleb about his experi- have a desire to make things better. They both are
ences including the reactions of his mother and present in therapy regardless of how they feel and
other family members. These conversations are actively seeking help.
brought to light the perceived and actual inten- This case example illustrates the application of
tions of family members with a special focus EE concepts as an important element in case for-
given to identifying the family needs related to mulation and intervention planning. It is worth
Caleb, but also to the family in general. These mentioning that this is done in conjunction with
conversations helped to identify the misattribu- other treatment modalities the therapist may use
tions being made about Caleb’s depression and and does not in and of itself encompass the whole
Expressive Leader in Families 985
treatment process. Other areas for consideration in Cole, J. D., & Kazarian, S. S. (1988). The level of
this case include the history of the problem (onset, expressed emotion scale: A new measure of expressed
emotion. Journal of Clinical Psychology, 44, 392–397.
duration, course), experiences of past treatment, Duclos, J., Vibert, S., Mattar, L., & Godart, N. (2012).
risk assessment, psychosocial history, and adjunct Expressed emotion in families of patients with eating
treatment (e.g., medication). Disorders are not the disorders: A review of the literature. Current Psychia-
result of these family environments (e.g., EE), but try Reviews, 8, 183–202.
Fichter, M. M., Glynn, S. M., Weyerer, S., Liberman, R. P.,
often impact family distress in ways that prove & Frick, U. (1997). Family climate and expressed emo-
problematic for the course of treatment. Taking tion in the course of alcoholism. Family Process, 36,
EE into account, the clinician provides additional 203–221.
resources to the family as well as strengthens the Hooley, J. M., & Teasdale, J. D. (1989). Predictors of
relapse in unipolar depressives: Expressed emotion, E
resources of the family to better support the effec- marital distress, and perceived criticism. Journal of
tive treatment of a number of psychological Abnormal Psychiatry, 98, 229–235.
disorders. Kavanagh, D. J., O’Halloran, P., Manicavasagar, V., Clark,
D., Piatkowska, O., Tennant, C., & Rosen, A. (1997).
The family attitude scale: Reliability and validity of a
new scale for measuring the emotional climate of fam-
ilies. Psychiatry Research, 70, 185–195.
Cross-References Leff, J. P., & Vaughn, C. (1985). Expressed emotion in
families: Its significance for mental illness. New York:
▶ Anderson, Carol Guilford Press.
Magaña, A. B., Goldstein, M. J., Karno, M., Miklowitz,
▶ Camberwell Interview for Assessing Expressed
D. J., Jenkins, J., & Falloon, I. R. H. (1986). A brief
Emotion in Families method for assessing expressed emotion in relatives of
▶ Communication in Couples and Families psychiatric patients. Psychiatry Research, 17,
▶ Communication Training in Couple and Family 203–212.
Shields, C. G., Franks, P., Harp, J. J., McDaniel, S. H., &
Therapy
Campbell, T. L. (1992). Development of the family
▶ Faloon, Ian emotional involvement and criticism scale (FEICS):
▶ Family Psychoeducational Treatments for A self-report scale to measure expressed emotion.
Schizophrenia in Family Therapy Journal of Marital and Family Therapy, 18,
395–407.
▶ Problem-Solving Skills Training in Couple and
Tarrier, N., Sommerfield, C., & Pilgrim, H. (1999). Rela-
Family Therapy tives’ expressed emotion (EE) and PTSD treatment
▶ Psychoeducation in Couple and Family outcome. Psychological Medicine, 29, 801–811.
Therapy Vaughn, C., & Leff, J. P. (1976). The measurement of
expressed emotion in families of psychiatric patients.
▶ Schizophrenia in Couple and Family Therapy
British Journal of Clinical Psychology, 15, 157–165.
▶ Shields, Cleveland Wearden, A. J., Tarrier, N., Barrowclough, C., Zastowny,
T. R., & Rahill, A. A. (2000). A review of expressed
emotion research in health care. Clinical Psychology
Review, 20, 633–666.
References
Barrowclough, C., & Tarrier, N. (1997). Families of schizo-

phrenic patients: Cognitive behavioural intervention.
Cheltenham: Nelson Thornes.
Brown, G. W. (1959). Experiences of discharged chronic Expressive Leader in Families
schizophrenic patients in various types of living group.
The Milbank Memorial Fund Quarterly, 37, 105–131.
T. Ciochon, Kristy L. Soloski and K. Finch
Brown, G. W. (1985). The discovery of expressed emotion:
Induction or deduction? In J. P. Leff & C. Vaughn Texas Tech University, Lubbock, TX, USA
(Eds.), Expressed emotion in families: Its significance
for mental illness (pp. 7–25). New York: The Guilford
Press.
Synonyms
Brown, G. W., Carstairs, G. M., & Topping, G. (1958). Post
hospital adjustment of chronic mental patients. The
Lancet, 272, 685–689. Emotional leader; Socio-emotional specialist
986 Expressive Leader in Families
Introduction home – reinforcing the minimization of role com-

plementarity (Foote 1956). Further research has
While many factors affect intrafamilial relation- challenged the universality of expressive leader-
ships, it is generally agreed that the family is an ship as a sex-specific function as opposed to an
economic unit as well as a social unit. Thus, it was integral component of parenting for both spouses.
expected that economic (instrumental) and social An examination of a 56-society sample size
(expressive) roles would evolve to preserve the revealed that the sociological trend for comple-
unit. The instrumental leader can be described as mentarity was challenged as too limited in scope
the task specialist, whereas the expressive leader (Parsons and Bales 1955). Future research span-
can be described as the socio-emotional ning over 180 societies worldwide challenged the
specialist*. permanency and universality of sex-role comple-
mentarity indicating an increased expressive func-
tion for women during childbearing and infancy,
Theoretical Context for Concept which later returns to a shared position of leader-
ship between male and female partners (Crano
In the mid-twentieth century, sociologists began and Aranoff 1978). Although the expressive
to question the appropriation of roles among leader role has been documented in heterosexual
partners within American households. This relationships, insufficient research has been
division of roles was evidenced most poignantly conducted to identify how expressive leadership
in the heterosexual, middle-class, Euro- functions are distributed within same-sex
American family of the time where wives/ relationships.
mothers tended to the internal affairs of the
home (also called the private sphere), while
husbands/fathers tended to the external Description
demands (public sphere) of the home. These
roles began to take on new, independent mean- Expressive or emotional leadership* within the
ing for the structural functionalists, leading to home is focused upon “child training,” emo-
the proposition of two family roles: emotionally tional nurturance, and undertaking the respon-
focused expressive leaders and economically sibility of the human caretaking associated with
focused instrumental leaders. This division family leadership. As opposed to the task orien-
became known as complementarity. Structural- tation of instrumental leadership, which empha-
functionalist sociologists sought to make sense sizes efficiency and productivity, expressive
of the American family’s trend toward differen- leadership is generally espoused by focusing
tiated roles as progressive: the family differen- on the cohesiveness and emotional health of
tiated roles in order to maintain pragmatic the group members. In egalitarian partnerships,
function and stability (Parsons and Bales partners can undertake equal expressive leader-
1955). This division according to gender was ship in a family system; conversely in more
known as sex-role complementarity. However complementary partnerships, one individual
over time, differentiation and complementarity tends to focus on expressive functions, while
as progressive functions were heavily critiqued, the other partner may focus upon instrumental
as well as the sex-specific breakdown of roles functions. The delegation of leadership roles
associated with this differentiation. can also change across time given family cir-
Critics of sex-role complementarity denied cumstances. Etiology of the traditional sex role
the structural-functionalist assumption that role of females undertaking the expressive leader-
disparity between partners was increasing in ship role in the family was proposed to be a
the mid-1900s, citing the increasing trend of direct result of the female’s sex-specific role of
female and male spouses to share in parenting in bearing and feeding the child post-conception
the home and employment outside the through infancy (Crano and Aranoff 1978).
Extended Family 987
Application of Concept in Couple judgment of some friends as it relates to her no

and Family Therapy longer undertaking the expressive role in the family.
Conversely, José has experienced societal push back
Satir’s (1988) experiential family therapy model faced by men in similar situations who have stepped
explained that family members undertake differ- away from the workforce. They are seeking therapy
ent roles within a family. Having a primary role to help during the adjustment period as the transition
within a family is not problematic; however, the has created interpersonal strain evidenced by dis-
value messages associated with various roles must tance between the partners and relational
be uncovered. Consistent with this perspective, dissatisfaction.
expressive leadership as a primary function of a
E
family member is not an issue unless there are
negative value messages associated with the Cross-References
role, and flexibility is withheld from members.
The freedom of partners to co-create the roles ▶ Complementarity in Structural Family Therapy
that are best for themselves and the family while ▶ Gender Roles
making future adjustments is paramount to thriv-
ing and dynamic family systems.
References
Clinical Example Crano, W. D., & Aronoff, J. (1978). A cross-cultural study

of expressive and instrumental role complementarity in
the family. American Sociological Review, 43(4),
José and Diane have been married for 10 years and 463–471.
have two young children, an 8-year-old boy and a Foote, N. N. (1956). Parsonian theory of family process:
5-year-old girl. Prior to both their children entering Family, socialization and interaction process. Sociom-
kindergarten, Diane stayed home to care for the etry, 19(1), 40–46.
Parsons, T., & Bales, R. F. (1955). Family, socialization
kids, while José was employed full time and took and interaction process. Glencoe: Free Press.
on the primary income earner in the family. The Satir, V. (1988). The new peoplemaking. Mountain View:
couple assumed traditional sex-role complementar- Science and Behavior Books.
ity in their marriage, with Diane undertaking the
primary expressive leadership role and José under-
taking the instrumental role as the main income
provider. Diane took pride in spending time with Extended Family
her children and talking with them. As a result,
Diane was often aware when someone in her family Bertranna A. Muruthi1, Megan McCoy2 and
was upset and was promptly there for them. José Andrea Leigh Farnham3
1
was proud of his professional accomplishments and Marriage and Family Therapy Program, Virginia
being able to provide for his family. Recently, since Tech - Northern Virginia Center, Falls Church,
both of the children entered primary school, José has VA, USA
2
decided to further his education and return to school. Firm Foundations Counseling, Columbia,
This change forced Diane and José to reconcile new SC, USA
3
roles within the family as José is unable to work in The University of Georgia, Athens, GA, USA
conjunction with his education, but is able to under-
take the majority of the parenting and household
functions for the family. This has proven to be Synonyms
challenging for the couple as Diane and José are
forced to confront the strain of adjusting to new Extended kinships*
roles within the family system. Diane as the new Psychological family* (this is more for
primary provider for the family is faced with the non-biological)
988 Extended Family
Fictive kin* (non-blood related friends who are and loaning a car, or it can be more formal and
seen as family) (Hall & Green 2003) contractual such as a grandparent watching chil-
Secondary family* dren while parents are at work.
Family networks*
Extrafamilial*
Surrogate kin network* Relevant Research
Families of choice* (Weston 1991)
African-American and Latino populations are
often the focus of research on extended families.
Introduction This is in part due to these two groups having
more collectivistic family orientations which
Extended family refers to the extended kinship incorporate having associations with larger kin
system outside of the nuclear family. This sys- networks. Historically these family relationships
tem can include biological relatives, relatives by have been viewed as “enmeshed” (Minuchin
marriage, and the functional kinship system of 1974) due to a perceived lack of differentiation
neighbors, friends, and associates (Pattison from the extended family network. Yet, these
et al. 1975). According to Nichols and Schwartz close family relationships have been proven to
(1998), some of the first therapists who take the be a valuable source of support and to also pro-
extended family into consideration were Murray mote viability and health in these family systems
Bowen and Ross Speck. Bowen stressed the role (Durant et al. 2013). For example, for African-
of the extended family in the transmission of American families, extended networks have been
family patterns, rules, beliefs, and values, and proven to support better mental health outcomes
the role those play in the current problems. (Lincoln 2007) and also to buffer the stresses
Speck mobilized the patient’s network of family associated with child-rearing and caregiving
and friends to aid in treatment and saw the (Brummett et al. 2012).
extended family as a resource that could be Positive outcomes have been noted with
accessed (457). other groups when extended family and informal
kin networks are involved with children
(e.g., Walsh 2015) and adolescents (e.g.,
Description McPherson et al. 2013). For example, McPherson
et al. (2013) found that positive extended family
According to Pattison et al. (1975), the extended support can reduce the likelihood of tobacco,
kinship system provides two major resources for alcohol, and drug use in adolescents. They also
individual and family well-being. One resource is found that positive family support appeared to
affective support, which is emotional involve- have a stronger buffering effect on risk behavior
ment, personal interest, and psychological sup- than parental monitoring and control.
port. Affective support can be seen in instances Extended family research has also explored the
of transition, crisis, and/or loss where family positive impact of extended family support on the
members look to extended family and kin net- elderly population (e.g., Sheffler and Sachhs-
works for emotional support. This type of affec- Ericsson 2015). This population has a higher risk
tive support can be elicited and exhibited through for social isolation including living alone in com-
various means such as phone calls, acts of kind- munity residence, living below the poverty level,
ness, or just physical presence. The other resource or residing in a neighborhood/community envi-
is instrumental support, which comes in the form ronment that does not encourage civic participa-
of money or other assistance in living. Instrumen- tion (Walker and Herbitter 2005). Limited access
tal support can be informal such as bringing meals to support in this population can lead to negative
Extended Family 989
physical and mental outcomes. These outcomes the family to allow each individual’s experience to
range from higher rates of cognitive decline change (Minuchin 1974). Yet, “a number of
(Seeman et al. 2001) to increased mortality rates pioneering family therapists – Murray Bowen,
(Everard et al. 2000). Ivan Boszormenyi-Nagy, James Framo, Carl
According to Bell (1962), the families’ ability Whitaker – incorporated generational issues in
to utilize their extended family as a social resource their work with families” (Goldenberg and
is a prerequisite for healthy functioning in the Goldenberg 2012, p.204). For example, Bowen
nuclear family system. He continues to posit that used genograms to explore the network of
when this is not achieved, the extended family can interlocking relationships (Goldenberg and
become pathological by (1) reinforcing family Goldenberg 2012). Ivan Boszormenyi-Nagy pro-
E
defenses, (2) stimulating conflict, (3) becoming a moted the concept of relational ethics based on
screen for projection of nuclear family conflict, two beliefs: family members are committed to
and (4) becoming competing objects for support meeting the needs of each member and each mem-
(Bell 1962). These pathological extended family ber will do what is necessary to maintain the
relationships have been associated with mental family (Boszormenyi-Nagy and Krasner 1986).
illness (Sapin et al. 2016), declines in physical James Framo broadened Bowen’s work to create
functioning (Seeman and Chen 2002), and intergenerational family therapy sessions, where
chronic illness (Rosland et al. 2012). he would encourage clients’ family of origin into
the therapy room, going as far as to cancel or
reschedule sessions if any family members
Special Considerations for Couple did not show up (Framo 1992). Finally, Carl
and Family Therapy Whitaker invited extended family members to be
consultants in family sessions (Goldenberg and
Therapists working with extended families should Goldenberg 2012).
explore an individual in the context of his or her Therapists must also be aware that a client
social context. Taylor et al. (2014) described four may not have access to an extended family net-
types of extended family networks: (1) high emo- work. In these times, it can be valuable to help a
tional support and high negative interaction client develop a surrogate kin network, which
(ambivalent), (2) high emotional support and can be made up of various kinds of supportive
low negative interaction (optimal), (3) low emo- kin, friendships, and community networks that
tional support and low negative interaction serve the function of extended family. For
(estranged), and (4) low emotional support and example, extended family networks and surro-
high negative interaction (strained). Their find- gate kin can serve as social and economic
ings show that the second type of family support resources when finances are drained by costly
(high emotional support and low negative interac- medical bills or in instances of the death of the
tion) is considered the optimal support, and indi- major breadwinner (Walsh 2015). Clinicians
viduals who experience these types of can help in mobilizing these surrogate kin net-
relationships within their life are closer to their works by maintaining a connection with the
families and interacted with them more and community and compiling possible networking
thereby would be less likely to experience depres- options for their clientele.
sive symptoms.
One of the earliest approaches to family ther-
apy, structural family therapy, has strong ties to Cross-References
extended family in the therapy room (Pattison et
al. 1975). This theoretical approach is directed ▶ Nuclear Family
toward changing the structure or organization of ▶ Structural Family Therapy
990 Externalizing in Narrative Therapy with Couples and Families
References older adults: MacArthur studies of successful aging.

Health Psychology, 20(4), 243.
Bell, N. W. (1962). Extended family relations of disturbed Sheffler, J., & Sachs-Ericsson, N. (2015). Racial differ-
and well families. Family Process, 1(2), 175–193. ences in the effect of stress on health and the moderat-
Böszörményi-Nagy, I., & Krasner, B. (1986). Between give ing role of perceived social support. Journal of Aging
and take. New York: Brunner/Mazel. and Health, 28, 1362. https://doi.org/10.1177/
Brummett, B. H., Siegler, I. C., Williams, R. B., Hilliard, 0898264315618923.
T. S., & Dilworth-Anderson, P. (2012). Associations of Taylor, R. J., Forsythe-Brown, I., Taylor, H. O., & Chatters,
social support and 8-year follow-up depressive symp- L. M. (2014). Patterns of emotional social support and
toms: Differences in African American and White care- negative interactions among African American and
givers. Clinical Gerontologist, 35(4), 289–302. Black Caribbean extended families. Journal of African
Durant, R. W., Brown, Q. L., Cherrington, A. L., Andreae, American Studies, 18(2), 147–163.
L. J., Hardy, C. M., & Scarinci, I. C. (2013). Social Walker, J., & Herbitter, C. (2005). Aging in the shadows:
support among African Americans with heart failure: Is Social isolation among seniors in New York City. New
there a role for community health advisors? Heart & York: United Neighborhood Houses of New York.
Lung: The Journal of Acute and Critical Care, 42(1), Walsh, F. (2015). Strengthening family resilience. New
19–25. York: Guilford Publications.
Everard, K. M., Lach, H. W., Fisher, E. B., & Baum, M. C.
(2000). Relationship of activity and social support to
the functional health of older adults. The Journals of
Gerontology Series B: Psychological Sciences and Externalizing in Narrative
Social Sciences, 55(4), S208–S212.
Framo, J. L. (1992). Family-of-origin therapy: An
Therapy with Couples and
intergenerational approach. New York: Psychology Families
Press.
Goldenberg, H., & Goldenberg, I. (2012). Family therapy: Maggie Carey
An overview. Cengage Learning.
Lincoln, K. D. (2007). Financial strain, negative interac-
Narrative Practices Adelaide, Adelaide, Australia
tions, and mastery: Pathways to mental health among
older African Americans. Journal of Black Psychology,
33(4), 439–462. Introduction
McPherson, K. E., Kerr, S., Morgan, A., McGee, E.,
Cheater, F. M., McLean, J., & Egan, J. (2013). The
association between family and community social cap- Externalizing is a practice that sits within a Nar-
ital and health risk behaviours in young people: an rative Therapy approach developed by Michael
integrative review. BMC Public Health, 13(1), 971. White and David Epston (1990; Epston 1998).
Minuchin, S. (1974). Families and family therapy. Cam-
A Narrative approach can be useful in working
Nichols, M. P., & Schwartz, R. C. (1998). Family therapy: with individuals, couples, families, and commu-
Concepts and methods. Boston: Allyn & Bacon. nities and can be used in addressing any concern.
Pattison, E. M., Defrancisco, D., Wood, P., Frazier, H., & A Narrative Therapy approach sees life as
Crowder, J. (1975). A psychosocial kinship model for
family therapy. American Journal of Psychiatry,
multistoried (Freedman and Combs 1996). When
132(12), 1246–1251. couples or families come to therapy, they often
Rosland, A. M., Heisler, M., & Piette, J. D. (2012). The come with a single “problem” account of their
impact of family behaviors and communication pat- relationships. This is a single story that has taken
terns on chronic illness outcomes: A systematic review.
on a status of “truth” and has become embedded in
Journal of Behavioral Medicine, 35(2), 221–239.
Sapin, M., Widmer, E. D., & Iglesias, K. (2016). From the identity of the relationship of the family or
support to overload: Patterns of positive and negative couple. The stories that each person has about
family relationships of adults with mental illness over who they are and what life is about for them are
time. Social Networks, 47, 59–72.
the lens through which life is viewed, and these
Seeman, T., & Chen, X. (2002). Risk and protective factors
for physical functioning in older adults with and without stories serve to shape the experiences that are had
chronic conditions MacArthur studies of successful of life and relationships. Stories for example of
aging. The Journals of Gerontology Series B: Psycholog- conflict, fighting, blame, betrayal, distance, or
ical Sciences and Social Sciences, 57(3), S135–S144.
Seeman, T. E., Lusignolo, T. M., Albert, M., & Berkman,
disappointment have often become fixed and
L. (2001). Social relationships, social support, and pat- immutable as the sole understanding of those rela-
terns of cognitive aging in healthy, high-functioning tionships and have left little room for shared
Externalizing in Narrative Therapy with Couples and Families 991
understandings that are different to these domi- other therapies, the problem is located in the psy-
nant accounts. When a story takes hold it is expe- chologies or characteristics or personalities of
rienced as the truth. each individual. “Family dynamics” is a term
Rather than collude with this single storied that is often used to ascribe the location of the
account, a Narrative approach is interested in peo- problem as being in the patterns of interaction in a
ple experiencing themselves as multistoried and family, or in individual personalities such as the
as having more than the problem story through “overprotective mother,” the “peace-keeper,” or
which to be defined. Michael White developed the the “scapegoat.”
practice of “externalizing” (White 2007; Morgan Narrative Therapy differs from these ways of
2000) to separate the problem story out from the thinking in that it locates the problem in the mean-
E
identities of the couple or family and to see the ings people are making of their experience. These
problem as something that is no longer intrinsic to meanings are held and conveyed through the
the relationships. These externalizing lines of stories that people have about themselves, and
enquiry serve to make visible the ways in which essential to Narrative practice, is the understand-
a problem story has taken hold of the relationships ing that meanings are always constituted relation-
and how the problem story is having unwarranted ally, in a context of cultural discourses, beliefs and
influence on the course of things. Through making practices (White and Epston 1990). Dominant and
this visible, it becomes possible for the couple or normalizing ideas of being a “couple” or of “fam-
the family to begin to take back the influence from ily” are interrogated and the expectations and
the problem and to determine which course of incitements of discourses, for example of being a
events would better fit for them. It becomes pos- “perfect” couple or a “perfect” family are exam-
sible for alternative and preferred accounts of ined and the social and cultural pressures and
relationship or of being a family, that were previ- expectations exposed.
ously cast in a shadow through the influence of the When it is understood that people’s relation-
problem, to be brought forward. ships with problems are shaped by history and
These preferred stories (White 2007; Russell and culture, it is possible to explore how gender,
Carey 2004) of what is meaningful and precious in race, culture, sexuality, class, and other relations
each person’s understandings of relationship or fam- of power have influenced the construction of the
ily can then be acknowledged and through further problem. By giving consideration to the politics
enquiry, be more richly described. The skills and involved in the shaping of identity, it becomes
know-how that each person brings to the relation- possible to enable new understandings of life
ship, or to being a family, can be storied and consid- that are influenced less by what the problem has
eration given to how these skills and know-how to say and more by an awareness of how our lives
might contribute to what could become. The Narra- are shaped by broader cultural stories. In this way,
tive approach is based in an appreciation that the externalizing conversations put back into the
therapist is not the expert on the family or couple’s realm of culture and history what was created in
experience or on the meanings that are being made. culture and history. This opens up a range of
Instead the family or couple are seen as the experts possibilities for action that are not available
and through practices of enquiry and curiosity, this when problems are located within individuals.
expertise and “knowing what to do” can be brought
forward.
The Practice of Externalizing
Naming the Problem

The Location of the Problem
We’ve both changed, we’re not the same people we
In some therapies, the problem is explained as were when we got together, we’ve become distant
and closed down. We can’t communicate any more
being located in “patterns” of interaction, for and everything seems to end in an argument. The
example, the “pursuer/distancer” pattern. In spark has gone out of the relationship.
992 Externalizing in Narrative Therapy with Couples and Families
In order to shift the location of the problem from “We are always fighting over what they are allowed to
being experienced as internal to the relationship, we do and what they are not, they argue with us con-
stantly. They want to go out with their friends mid-
create, through language, a separation between the week and when we say no it always end up in tears. It
concern and the relationship. We begin to see feels like we are always fighting and arguing”.
the problem as something external that is impacting
the relationship. Through the use of language the Talking about the problem as “the conflict” or “the
problem is changed from a description of the rela- fighting and arguing thing” creates some distance
tionship (“our relationship has become distant, from a sense of “we are the fighting and arguing
closed down, lacking a spark”) to something that is family” as an account of the identity of the family,
experienced as external. Rather than using descrip- and that this is the only story of the family.
tions or adjectives as accounts of the relationship,
the practice of externalizing languages the problem Mapping the Effects and Consequences of the
as a noun (“This ‘Distance in the relationship’, what Problem on Different Areas of Life or
has made it possible for it to get so big?” “The Relationship
closed-downness” of which you speak, are there Once problems are externalized, they can then
times when it is not so effective in its efforts to start to be put into story lines through asking
keep you from talking? This “lack of spark” thing, questions that reveal the effects and consequences
what effect does it have on how you see each other? on each of the members of the couple or family,
What does it try to talk you into about your partner?” and on the relationship itself (Russell and Carey
Descriptions of what is problematic such as 2004).
being distant, ambiguous, disappointed, betrayed, “When did this ‘fighting and arguing thing’ get a
mistrustful, worried, ashamed, guilty, angry, hold of the family? What might have opened the
stressed become externalized as “the distance,” door for the ‘fighting and arguing thing’ to come in?”
“the ambiguity,” “the disappointment,” “the Asking how long the problem has been an
betrayal,” “the mistrust,” “the worry,” “the influence in the life of the relationship, when it
shame,” “the guilt,” “the anger,” “the stress.” took up residence and if there were factors that
This is more than a linguistic “trick” or “tech- contributed to its entry is a useful starting point to
nique” and relies on the underlying principle of the have persons see that this has not always been the
social construction of meaning through the storying sole defining story of their family.
of experience. We are not born with these problem Placing problems like ‘the distance’ or ‘the
accounts of who we are, but rather they are arguing and fighting thing’ into story lines can
constructed through social relations. Externalizing begin to throw some light on how the problem
involves questioning the internalizing practices that has come to have such a big influence on the
are such a pervasive part of everyday life and that relationship. It can also begin to provide the cou-
determine the location of the problem within per- ple or the family with a lot of information and
sons and so can seem quite unfamiliar to begin with. richer understandings of how they might be able
It is not necessary for there to be only one to reclaim their relationship from the influence of
externalized definition of the problem. In fact, the problem.
when working with more than one person, it is
quite likely that there will be more than one defini- Revealing the “Operations” or Tricks and Tactics of
tion, and it can help in these instances to start with a the Problem
broader naming of the problem in which each per- When a problem is externalized, it also becomes
son is able to have their experience included. possible to identify the particular practices that
Families who seek out therapy are often in the sustain this problem. For instance, if “the dis-
grip of conflict, or things have “broken down” tance” has come to significantly affect a relation-
between them. ship, there is a good chance that particular
Externalizing in Narrative Therapy with Couples and Families 993
practices such as judgment or criticism or blame respectful or empathic or open in a relationship).

have made this possible. Externalizing conversa- Because it is understood that being respectful and
tions about these particular practices can lead to open is also a product of history and culture,
increased understanding about their operation. questions can be asked about how this “openness
Making visible how the problem operates can and respect” has developed in the life of the rela-
provide people with the skills and know-how tionship. “What are the practices of ‘respect and
with which to resist these operations. openness’? How do you go about ‘doing’ ‘respect
and openness’? What has each person contributed to
Taking a Position on the Effects of the it; who are the people are who’d be least surprised to
Problem hear about it; what sustains it, and what particular
E
Once the problem has been explored in this way and problem-solving skills it may be linked to?”
the effects and consequences and operations made This process can make these qualities of being
visible along with the social relational political con- respectful and open, more meaningful and rele-
text, there can be a chance for the couple or family to vant to people in addressing the effects of prob-
take a position on what the problem is doing. They lems in their lives. Asking questions about what
can be asked to evaluate the effects and to decide if other things this “respect and openness” stands for
allowing the problem to continue in this way is in in each person’s life, what it means, and how it is
line with their preferences for relationship. An edi- linked to certain values and commitments and the
torial summary is offered that captures all of the histories of these values and commitments, will
consequences and operations (tricks and tactics) of contribute in to an even richer and so more sus-
the problem, and questions are asked along the line tainable and available story.
of “When you look at all of this, how do you feel Narrative Therapy is founded on the under-
about what the distance is doing? Is this ok with you, standing that it is the rich description of the alter-
or not ok, or perhaps a bit of both?” native stories of people’s lives that provides
people with more options for action and therefore
Finding What Is Given Value to That the enables significant changes to occur.
Problem Is Getting in the Way of
Through having some distance from the problem,
it becomes possible to see that it is getting in the Cross-References
way of some things that the couple or family
would prefer, and to which they give value and ▶ Deconstruction in Narrative Couple and Family
importance (White 2007). “What does this fit with Therapy
or not fit with in terms of what you value in ▶ Deconstructive Listening in Couple and Family
relationships? How does this work or not work Therapy
for you in regard to what is important to you as a ▶ Narrative Couple Therapy
family?” Further enquiry can bring forth the story ▶ Narrative Family Therapy
of these preferred ways of doing relationships or ▶ Postmodernism in Couple and Family Therapy
family, and the skills and know-how identified to ▶ Poststructuralism in Couple and Family
be able to reclaim the relationship from the prob- Therapy
lem (Marsten et al. 2016). A sense of collabora- ▶ Problem-Saturated Stories in Narrative Couple
tion is made possible through this approach and and Family Therapy
space can be created for each person to make ▶ Re-authoring Teaching
visible their own stories of relationship. ▶ Social Construction and Therapeutic Practices
Externalizing conversations don’t just focus on ▶ Social Constructionism in Couple and Family
problems but can also be used in relation to pos- Therapy
itive internalized qualities (such as being ▶ Talk as Action in Couple and Family Therapy
994 Extinction in Couple and Family Therapy
References trails to complete. It is important to note that in the

beginning of this process the undesirable behavior
Epston, D. (1998). Catching up with David Epston: may increase, which is referred to as an extinction
A collection of narrative practice-based papers. Ade-
burst. Another potential temporary outcome of
laide: Dulwich Centre Publications.
Freedman, J., & Combs, G. (1996). Narrative therapy: The this process is spontaneous recovery, which
social construction of preferred realities. New York: involves extinction bursts that occur after an
Norton. extended amount of time in which the undesirable
Marsten, D., Epston, D., & Markham, L. (2016). Narrative
behavior has not occurred (Dunsmoor et al. 2015).
therapy in wonderland. Connecting with children’s
imaginative know-how. New York: Norton. Additionally, contextual renewal may occur when
Morgan, A. (2000). What is narrative therapy? An easy-to- the cues that were previously extinguished are
read introduction. Adelaide: Dulwich Centre encountered outside of the extinction context
Publications.
(Dunsmoor et al. 2015). It is imperative that cli-
Russell, S., & Carey, M. (2004). Narrative therapy:
Responding to your questions. Adelaide: Dulwich Cen- nicians remain consistent throughout treatment in
tre Publications. order to counteract extinction bursts and to reduce
White, M. (2007). Maps of narrative practice. New York: undesirable behaviors should they return via
Norton.
spontaneous recovery.
White, M., & Epston, D. (1990). Narrative means to ther-
apeutic ends. New York: Norton. Extinction techniques take three different forms,
which all decrease the targeted behavior over time
(Lattal et al. 2013). The first is using extinction to
target behaviors that have been maintained by pos-
Extinction in Couple and itive reinforcement. The second is used to target
Family Therapy behaviors that have been maintained by negative
reinforcement (Lattal et al. 2013). The third is used
Nicole Ortiz to target behaviors maintained by automatic rein-
Clinical Psychology, California School of forcement (Lattal et al. 2013). In order for this
Professional Psychology, Alliant International technique to be effective, the clinician or client
University, Los Angeles, CA, USA participating must not respond when the target
behavior occurs. For example, in couple therapy,
if one partner does not respond to the target behav-
Introduction ior of the other partner, eventually the target behav-
ior will decrease until it has become fully extinct. It
Extinction is a behavioral technique that originated is often used in family therapy to target disruptive or
from principles of classical and operant condition- maladaptive behaviors of children and occurs when
ing. It is utilized in cognitive behavioral models of the other family members refrain from responding
intervention for couple and families and is a major to the child’s behavior until the behavior eventually
component of exposure therapy. It is utilized in becomes extinct (Bitter 2014).
order to reduce behaviors that have been reinforced
by removing the agent that is reinforcing it.
Description of the Strategy or This technique is utilized most in behavior and

Intervention cognitive behavioral therapies (CBT) (Waters and
Pine, 2016) and applied behavior analysis (Lattal,
This process occurs when a conditioned stimulus et al. 2013). While it is commonly used in work
(CS) that was paired with an unconditioned with children with developmental disabilities, it is
stimulus (US) is presented on its own without also used to target a wide range of behavioral
the US (Lovibond 2004). This process occurs problems. In CBT it is used during exposure ther-
gradually and typically takes practice and multiple apy, in which the therapist exposes the patient to
Extinction in Couple and Family Therapy 995
the CS without the US until the behavior, typically Therefore, the goal of the family therapy work
a fear response, is extinct. In regard to the poten- was to educate the family about the process of
tial occurrences of spontaneous recovery and con- reinforcement of behaviors, and each of their roles
textual renewal within the extinction process, it in reinforcing John’s behavior. Next, the concept of
has been theorized that these occurrences may be extinction was introduced and a dialogue
adaptive (Dunsmoor et al. 2015). Thus, the mem- was opened with the family about how each of
ory of the fear evoked by the stimulus is not fully them felt they could effectively work together
erased but stored for later in the event that to help decrease this problem behavior. It was
it becomes a threat once again. important that they each recognized their role in
the extinction process, namely, not providing rein-
E
forcement for John’s behavior. Ultimately with the
guidance of the therapist, the family was able to help
Intervention
John decrease this behavior and find more effective
ways to communicate as a family.
Extinction has been empirically proven effective in
treating an array of psychological disorders. Specif-
ically, research has shown it is effective in treating
obsessive compulsive disorder in adults and chil- Cross-References
dren (McGuire et al. 2016), specific phobias, anxiety
(Neudeck and Wittchen, 2012), panic disorder ▶ Cognitive Behavioral Couple Therapy
(Lovibond 2004) and has also been used in the ▶ Cognitive-Behavioral Family Therapy
treatment of autism spectrum disorders (Kelly
et al. 2015). In addition, it has been utilized to
modify maladaptive or disruptive behaviors within References
social and interpersonal contexts. The goal in utiliz-
ing this technique in couple and family therapies is Bitter, J. R. (2014). Theory and Practice of Family Therapy
to guide the partners or family members to a place and Counseling. S.1.: Brooks/Cole Cengage Learning.
where they can identify and change their behaviors Dunsmoor, J. E., Niv, Y., Daw, N., & Phelps, E. A. (2015).
Rethinking extinction. Neuron, 88(1), 47–63.
and ways of interacting and responding to each Kelly, M. P., Leader, G., & Reed, P. (2015). Stimulus over-
other in a safe environment. selectivity and extinction-induced recovery of perfor-
mance as a product of intellectual impairment and
autism severity. Journal Of Autism And Developmental
Case Example Disorders, 45(10), 3098–3106.
Lattal, K. A., St. Peter, C., & Escobar, R. (2013). Operant
extinction: Elimination and generation of behavior. In
Lauren and Adam presented to family therapy
APA handbook of behavior analysis, Vol. 2: Translating
with both their children in order to address a principles into practice. (pp. 77–107). Washington, DC:
behavioral problem they were experiencing American Psychological Association.
with their younger child John. For the past few Lovibond, P. F. (2004). Cognitive processes in extinction.
Learning & Memory, 11(5), 495–500.
months, John (age 7) had been having tantrums
McGuire, J. F., Orr, S. P., Wu, M. S., Lewin, A. B., Small,
when he was not allowed to stay up past his B. J., Phares, V., . . . Storch, E. A. (2016). Fear Condi-
bedtime playing video games with his older tioning and Extinction in Youth with Obsessive-Com-
brother Liam (age 12). When Lauren and Adam pulsive Disorder. Depression And Anxiety, 33(3),
229–237.
told John he needed to go to bed he began to cry
Neudeck, P., & Wittchen, H. U. (eds). (2012). Exposure
and proceeded to have a tantrum until Lauren and therapy: Rethinking the model – Refining the method.
Adam allowed him to stay up for an extra hour. New York: Springer Science + Business Media.
Additionally, when this occurred, Liam would ask Waters, A. M., & Pine, D. S. (2016). Evaluating differences
in Pavlovian fear acquisition and extinction as predic-
his parents to let John have a few more minutes to
tors of outcome from cognitive behavioural therapy for
play. Liam’s actions as well as Lauren and Adam’s anxious children. Journal Of Child Psychology And
reinforced John’s behavior. Psychiatry, And Allied Disciplines, 57(7), 869–876.
F
FACES IV 1999). FACES IV is based on major studies by

Dean Gorall (2002) and Judy Tiesel (1994) which
David H. Olson were designed to improve the adequacy of the
Family Social Science, University of Minnesota, assessment and measure the full dimensions of
St. Paul, MN, USA cohesion and flexibility.
More than 1200 published articles and disser-
tations have used a version of FACES and/or the
Name and Type of Measure Circumplex Model of Marital and Family System
(Kouneski 2002) since the first version of the
The FACES IV is a family self-report measure model was published (Olson et al. 1979). The
with 6 scales and 42 items. model has also stimulated discussion and debate
regarding family functioning generally and the
cohesion and flexibility concepts specifically.
Synonyms The concepts have been defined in various ways,
both conceptually and operationally, by
The Circumplex Model; The Family Adaptability researchers and theorists to include various
and Cohesion Evaluation Scales aspects of family functioning (Barber and Buehler
1996; Doherty and Hovander 1990). The one con-
stant across these discussions and debates has
Introduction been the consensus on the importance of these
two concepts in understanding couple and family
FACES IV is the latest version of a family self- systems.
report measure designed to assess family cohesion
and family flexibility, which are the two central
dimensions of the Circumplex Model* of Marital Developers
and Family Systems (Olson 2011). Previous self-
report assessments include three versions of the David Olson is the primary developer of a variety
self-report measure called FACES I, II, and III of assessments including AWARE for individuals,
(Family Adaptability and Cohesion Evaluation PREPARE-ENRICH for dating to married couples,
Scales*) and the observational assessment called a self-directed Couple Checkup for couples, and
the Clinical Rating Scale (CRS) (Olson 2000, FACES for families. He has revised these and other
Thomas and Olson 1993, Thomas and Lewis assessments several times to improve their

https://doi.org/10.1007/978-3-319-49425-8
998 FACES IV
scientific rigor (i.e., reliability, validity, and facilitating dimension that helps families alter
national norms). These assessments have become their levels of cohesion and flexibility.
popular both nationally and in over 25 other There are five levels of cohesion, and the three
countries. central ones are called balanced, ranging from
“somewhat connected” to “connected” to “very
connected.” The two unbalanced extremes on
Description of Measure cohesion are “disengaged” (extremely low) and
“chaotic” (extremely high). There are also five
The FACES measure was developed to tap the full levels of flexibility, and the three central ones are
continuum of the cohesion and flexibility dimen- balanced, ranging from “somewhat flexible” to
sions from the Circumplex Model of Marital and “flexible” to “very flexible.” The two unbalanced
Family Systems. Six scales were developed, with extremes on flexibility are “rigid” (extremely low)
two balanced scales and four unbalanced scales and “chaotic” (extremely high) (Fig. 1).
designed to tap low and high cohesion By combining the 5 levels of cohesion and
(disengaged and enmeshed) and flexibility (rigid 5 levels of flexibility, this creates 25 types of
and chaotic). The six scales in FACES IV were relationships. There are 9 balanced types, 4 unbal-
found to be reliable and valid (Olson 2011). Con- anced types, and 12 midrange types – where the
current and discriminant validity was established relationship has unbalanced types on one dimen-
(Olson 2008), and new ratio scores measure the sion and balanced types on the other dimension.
balanced and unbalanced level of cohesion and The main hypothesis of the Circumplex Model
flexibility (Olson 2011). is: Balanced levels of cohesion and flexibility are
More details on all aspects of FACES IV are most conducive to healthy couple and family func-
contained in the FACES IV Manual (Olson 2008). tioning. Conversely, unbalanced levels of cohesion
The goals in developing FACES IV were as and flexibility (very low or very high levels) are
follows: associated with problematic couple and family func-
tioning. This hypothesis has received strong support
1. To develop self-report scales that tap the full using both FACES and the Clinical Rating Scale
dimensions (balanced and unbalanced) of (Kouneski 2002; Thomas and Lewis 1999).
cohesion and flexibility A second hypothesis is: Balanced couples and
2. To develop self-report scales that are reliable, families will have better communication skills
valid, and clinically relevant than Unbalanced relationship, and these skills
3. To develop a family assessment tool that is useful help Balanced relationship maintain balance
for research and clinical work with families over time. Furthermore, poor communication
skills are often considered part of the reason that
Brief Overview of Circumplex Model. The unbalanced relationship stay stuck in more dys-
Circumplex Model is comprised of three key con- functional behavior. As a result, teaching couples
cepts for understanding family functioning. Cohe- and families more positive communication skills
sion is defined as the emotional bonding that can be a useful first step in helping them develop a
family members have toward one another. Family more balanced relationship.
flexibility is defined as the quality and expression A third hypothesis is: If the normative expec-
of leadership and organization, role relationship, tation of a couple or family support behavior is
and relationship rules and negotiations. Flexibil- more extreme on one or both dimensions, they will
ity, as previously used in the model, was defined function well as long as other family members
as the amount of change in family leadership, role accept these expectations. This hypothesis is
relationships, and relationship rules. Communica- very important in applying the Circumplex
tion is defined as the positive communication Model to other cultures that have normative
skills utilized in the couple or family system. The expectations that are more extreme on one or
communication dimension is viewed as a both of the dimensions. This is especially true
FACES IV 999
FACES IV, Fig. 1 Circumplex Model and FACES IV
for cultural groups that encourage and support have a linear relationship with healthy/unhealthy
more extreme togetherness (enmeshment) and family functioning (Olson 2000). In addition, there
extremely low flexibility (rigidity). were not distinct scales that measured the two unbal-
Assessing the Extremes of Cohesion and Flexi- anced areas (extremes) areas of cohesion
bility. The cohesion and flexibility scales from (disengaged and enmeshed) or flexibility (rigid and
FACES II and III have been consistently found to chaotic).
1000 FACES IV
Initial attempts with early versions of FACES IV Using these four unbalanced scales, Craddock
were also not successful in assessing the full dimen- (2001) found support for the basic hypothesis that
sions of cohesion and flexibility. One approach used families with higher scores on these scales had
a bipolar response format instead of a Likert higher levels of family stress and lower levels of
response format, based on the suggestions of Pratt satisfaction. Franklin et al. (2001) examined these
and Hansen (1987). The second approach was to use same four scales using factor and correlational
items based on the Clinical Rating Scale and have analysis, and their findings replicated the four
families rate themselves in much the same way they scales. They found some cross-loading of items
are rated by outside observers, based on the sugges- and a 0.60 correlation between the disengaged and
tions of Perosa and Perosa (1990). Both of these chaotic scales and suggested further work on the
attempts yielded measures that were linear in rela- independence of these two scales.
tion to family functioning.
A significant step in developing the current
FACES IV instrument was a study by Tiesel Psychometrics
(1994) in which she developed four unbalanced
sub-scales aimed specifically at the low and high Reliability of the Six FACES IV Scales. Using a
extremes of cohesion and flexibility. Items were sample of 489 adults, the alpha reliability of the
developed by having 154 clinical members of the 6 scales was assessed (Olson 2011). The reli-
American Association for Marriage and Family ability of the two balanced scales of cohesion
Therapy (AAMFT) rate the degree to which they (.89) and flexibility (.84). For the four unbal-
felt an item was representative of either cohesion or anced scales, the reliability of the scales was
flexibility. Then they rated the item as falling into disengaged (.87), enmeshed (.77), chaotic
one of the four extremes. This work yielded four (.86), and rigid (.82).
scales tapping the very low and very high levels of Discriminant Analysis of FACES IV Scales. To
cohesion (disengaged and enmeshed) and flexibility determine the ability of the FACES IV scales to
(rigid and chaotic). These four scales were found to distinguish between problem and non-problem fam-
be reliable and valid and were able to discriminate ily systems, a discriminant analysis was run for the
between problem and non-problem families. FACES IV scales and validation (see Table 1). The
FACES IV, Table 1 Discriminant analysis of problem and non-problem families (Percent accuracy in discriminating
groups)
Top vs. bottom 50% on Top vs. bottom 40% on Top vs. bottom 40%
SFI and FAD SFI and FAD Top vs. bottom 50% on family
Scale functioning functioning on family satisfaction satisfaction
N for each Top = 199 Top = 142 Top = 231 Top = 211
group Bottom = 192 Bottom = 149 Bottom = 228 Bottom =177
Unbalanced
scales
86 89 76 82
Disengaged
Chaos 80 85 60 77
Enmeshed 64 65 53 61
Rigid 54 55 51 52
Balanced
scales
Cohesion 89 94 80 87
Flexibility 74 80 72 76
Six scales 94 99 84 89
together
FACES IV 1001
analysis demonstrates that using the four unbal- They tried every different parenting approach
anced scales, it is possible to discriminant between they could imagine and read every book on
those high and low on family functioning and family handling difficult children.
satisfaction with high accuracy with the disengaged After being seen by a child psychiatrist, both
scale (.76–89) and chaos scales (.60–85). Less use- Alex and Sam were diagnosed with an early
ful were the unbalanced scales of enmeshment onset of bipolar disorder. Medication was pre-
(.53–.65) and rigid (.51–.55). The two balanced scribed to aid in reducing the turbulence of the
scales were very predictive: cohesion (.80–.94) and emotions and behavioral difficulties experi-
flexibility (.72–.80). The best were based on using enced by the brothers. In conjunction with psy-
all six scales together, and the range was very high chiatric services, intensive family therapy
(.84–.99). In summary, these analyses demonstrate services were instituted to assist the parents in
the high discriminant validity of the FACES IV adapting their parenting styles and approaches. F
scales. At the same time, couple therapy was initiated
Creating a Dimension Score for Cohesion when the therapists conducting the family ther-
and Flexibility from Six Scales. The dimen- apy determined that significant couple conflict
sional scores for cohesion and flexibility are prevented the parents from cooperatively insti-
used for plotting the one location of the family tuting any of the parenting approaches they had
onto the updated graphic representation of the attempted in the past.
Circumplex Model of Couple and Family Sys- FACES IV was administered to assess the par-
tems. In order to create a single score for cohe- ticular strength and growth areas of the family. The
sion and flexibility dimensions, the following scores on FACES IV from the two parents can be
formula was created. This dimension score is seen in the couple’s scores on the FACES IV profile
created by using the balanced score and and on the Circumplex Model (Figs. 2 and 3). Areas
adjusting it up or down the scale based on of difficulty for the family indicated by the FACES
whether the difference in the two unbalanced IV profile scores include low levels of “balanced
scale is at the high or low of the dimension. cohesion” and high levels of the disengaged scale.
Percentile scores are used for each scale, and The high levels of disengagement, particularly by
they are based on the raw scores. The formulas the report of Peggy, and low levels of balanced
are cohesion = balanced cohesion + cohesion indicate a lack of emotional closeness she
(disengaged – enmeshed / 2) and flexibil- feels in family. There were average scores on “bal-
ity = balanced flexibility + (rigid – chaotic / anced flexibility” but very high levels of chaos. The
2). So if the enmeshed score is higher than high level of chaos reported by the husband and
disengaged, then the balanced cohesion score wife was an indicator of problems with organization
is adjusted upward. and leadership that the couple could not effectively
provide. This was due to a combination of difficul-
ties in their couple relationship and the overwhelm-
Example of Application in Couple and ing task of parenting two boys who did not seem to
Family Therapy respond to any of their attempts at providing
structure.
The FACES IV was implemented with a family Family Treatment and Post Assessment. Ther-
where the presenting problem was significant apeutic work with the couple and family was
emotional and behavioral problems exhibited guided by FACES IV results and clinical observa-
by two children. Peggy and Doug are a married tions. Intervention focused on increasing the emo-
couple in their mid-30s who had three children, tional bonding in the couple relationship to enable
Alex (age 10), Sam (age 8), and Taylor (age 3). Doug and Peggy to more effectively function as a
The couple began having trouble with emo- co-parenting unit. As the couple relationship
tional outbursts and oppositional behavior in improved over time, they also improved at reduc-
both of their older children from an early age. ing the chaos as they began to work more as a
1002 FACES IV
team. They implemented specific parenting tech- flexibility at pre- and post-test for both partners. It
niques aimed at increasing structure and consis- clearly demonstrates that while Peggy was disen-
tency in the home for the boys, as well as gaged at pretest, she became more emotionally
increasing the positive emotional connections connected and that both described their relation-
between the parents and children. ship as more balanced in both cohesion and
As illustrated in the FACES IV profile (Fig. 2), flexibility.
there was a moderate increase in balanced flexibility In summary, this intake assessment and post-
for both members of the couple, reflecting improve- therapy assessment enables the therapist to see
ment in conflict resolution and negotiation in the the progress in the therapeutic process. The ini-
couple relationship. There was a dramatic decrease tial assessment provided information on how
in the chaos scores of both parents. This demon- the system is functioning and helped the thera-
strated an increase in the discipline and control pist develop a treatment plan. The six scales in
exercised by the parents. There was also a positive the FACES IV profile provide a picture of bal-
increase in balanced cohesion and a dramatic drop in anced and unbalanced scales as perceived by
disengagement scores for both partners. each family member. The post assessment dem-
Figure 3 provides a graphic summary of the onstrated the progress as perceived by the fam-
changes on the dimension scores of cohesion and ily members.
100
90 90
87
80
76
74
70
67
65
60
57 55
Percentile
54
52
50
45 44 43
40
34
32
30 27 32 27
28
30
20 18 20
13 15
10
0
COHESION FLEXIBILITY DISENGAGED ENMESHED RIGID CHAOTIC
BALANCED UNBALANCED
(Higher Scores Healthier) (Higher Scores Problematic)
Wife Pre Wife Post

Husband Pre Husband Post
FACES IV, Fig. 2 FACES IV profile: pre- and post-test

FACES IV 1003
FACES IV, Fig. 3 Pre- and post-test of couple in therapy
Cross-References Olson’s revision of the circumplex model. Journal of

Family Studies, 7, 29–39.
Doherty, W. J., & Hovander, D. (1990). Why don’t family
▶ Circumplex Model of Marital and Family Sys- measures of cohesion and control behave the way they‘re
tems, The supposed to? The American Journal of Family Therapy,
▶ Olson, David 18, 5–18.
▶ PREPARE/ENRICH Franklin, C., Streeter, C. L., & Springer, D. W. (2001).
Validity of the FACES IV family assessment measure.
Research on Social Work Practice, 5, 576–596.
Gorall, D. M. (2002). FACES IV and the circumplex
References model of marital and family systems (Doctoral dis-
sertation, University of Michigan). Dissertation
Barber, B. K., & Buehler, C. (1996). Family cohesion and Abstracts, 63.
enmeshment: Different constructs, different effects. Kouneski, E. (2002). Circumplex model and FACES: Review
Journal of Marriage and the Family, 58, 433–441. of literature. Available online at: www.faces.IV.com
Craddock, A. E. (2001). Relationships between family Olson, D. H. (2000). Circumplex model of family system.
structure and family functioning: A test of Tiesel and Journal of Family Therapy, 22(2), 144–167.
1004 Fair Fighting in Couple Therapy
Olson, D. H. (2008). FACES IV manual. Roseville: identified a framework that carves out clear roles for
PREPARE-ENRICH, LLC. the speaker, listener, and partnership in working
Olson, D. H. (2011). FACES IV and the circumplex model:
Validity study. Journal of Marital and Family Therapy, toward managing conflict. The focus of the
3(1), 64–80. speaker-listener framework is to utilize techniques
Olson, D. H., Sprenkle, D. H., & Russell, C. (1979). that harness skills to speak to each other in a mean-
Circumplex model of marital and family systems: ingful and fair way that creates space for fair
I. Cohesion and adaptability dimensions, family types,
and clinical applications. Family Process, 18, 3–28. fighting.
Perosa, L., & Perosa, S. (1990). The use of a bipolar item
format for FACES IV: A reconsideration. Journal of
Pratt, D. M., & Hansen, J. C. (1987). A test of the curvi-
linear hypothesis with FACES II and III. Journal of
Description
Thomas, V., & Lewis, R. A. (1999). Observational couple Fair fighting includes active listening, gaining per-
assessment. A cross-model comparison. Journal of spective, awareness of thoughts/words and body
Thomas, V., & Olson, D. H. (1993). Problem families and
language, and taking a time out (Gottman et al.
the circumplex model: Observational assessment using 1995). Unfair fighting consists of manipulation,
the clinical rating scale (CRS). Journal of Marital and abuse, name-calling, avoidance and blaming. Unfair
Family Therapy, 19, 159–175. fighting exacerbates and maintains active conflict,
Tiesel, J. W. (1994). Capturing family dynamics: The reli-
ability and validity of FACES IV (Doctoral disserta-
whereas fair fighting promotes conflict resolution. It
tion, University of Minnesota, 1994). Dissertation is important to consider that some problems may
Abstracts International, 55, 3006. arise because of cultural differences in styles of
negotiating and handling conflict (Morris et al.
1998). Fighting is an acceptable way of getting
what you want but most family members do not
Fair Fighting in Couple know how to do this effectively. It is important for
Therapy the therapist to consider individuals’ expectations in
these sessions.
Dara Winley, Elizabeth Adedokun and
Jessica Chou
Family Therapy
Introduction
Fair fighting is a concept crucial for conflict resolu-
Conflict is inevitable in couple relationships and tion and to aid couples in better understanding each
the ability to do it in a healthy way can yield other. The process of fighting often reveals more
desired resolution for the partnership (Gurman than the content of the argument; if done correctly
et al. 2015). and healthily, fair fighting can strengthen the part-
nership. Majority of couples attend therapy because
of threats to the security and stability of their rela-
tionship (Johnson and Denton 2002). Helping cou-
Theoretical Context for Concept ples identify and verbalize their unmet needs is a
core change mechanism. A speaker-listener exercise
A crucial element to fair fighting is the ability to can be employed where safety becomes the primary
communicate among partners. Oftentimes, when focus keeping in mind each partner’s vulnerabilities
conflict begins among a couple each person spends (Stanley et al. 1997). Once partners feel safe, the
time attempting to prove their partner wrong speaker and listener can create an agreement to treat
(Gottman et al. 1995). Markman et al. (1998) have one another with respect while fighting.
Fairness in Couples and Families 1005
Clinical Example Gurman & N. S. Jacobson (Eds.), Clinical handbook of

couple therapy (pp. 221–250). New York: Guilford Press.
Markman, H., Stanley, S., & Blumberg, S. L. (1998).
Rob, a 43-year-old Asian male, and Connie, a Fighting for your marriage: Positive steps for pre-
41-year-old Asian female, sought couple therapy venting divorce and preserving a lasting love. Family
as they wanted to amicably separate and learn to Court Review, 36(1), 95–95.
co-parent their two children, Eric, 5 years old, and Morris, M. W., Williams, K. Y., Leung, K., Larrick, R.,
Mendoza, M. T., Bhatnagar, D., Jianfeng, L. M. K., Jin-
Sam, 7 years old. The couple report that they are still Lian, L., & Hu, J. C. (1998). Conflict management
living together but plan to live separately in the near style: Accounting for cross-national differences. Jour-
future. They tell the therapist that they rarely talk, nal of International Business Studies, 29(4), 729–747.
and when they do, it is only to coordinate schedules Stanley, S. M., Markman, H. J., & Blumberg, S. L. (1997).
The Speaker/listener technique. The Family Journal,
for the children via text message. Additionally, 5(1), 82–83.
Connie feels that Rob is constantly making com- F
ments to the children that puts her in a bad light and
insists she is a bad mother. When Rob picked up
Sam from school unexpectedly one day, Rob made
sure to say that his mother “didn’t have the time” to Fairness in Couples
pick him up. During the session, Connie continued and Families
to make remarks about Rob’s parenting skills and
express that she feels he needs to be in individual Rashmi Gangamma1, Tatiana Glebova2 and
therapy to work out his personal issues. Jennifer Coppola1
1
The role of the therapist in this case is to guide Syracuse University, Syracuse, NY, USA
the couple to feel understood by each other by 2
Alliant International University – California
slowing them down and giving them two roles: School of Professional Psychology, Sacramento,
one as a listener and one as a speaker. The thera- CA, USA
pist assists the speaker in this case to speak for
themselves, avoid mind reading, and keep conver-
sation brief. For the listener, the therapist carefully Name of Concept
guides them in paraphrasing what they heard the
speaker say without rebutting. The therapist’s goal Fairness
is to get the couple comfortable with the skills
from this technique and eventually internalize
this method in future conversations. Synonyms
Balance of give and take; Relational ethics

Cross-References
Introduction
▶ Blamer Stance in Couples and Families
Growing evidence in developmental and neuro-
science research suggest that an intuitive sense of
References fairness and concern for others exists in infancy
(e.g., Decety and Howard 2013). Fairness in rela-
Gottman, J., Gottman, J. M., & Silver, N. (1995). Why
marriages succeed or fail: And how you can make tionships is an important concept and is some-
yours last. New York: Simon and Schuster. times described in terms of equity (e.g.,
Gurman, A. S., Lebow, J. L., & Snyder, D. K. (Eds.). Kuperminc et al. 2013). In this chapter we discuss
(2015). Clinical handbook of couple therapy.
fairness as a central construct of contextual ther-
New York: Guilford Publications.
Johnson, S. M., & Denton, W. (2002). Emotionally focused apy theory (Boszormenyi-Nagy and Krasner
couple therapy: Creating secure connections. In A. S. 1986) which is the only one that explicitly puts
1006 Fairness in Couples and Families
relational fairness or justice as a cornerstone of “parentified” (i.e., they are asked to take on
family relationships and well-being. Contextual adult-like relational responsibilities before being
therapy theory is an intergenerational, integrative, developmentally ready) and/or experience “loy-
strengths-based theory whose hallmark feature is alty conflicts” (i.e., they may be forced to either
relational ethics* or balance of give and take* or consciously or unconsciously choose between
fairness in relationships. Emerging research indi- competing interests). The lack of due care in
cates that perceptions of fairness are related to early life experience impacts levels of trust and
indicators of health and well-being (Grames may carry forward to the individual’s adult rela-
et al. 2008), as well as symptoms of depression tionships with difficulties in either giving freely to
and partner relationship satisfaction (Gangamma and caring about the partner or receiving and
et al. 2015). The following sections examine the acknowledging care from the partner.
theoretical underpinnings of the concept and pro- Contextual therapy acknowledges the influ-
vide an example of application in couples’ ence of at least three generations in the experience
therapy. of fair or balanced relating. However, it is essen-
tial to consider the context in which each genera-
tion lived in order to adequately assess its impact
Theoretical Context for Concept on current relationships. For instance, the current
generation of adolescents, who have carried the
Contextual therapy theory suggests that symp- burden of global terrorism, may have very differ-
toms of individual and interpersonal ill health ent ideas of a “safe” society compared to their
are related to unfair relational patterns where parents who probably were not as exposed to it
there is an imbalance in giving and receiving as they are. Another example would be in the
care and consideration (Boszormenyi-Nagy differences in gender role expectations over the
et al. 1991). The balance of give and take is years and its impact of perceptions of fairness.
dynamic and changes across the life span and Societal expectations of what men and women
stages. There are two types of relationships in can do in terms of gainful employment and par-
regard to that balance: symmetrical and asymmet- enting are evolving; this may result in discrepan-
rical (Boszormenyi-Nagy and Krasner 1986). cies in intergenerational conceptions of fairness.
Symmetrical relationships exist among partners
or friends and are based on expectations of equi-
table give and take. The caregiver-child relation- Description
ship, in contrast, is inherently unequitable
(asymmetrical), with the caregiver expected to In order to comprehensively assess fairness in
give more to the child than vice versa. relationships, contextual therapy theory proposes
Fairness is an intergenerational concept; that is, its conceptualization within five interrelated
experiences of fair relating in one’s family of dimensions (Ducommun-Nagy 2002): (a) facts,
origin influence experiences, expectations, and (b) individual psychology, (c) systemic transac-
perceptions of fairness in partner relationships as tions, (d) relational ethics, and (e) the ontic dimen-
well as future generations (Boszormenyi-Nagy sion. These dimensions provide a framework to
and Spark 1984). The lack of due care in early understand experiences of fairness and develop
relationships may lead to the development of interventions in therapy.
unfair patterns where individuals either overgive Facts refer to actual events that occur during
(for instance, in the form of constant caring for the course of one’s life such as birth, death, mar-
another along with denial of one’s own care and riage, or divorce. For instance, parental infidelity
needs) or over-receive (for instance, in the form of could be a fact that influences not just how fair-
excessive expectation of being taken care of by ness is perceived in the parental relationship but
another). Typically, as a result of unfair caregiver- also between the parent and child. Additionally,
child relationship, individuals may become aspects of identity such as a person’s age, sex at
birth, national origin, race/ethnicity, ability status, imbalanced. Systemic concepts here help in
and sexual orientation are considered facts that understanding interactional processes underlying
could influence experiences of fairness. Individ- unfairness in relationships. In planning interven-
uals who belong to traditionally oppressed groups tion for this relationship, the therapist may work to
due to their identities may face societal discrimi- reduce unfairness for the child by attempting to
nation which may influence how balance in rela- establish clearer and healthy boundaries between
tionships is developed. Thus, processes of power, parents and between the parents and child. Thus,
privilege, and oppression are also facts that impact family systemic concepts and techniques provide
how fairness is constructed. For instance, in a a blueprint for changing interactional patterns.
same-sex couple relationship, one partner may The dimension of relational ethics is consid-
feel that the relationship is unfair if her partner is ered the hallmark feature of the contextual
not as “out” as she is with family and friends. approach. Relational ethics are founded on the F
Being closeted may be tied to systemic and family principle of equitability. It refers to concepts of
processes of homophobia; however, it influences trust, loyalty, and entitlement which influence jus-
what may be perceived as fair in the interpersonal tice and fairness in relationships and are transmit-
relationship. ted through generations. Within the family
The dimension of individual psychology context, it means every member is entitled to due
refers to cognitions, affect, perceptions, and expe- consideration of their interests by others in the
riences that vary from one individual to another. It family (Boszormenyi-Nagy and Krasner 1986).
is possible to incorporate concepts from other A trusting, caring relationship with one’s care-
psychotherapy theories here in order to get a givers lays the foundation for continued trustwor-
more comprehensive understanding of the rela- thy interactions with others. Early experiences of
tional system. For instance, in a couple relation- violations of trust may result in difficulties in
ship, we may note that one partner has a tendency developing trustworthy and fair adult relation-
to withdraw in the face of conflict, while the other ships (Hargrave and Pfitzer 2003). The difficulties
person has a tendency to pursue. These differ- arise not from an intent to cause harm to others but
ences could be indicators of coping mechanisms from one’s own lack of access to relational
developed over time. These differences, however, resources. For instance, growing up in an environ-
impact how the couple perceives balance. In this ment of abuse and exploitation, an individual may
example, the partner who pursues may believe not develop the resources to be trustworthy in
that they do more in the relationship and that is their partner relationship. This in turn may impact
unfair. It is important to keep in mind, however, how much the individual is able to give to and
that the individual factors are considered within receive from the partner. It is possible that the
the context of relationships. Thus, the term “indi- individual would demand more of the partner as
vidual” does not refer to a person in vacuum but to a way of seeking compensation for something
unique responses of the individual within the con- they did not receive in the earlier relationships,
text of interpersonal relationships. which may in turn contribute to an unfair
The dimension of systemic transactions refers relationship.
to patterns of interactions between members of a Early experiences of unfair relationships with
relationship and incorporates concepts from fam- caregivers may also include loyalty conflicts. Loy-
ily systems theory (Whitchurch and Constantine alty refers to a deep sense of commitment that exists
1993) such as hierarchies, boundaries, roles, between parent and child due to the two legacies of
rules, and triangles. For instance, a couple unable parental accountability and filial indebtedness
to manage anxiety in their relationship directly (Boszormenyi-Nagy et al. 1991). In intimate part-
may pull in their child as a mediator to defuse ner relationships, it refers to the commitment
it. This relational pattern of triangulation may between partners who have merited trust due to
result in the child shouldering the burden of paren- their mutual concern and care. Problems may
tal anxiety, which can be considered unfair or arise when the individual is forced to take sides.
Loyalty conflicts can be seen in terms of split individual’s sense of what one is owed in a partner
loyalty (i.e., being torn between two significant relationship may be influenced by his emotional
people) and/or invisible loyalty (i.e., an indirect reactivity to a partner’s demands (individual psy-
allegiance that blocks loyalty in the most current chology) or experiences of loyalty conflicts
relationship) and can be a major deterrent in inter- (relational ethics) as well as by processes of trian-
personal fairness and impact health and well-being. gulation (systemic transaction) catalyzed by a
In some instances, the legacy of filial loyalty parental divorce (fact).
and existential debt to parents could set the stage Finally, the fifth dimension, the ontic, refers to
for parentification of the child (Boszormenyi-Nagy the core idea of contextual therapy that the self
and Krasner 1986). Parentification occurs when an exists in relationships and existential meaning
individual is expected to take on adult roles prior to occurs in relationships with others. Genuine or
the appropriate developmental stage. For instance, meaningful connections are free of exploitation
when a 10-year-old daughter becomes the sole and include acknowledgment and validation of
caregiver of an alcoholic parent, the daughter is the self and other. For instance, a meaningful
taking on a role whose responsibilities far exceed connection between partners could develop if
her developmental capabilities. Parentification that they are able to see each other and connect with
is sustained and not adequately acknowledged can each other genuinely and not if they see each other
result in the daughter’s continued overgiving as a as mere projections of their parents or others.
way of being in relationships. Ontic care (Boszormenyi-Nagy and Krasner
Symptoms may also develop due to invisible 1986) refers to active consideration of the context
loyalties. Invisible loyalty is regarded as an indi- of fairness and justice in relationships. This was
rect and often unintentional attempt to remain introduced as a separate dimension after much of
connected to the past. For instance, immigrant the early formulations of the theory were devel-
parents may continue to unconsciously adhere to oped (Ducommun-Nagy 2002). It is possible to
familial practices from their home country while conceptualize the ontic aspect of the existence of
raising their children in the United States. Con- self in relationships as a fundamental assumption
flicts may arise if there is a discrepancy in their of the theory.
traditional familial practices versus those that their
children are exposed to growing up in the United
States. In this instance, children may experience Application of Concept in Couple
their parental standards as unfair, while the immi- and Family Therapy
grant parent may feel it is unfair that the children
rebel against them despite all that they have Contextual therapy interventions and techniques
sacrificed in their own lives. This sense of what are closely related to its theoretical principles. The
one is owed in relationships is called entitlement, idea of family of origin experiences affecting
which takes two forms based on the actions of individual symptoms and interpersonal processes
those in relationship (Boszormenyi-Nagy and in partner relationships is well documented by
Krasner 1986). Constructive entitlement is where other intergenerational family therapy theories
an individual may expect to receive care in a (Bowen 1976). In contextual therapy, however,
relationship by actually caring for and giving to the focus of intergenerational work is to ensure
another. Constructive entitlement earned through the revolving slate of unfairness is stopped and a
balanced relating promotes fairness and justice. legacy of fair relating is passed on to the future
However, individuals could also earn destructive generation (Hargrave and Pfitzer 2003). Working
entitlement which perpetuates unjust relational to exonerate those who have perpetuated unfair-
patterns. Destructive entitlement, often a result ness in one’s family of origin could tremendously
of one’s experiences with imbalanced relation- impact one’s capacity to more freely give and
ships, promotes repetitive and harmful behaviors receive in current relationships. Contextual thera-
toward themselves or others. For instance, an pists strive to be accountable and fair to
everybody who may be potentially affected by physical conditions that make her intensely afraid
therapeutic interventions through a technique for her health in the future. Tim was laid off but
called multidirected partiality or multilateral recently found night shift work, but struggles with
stance. Acknowledging the context in which an injury that if left untreated may also render him
unfairness was perpetuated (which may include disabled. The couple presented for therapy after
caregivers’ own experiences of not receiving due arguments had escalated to verbal abuse and
care) sets the stage for this stance which allows destruction of property by both partners. In ses-
space for due consideration of multiple, equally sions it was revealed that after an argument, Tim
valid perspectives (Boszormenyi-Nagy and Kras- often left the house and did not return until the
ner 1986; Krasner and Joyce 1995). Thus, the next morning, while Nancy would lock herself in
intention of working with one’s family of origin her bedroom. The couple was not physically inti-
in contextual therapy is to promote rejunction or mate and had not been for more than 1 year. Both F
repair of relationships by viewing them as disclosed drug and alcohol abuse earlier in life.
resources and not as avenues for blame. Tim had relapsed 3 months prior to coming to
The therapist’s self is an important tool in therapy after being sober for 10 years.
contextual therapy. The practice of multidirected Most recently, the couple’s arguments centered
partiality and helping move clients toward a place around Tim’s relationships with his siblings and
of Martin Buber’s I-Thou stance (Friedman 1998; his “unfair” level of attention to them, as Nancy
Fishbane 1998) requires understanding of issues perceives it. However, both Tim and Nancy were
related to fair give and take in the therapist’s own quick to agree that the sisters were “bullies” and
experiences. The I-Thou stance of dialogue is frequently devalued Tim by telling him he was
characterized by a willingness to hold both one’s “worthless” and “would not amount to anything,”
own perspective and another’s and validation of This was reminiscent of messages from his par-
one’s experience as well as acknowledgment of ents who were both deceased. Nancy reported that
another’s. Boszormenyi-Nagy and Krasner she too received phone calls from the sisters call-
(1986) suggest that a firm conviction in the impor- ing her names and shaming her physical
tance of justice and fairness in relationships and a appearance.
willingness to examine them in their lives are Nancy expressed intense anger toward Tim
essential. This, along with the belief that there for wanting to buy one of the sisters a birthday
are multiple, valid perspectives of any situation, gift and criticized him for betraying her, choos-
is important for a contextual therapist. The con- ing his sibling over her and allowing her to be
textual therapist, therefore, examines their own mistreated. Tim expressed defensiveness by
entitlements in relationships and is prepared to explaining that Nancy is constantly attempting
work toward fair relationships in their lives. to control his interactions with his family and he
simply wants the relationships to be peaceful.
Nancy admitted to attacking Tim when she is
Clinical Example angry, which escalates the argument, and Tim
would react by either attacking or pulling away.
*NOTE: All identifying information have been Tim stated that he feels controlled and Nancy
changed. stated she feels abandoned.
Additionally, Tim reported chronic physical
Background abuse at the hands of his father who was an
Nancy and Tim are a biracial, heterosexual couple alcoholic. Tim’s mother did not intervene to
who have been married for 5 years and together protect him from the abuse, but made excuses
for fifteen. Both are in their mid-50s. This is the for it. The sisters remained protected from the
second marriage for both and neither partner has father as well. After years of being subjected to
children. Nancy is currently disabled and unable the abuse and effects of alcoholism, Tim
to work; she copes with chronic pain and other described his mother as absent and that he was
often left to care for his sisters. Nancy revealed Interventions

emotional neglect and physical abuse by both of Using empathy and multidirected partiality, the
her parents and reported being scapegoated, contextual therapist gave equal weight to each
while her older siblings were dubbed the “hero partner as they stated their situation. The over-
children.” Beginning in her teenage years, arching treatment goal was to build the ability
Nancy had a string of abusive relationships for crediting and acknowledging for each part-
with men as she attempted to have her emotional ner so that they could benefit from an increased
needs met. Tim was the only person Nancy felt sense of trust in each other and a more balanced
safe with. relational ethics* ledger. To begin this process,
the therapist acknowledged the stress that had
Conceptualization been generated by the couple’s blocked give and
A contextual therapist would begin conceptualiz- take and the loyalty conflict. The therapist
ing the case by understanding the complexities of gently held both partners accountable for their
the couple’s reality as put forth in the first four destructive actions and for their lack of account-
dimensions (facts, individual psychology, sys- ability to each other. Then, the therapist
temic transactions, and relational ethics). As a engaged the couple in understanding their
result, the therapist would have a sense for the respective intergenerational patterns, allowing
couple’s feeling about what is fair and unfair to space in sessions for them to begin the process
each in the relationship based on actions and of exoneration.
accountability. In his family of origin, given the Nancy was the first able to see her unfair
emotional and physical absence of his parents, treatment as a child as the result of her parents’
Tim was parentified by being forced to care for victimization and limited resources. She began
his sisters. In overgiving to his sisters as an adult, to recognize the pattern that had been
he continued to participate in the intergenerational established in her intimate partnerships, and as
parentification that was established by his parents the therapist modeled acknowledgment for the
and the pull of invisible loyalty (or sense of obli- unfairness that had occurred, Nancy expressed
gation to them despite mistreatment by them). her true vulnerabilities to Tim, who was able to
Tim was therefore blocked from giving freely to witness qualities of Nancy’s genuine self. Tim,
the welfare of the partner relationship, and trust/ in turn, acknowledged the unfairness Nancy had
trustworthiness eroded. The fear of being unwor- experienced as well as his actions that had
thy was also a legacy he carried with him in his exploited the relationship. The therapist then
conflict with Nancy, which precipitated his gave Tim the opportunity to understand the vio-
shutdown. lations of trust he had experienced with his
Nancy had experienced chronic abandonment parents in a different way, which allowed
and abuse in her family of origin and as a result Nancy to understand and witness Tim’s
also lacked the resources to be trustworthy in the vulnerability – a quality of his true self that
partner relationship. As such, building trust with was not readily expressed. The therapist
Tim had been difficult as he too did not have a highlighted the loyalty conflict that the couple
foundation of trustworthy interactions. As Nancy was experiencing, which made it possible to talk
was not given due consideration in either family about Tim’s need for his relationship with his
of origin or previous partner relationships, her siblings while at the same time holding Nancy’s
quest for trust and availability in Tim may have perspective of needing an available partner.
been demanding more of him than he was able to The therapist noted these actions as an
give. These patterns from their families of origin unblocking of relational resources and moved
influenced development of destructive entitlement the couple into a process of learning to credit
where each partner, unable to see beyond their each other for the contributions made to the rela-
own pain, did not acknowledge and validate the tionship, including actions of care, trust, loyalty,
other. respect, and love. The couple and therapist
Falicov, Celia 1011
navigated this process by working through spe- Kuperminc, G. P., Wilkins, N. J., Jurkovic, G. J., & Perilla,
cific current needs where mutual giving and J. L. (2013). Filial responsibility, perceived fairness,
and psychological functioning of Latino youth from
receiving could increase trustworthiness. Over immigrant families. Journal of Family Psychology,
time each partner was able to benefit from an 27(2), 173. https://doi.org/10.1037/a0031880.
increased sense of freedom to be their true selves Whitchurch, G., & Constantine, L. (1993). Systems theory.
with each other, and to enjoy giving and receiving In P. Boss, W. Doherty, R. LaRossa, W. Schumm, &
S. Steinmetz (Eds.), Sourcebook of family theories and
to/from the other, which led to a restored level of methods: A contextual approach (pp. 325–352). New
trust and fairness. York: Plenum Press.
References Falicov, Celia F

Boszormenyi-Nagy, I., & Krasner, B. (1986). Between give
Froma Walsh
and take: A clinical guide to contextual therapy. New
York: Brunner/Mazel. Chicago Center for Family Health and Firestone
Boszormenyi-Nagy, I., & Spark, G. M. (1984). Invisible Professor Emerita, The University of Chicago,
loyalties. New York: Brunner/Mazel. Chicago, IL, USA
Boszormenyi-Nagy, I., Grunebaum, J., & Ulrich,
D. (1991). Contextual therapy. In A. S. Gurman &
D. Kniskern (Eds.), Handbook of family therapy: Vol-
ume II (pp. 200–238). New York: Brunner/Mazel. Celia Jaes Falicov, Ph.D., is a leading clinical
Bowen, M. (1976). Theory in the practice of psychother- scholar and trainer in the field of family therapy, at
apy. In P. J. Guerin (Ed.), Family therapy. New York:
the forefront in addressing cultural aspects of
Gardner.
Decety, J., & Howard, L. H. (2013). The role of affect in the mental health treatment and therapy with immi-
neurodevelopment of morality. Child Development grant and Latino families. A licensed Clinical
Perspectives, 7(1), 49–54. https://doi.org/10.1111/ Psychologist, Dr. Falicov is Clinical Professor in
cdep.12020.
the Department of Family Medicine and Public
Ducommun-Nagy, C. (2002). Contextual therapy. In
R. F. Massey & S. D. Massey (Eds.), Comprehensive Health, University of California, San Diego,
handbook of psychotherapy (Vol. 3, pp. 463–488). New where she provides leadership of mental health
York: John Wiley & Sons. services at the Baker Student Run Free Clinic. Her
Fishbane, D. M. (1998). I, Thou, and we: A dialogic
community-based work addresses the mental
approach to couples therapy. Journal of Marital and
Family Therapy, 24, 41–58. health care needs of underserved families, facili-
Friedman, M. (1998). Buber’s philosophy as the basis for tates empowerment groups for Latino parents, and
dialogical psychotherapy and contextual therapy. Jour- provides clinical training to integrate issues of
nal of Humanistic Psychology, 38, 25–40. https://doi.
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org/10.1177/00221678980381004.
Gangamma, R., Bartle-Haring, S., Holowacz, E., Hart- health risks and strengths in psychotherapy prac-
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depressive symptoms, and relationship satisfaction in cal Rese

Encyclopedia of Couple and Family Therapy by Jay Lebow, Anthony Chambers, Douglas C. Breunlin

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Encyclopedia of Couple and Family Therapy by Jay Lebow, Anthony Chambers, Douglas C. Breunlin

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Jay L.

With 54 Figures and 14 Tables

ISBN 978-3-319-49423-4 ISBN 978-3-319-49425-8 (eBook)

© Springer Nature Switzerland AG 2019

Welcome to the Encyclopedia of Couple and Family Therapy, an evolving

systemic interventions, and descriptions of the many models of couple and

IL, USA Jay L. Lebow

Anthony L. Chambers, Ph.D., ABPP, is the Chief Academic Ofﬁcer and a

latest knowledge about how to have a healthy relationship. He is the author of

Douglas C. Breunlin, MSSA, LMFT, LCSW, is Clinical Professor of Psy-

Richard Schwartz) of the Handbook of Family Therapy Training and Supervi-

Brian R. W. Baucom Department of Psychology, University of Utah, Salt

Maria Borcsa University of Applied Sciences Nordhausen, Nordhausen,

Douglas C. Breunlin The Family Institute at Northwestern University, Cen-

Kristina S. Brown Couple and Family Therapy Department, Adler Univer-

Corinne Datchi Seton Hall University, South Orange, NJ, USA

Sean D. Davis California School of Professional Psychology, Alliant Inter-

Rachel M. Diamond University of Saint Joseph, West Hartford, CT, USA

Ryan M. Earl The Family Institute at Northwestern University, Evanston, IL,

Adam R. Fisher The Family Institute at Northwestern University, Evanston,

Molly F. Gasbarrini California School of Professional Psychology, Alliant

Farrah Hughes McLeod Health, Florence, USA

Eli Karam University of Louisville, Louisville, KY, USA

David Kearns University of Iowa, Iowa City, USA

Jay L. Lebow The Family Institute at Northwestern University, Center for

Thorana Nelson Santa Fe, NM, USA

Heather Pederson Council for Relationships, Philadelphia, USA

Kelley Quirk Marriage and Family Therapy Program, Human Development

Mudita Rastogi Illinois School of Professional Psychology, Argosy Univer-

Jessica Rohlﬁng Pryor The Family Institute at Northwestern University,

Allen Sabey The Family Institute at Northwestern University, Evanston, IL,

Bahareh Sahebi The Family Institute at Northwestern University, Evanston,

Diana J. Semmelhack Midwestern University, Downers Grove, IL, USA

Margarita Tarragona PositivaMente and Grupo Campos Elíseos, Mexico

Jessica Rohlﬁng Pryor, M.S., Ph.D., is full-time faculty in the Counseling

Adam R. Fisher, Ph.D., is Assistant Clinical Professor at Brigham Young

Jukka Aaltonen Department of Psychology, University of Jyväskylä,

Donna Rosana Baptiste The Family Institute at Northwestern University,

Ulrike Borst Familiendynamik, Heidelberger Institut für systemische

Kesha Burch The Family Institute at Northwestern University, Evanston,

Anthony L. Chambers The Family Institute at Northwestern University,

Dan Booth Cohen Wickford, RI, USA

Iman Dadras Department of Couple and Family Therapy, Alliant Interna-

Carol Djeddah Ethno-Systemic Narrative School of Psychotherapy, Rome,

Todd M. Edwards Marital and Family Therapy Program, University of San

Sallie Foley University of Michigan, Ann Arbor, MI, USA

Adia Gooden The University of Chicago, Chicago, IL, USA

Kaylyn E. Gyden Purdue University Northwest, Hammond, IN, USA

Blendine P. Hawkins University of Oregon, Eugene, OR, USA

Jasara N. Hogan University of Utah, Salt Lake City, UT, USA

Evan Imber-Black Marriage and Family Therapy, Mercy College, Dobbs

Alexander Julian Brigham Young University, Provo, UT, USA

David Kitchings The Family Institute at Northwestern University, Evanston,

Crystal Duncan Lane Western Michigan University, Kalamazoo, MI, USA

Antonella Leonelli Family System Psychotherapist, Trainer Trainee at I.E.F.

Heather A. Love Kansas State University, Manhattan, KS, USA

Sandra Marco Mexico City, Mexico, Mexico

Ryan A. McKelley University of Wisconsin-La Crosse, La Crosse, WI, USA

Amanda M. Mitchell University of Louisville, Louisville, KY, USA

Susan Nash Department of Family and Community Medicine, Baylor

Thomas G. O’Connor University of Rochester Medical Center, Rochester,

Aikin Paul Sacramento-Davis EFT Center, Davis, CA, USA

Timothy F. Piehler University of Minnesota, Twin Cities, Minneapolis, MN,

Incia Rachid The Family Institute at Northwestern University, Evanston, IL,