Journal of Family Psychology Copyright 1994 by the American Psychological Association, Inc

1994, Vol. 8, No, 4, 390-416 0893~3200/94/$3.00

What We Do and Don't Know About the Process of

Family Therapy
Myrna L. Friedlander, Julie Wildman, Laurie Heatherington, and
Elizabeth A. Skowron

Despite convincing outcome evidence and the popularity of family therapy, little is
known about how interpersonal change actually comes about in this context. To
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

synthesize and integrate what is known and to offer recommendations for future,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

clinically relevant research, all published process studies on family therapy were
reviewed. Included were naturalistic studies of conjoint treatment in which the focus
was the in-session verbal behavior of the participants or their self-reported perceptions
of actual interactions. Dating from 1963, 36 studies met the inclusion criteria. The
review was organized according to 3 hierarchically ordered levels of in-session
processes (L. S. Greenberg, 1986): observations of (a) speech acts, followed by studies
of (b) important incidents or change episodes and (c) the therapeutic relationship. The
implications of what is "known" are followed by a discussion of what is not "known"
and suggested directions for future research.

Since the 1950s, when family therapy was
considered an unusual, if not heretical, mode of
treatment, its popularity has been rapidly accel-
erating. Family therapy is now routinely taught
to students in all of the major mental health
professions and to practitioners seeking to im-
prove their skills in professional workshops,
conferences, and free-standing training centers.
The process of family treatment is described,
debated, and analyzed not only in practice-ori-
ented periodicals and books but also in well-
respected journals of psychotherapy research.
Despite the ever-growing popularity of fam-
ily therapy, little is known about how interper-
sonal change actually comes about in this
context. One reason for this lack of knowl-
edge may be because, to date, investigators
have emphasized the global efficacy of family
Myrna L. Friedlander, Julie Wildman, and Eliza-
beth A. Skowron, Department of Counseling Psy-
chology, University at Albany, State University of
New York; Laurie Heatherington, Department of
Psychology, Williams College.
This article was presented in June 1993 at the
annual conference of the Society for Psychotherapy
Research in Pittsburgh, Pennsylvania.
Correspondence concerning this article should be
addressed to Myrna L. Friedlander, Department of
Counseling Psychology, Education 220, University at
Albany, State University of New York, 1400 Wash-
ington Avenue, Albany, New York 12222.
390
treatment for various psychological disorders.
Although outcome research was needed to es-
tablish the efficacy of family treatment, and
the evidence is indeed convincing (Gurman,
Kniskern, & Pinsof, 1986), such research
tends to be of little value to the practicing
therapist, who is concerned with effective
strategies and interventions. Practitioners tend,
instead, to turn to theoretical or technical arti-
cles, books, and workshops for such clinically
relevant information.
Another reason for the lack of knowledge
concerning interpersonal change processes is
that the overriding concern of theorists is what
therapists should do to effect change (Kuehl,
Newfield, & Joanning, 1990). Rarely do theo-
rists discuss— or even comment on—what fam-
ily members need to do. Furthermore, it is rare
for theorists to focus on processes common to
many therapeutic approaches. Instead, the con-
cern of most theorists is how to distinguish their
approach from others.
The purpose of this article is to redress these
imbalances (across all schools of family ther-
apy) by reviewing the existing research on pro-
cesses of change in family therapy and by of-
fering recommendations for future research.
We have made an attempt to provide a com-
prehensive review of all the published process
research on family therapy. Both computer-
assisted and human searches were used to iden-
 PROCESS OF FAMILY THERAPY
tify publications with empirical evidence (qual-
itative as well as quantitative) on family treat-
ments. Only studies of naturally occurring
processes in family therapy were included in the
review. Although there are a number of excel-
lent controlled studies of treatment components
(e.g., Jacobson, 1984), these investigations were
designed to test the effectiveness of those com-
ponents rather than to observe the naturally
unfolding process of change. Our intent was not
to disparage those important efforts but, rather,
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to highlight naturalistic process research in fam-
ily therapy.
To be included in the review, the study had to
focus on the actual in-session verbal behavior of
the participants or on their self-reported percep-
tions of in-session behaviors.1 Consequently,
we excluded retrospective studies of clients'
reactions (e.g., Beck & Jones, 1973; Greenberg,
James, & Conry, 1988; Kuehl et al., 1990;
Shapiro & Budman, 1973) as well as studies
with only pre- and postmeasures of family be-
havior or other outside-of-therapy observations
(e.g., Seeman, Tittler, & Friedman, 1985), that
is, those that typify outcome research. Studies
of therapists' general or characteristic styles of
behavior (e.g., Rice, Gurman, & Razin, 1974)
were also excluded. Finally, while we recog-
nize that family therapy is neither conceptually
nor practically limited to conjoint treatment
(Gurman, 1988), we assume that in-session
processes are affected when more than a sin-
gle client is present. Thus, for purposes of this
review, we only included studies of conjoint
treatments involving two or more family
members.
In contrast to Pinsof's (1981) and Gurman et
al.'s (1986) reviews of family therapy research,
we excluded unpublished dissertations and con-
ference papers (e.g., Presser, Sigal, Mayero-
vitch, & Chayoga [cited in Pinsof, 1981]), as
well as articles reporting programs of instru-
ment development (e.g., Allred & Kersey,
1977). Rather than organizing the review by
investigator or by instrument, as have others
(e.g., Beutler & Crago, 1991; Greenberg &
Pinsof, 1986b; Pinsof, 1981), we focused on
three hierarchically ordered levels of in-session
processes (Greenberg, 1986). We first reviewed
investigations (a) at the speech act level, fol-
lowed by studies of (b) therapeutic episodes
and, at the most global level, (c) the therapeutic
relationship. In this model of process research,
each unit or level is subsumed by successive
391
levels, so that speech acts can be studied in the
context of specific change events or episodes,
and each of these units can be "nested" within a
study of the relational aspects of the therapy
(Greenberg, 1986). From this perspective, pro-
cess variable C is not only composed of other,
more microscopic process variables (A, B) but
is also, itself, a component of the therapeutic
process (D) at a macroscopic level (e.g., Green-
berg, 1986; Greenberg & Pinsof, 1986a; Pinsof,
1989; Shoham-Salomon, 1990).
We chose this schema to organize the review
for two reasons. First, this schema is particu-
larly useful from the standpoint of practice.
Clinicians are best able to evaluate the conclu-
sions of a given program of research when the
process unit is clearly specified. In other words,
the practical relevance of the finding that vari-
able A predicts variable B requires knowledge
of the context (Greenberg, 1986; Heatherington,
1990). Consider the following hypothetical ex-
ample. Speech act B (therapist confrontation) is
found to occur frequently in family therapy
sessions. It would be more useful to know,
however, that B follows A (therapist support)
significantly more often than chance. In addi-
tion, if the sequential relationship between A
and B (support and confrontation) is found to
characterize specific, well-defined change epi-
sodes (C; e.g., challenging parents to work to-
gether to set limits for their young children) in
the context of a supportive therapeutic relation-
ship (D), this finding is even more meaningful
for the practicing therapist. Indeed, in a recent
survey of practitioners, Beutler, Williams, and
Wakefield (1993) found that the most strongly
endorsed request was for "research that focuses
on therapist and/or client behaviors leading to
important moments of change during psycho-
therapy" (p. 56).
1
In a case study of a single session, Scheflen
(1973) developed an elaborate analysis of the coor-
dination of verbal and kinesic behaviors in a demon-
stration session with a mother and her daughter, who
had schizophrenia. The therapists were Carl Whitaker
and Thomas Malone. While this is the sole study, to
our knowledge, in which nonverbal behaviors were
analyzed in a family therapy context, the results are
not only exceptionally complex but also do not lend
themselves to drawing conclusions about the process
of therapeutic change. As Pinsof (1981) noted in his
review of Scheflen's work, the research was more
ethnographic than psychological in nature.
 392 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
Second, by organizing the review according
to this hierarchy of contexts, we are able to
present an overview of the entire literature base
from a perspective that is different from that of
earlier reviewers but which builds on their
collective wisdom (e.g., Gurman et al., 1986;
Pinsof, 1981, 1989; Wynne, 1988). In conduct-
ing the review, for example, we rapidly became
aware that the majority of published research
has been conducted at the speech act level, with
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relatively few studies of speech acts nested
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within either of the two higher order contexts.
Because the nested approach to process research
has the greatest appeal for practitioners, orga-
nizing our review in this manner seemed to be
the best way to communicate the research find-
ings to practitioners as well as to underscore the
need for coordinating future scientific efforts
(e.g., Pinsof, 1989).
On the other hand, despite having organized
the studies on the basis of research design, we
chose not to highlight their methodological fea-
tures. Many earlier reviewers of the family ther-
apy literature (e.g., Gurman et al., 1986; Pinsof,
1981,1988,1989; Wynne, 1988) have provided
excellent, detailed critiques of research meth-
ods, instruments, procedures, and analyses, with
extensive recommendations for methodological
improvements. Our aim, by contrast, was to
synthesize and integrate the substantive find-
ings of the available empirical evidence—pre-
cisely what we do know about the process
of family therapy. Of course, the findings of
individual studies and programs of research
need to be considered in light of their method-
ological shortcomings. Rather than providing
extensive critiques of each study, however, we
indicate, within each section or subsection of
the review, the major limitations. We con-
clude with general implications about what is
"known," followed by suggested directions for
future research.
What We Do Know
In Table 1, the family therapy process studies
reviewed below are listed, organized according
to speech acts, therapeutic episodes, and rela-
tionship variables. Within each section and sub-
section the studies are grouped by their substan-
tive focus or content.
Speech Acts
At the first, most microscopic level of the
therapeutic process is the individual speech act,
that is, a single statement or speaking turn
(Greenberg, 1986). In the studies reviewed be-
low, no higher order contexts (episodes or rela-
tionship) were taken into account. Although
sequences of speech acts (i.e., reciprocal inter-
actions) were observed in a few of the studies,
the variables of interest in the majority of these
investigations were frequencies or proportions
of individual speech acts. Most often, the aim of
the investigators was to describe some aspect of
the therapeutic process in single sessions or,
more rarely, over the course of treatment.
The following speech act variables have been
investigated: participation rates, interactional
frequencies, type of response, mode of expres-
sion, relational control patterns, and interper-
sonal complementarity. Investigators have ad-
dressed the following substantive questions:
Which therapist and family behaviors predict
premature termination? Which features of the
process are common across theoretical orienta-
tions and which are distinctive, and are the
distinctive features consistent with theory? How
do participant characteristics (e.g., gender, role)
and the treatment context affect in-session ther-
apeutic processes? What changes can be ob-
served over the course of family therapy, and
which changes in speech acts, if any, predict
treatment outcome? The following review ad-
dresses each of these questions in turn.
Premature termination. We located only
three studies in which speech acts were used to
predict discontinuance of treatment. In a study
of 21 families with "soft delinquent]" (p. 657)
youth, Alexander, Barton, Schiavo, and Parsons
(1976) coded family members' modes of ex-
pression. They found that the ratio of supportive
to defensive speech acts was significantly lower
in prematurely terminated treatments as com-
pared with successful cases. It is interesting that
these differences were observed only in the
latter phase of treatment, not in the initial ses-
sions. In another study of problem adolescents,
Chamberlain, Patterson, Reid, Kavanagh, and
Forgatch (1984) found that, on the basis of
speech acts, more highly resistant families had a
greater dropout rate. In the third, more recent
study, Shields, Sprenkle, and Constantine
(1991) hypothesized that joining, structuring,
and solution focusing would discriminate be-
 PROCESS OF FAMILY THERAPY
Table 1
Family Therapy Process Investigations
Focus Reference
Speech act
Premature Alexander et al. (1976)a a
termination Chamberlain et al. (1984)
Shields et al. (1991)
Common, Friedlander & Highlen (1984)b,
distinctive Friedlander et al. (1985)"
features Friedlander et al. (1987)b
Friedlander et al. (1991)"
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Treatment Chamberlain et al. (1984)a
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context Heatherington & Friedlander
(1990b)
Gender Mas et al. (1985)
Brown-Standridge & Piercy
\lyoo)
Heatherington & Friedlander
(1990b)
Newberry et al. (1991)
Shields & McDaniel (1992)
Participant Postner et al. (1971)a
role Dowling (1979)
Pinsof (1979, 1986)
Friedlander et al. (1985)b
Mas et al. (1985)
Changes over Postner etal. (1971)a
treatment Winer (1971)
Chamberlain et al. (1984)a
Cline et al. (1984)a
Laird & Vande Kemp (1987)"-°
Munton & Antaki (1988)*
Raymond et al. (1993) bc
Therapeutic episodes
Important Zuk et al. (1963)b
moments De Chenne (1973)d
Patterson & Forgatch (1985)d
a
Patterson & Chamberlain (1988)
Crits-Christoph et al. (1991) bc
Effective Johnson & Greenberg (1988)d
sessions Holloway et al. (1990)b'c'd
Gale & Newfield (1992) bd
Change Heatherington & Friedlander
events (1990af-d
Greenberg et al. (1993) ad
Friedlander et al. (1994)d
Relationship variables
Therapist Shapiro (1974)
responsiveness Sigal et al. (1967)a
Therapeutic Pinsof & Catherall (1986)
alliance Holtzworth-Munroe et al.
(1989)"
Bourgeois et al. (1990)"
Heatherington & Friedlander
(1990ba, 1990c)
Note. References listed on the same line were based
on the identical sample. Some references appear
more than once.
a
Client improvement was assessed objectively.
b
Master therapists were involved. c Client im-
provement was reported by therapists. d Speech
acts were observed within a higher order process unit.
393
tween "completer" and "noncompleter" cases
(p. 6). Families (N = 63) were seen by struc-
tural-strategic therapists for child-focused
problems. To compare families who discontin-
ued treatment prematurely with those who con-
tinued until an agreement about termination was
reached with the therapist, Shields et al. coded
selected speech acts using their Therapeutic In-
teraction Coding Scheme. Results showed that
the noncompleter cases were characterized by
more frequent attempts by family members to
structure the therapist and by more within-
family disagreements. By contrast, the com-
pleter cases were characterized by more thera-
pist structuring in response to family disagree-
ments and by more family dialogues about
problems.
Although each investigation relied on a dif-
ferent coding system, these results suggest, in
general, that defensiveness or resistance may be
predictive of premature termination. As several
reviewers of process research (e.g., Pinsof,
1989; Shoham-Salomon, 1990) have pointed
out, however, correlating speech acts with
global outcome in the absence of immediate
context can be problematic. We do not know,
for example, whether the defensive and resistant
acts by family members observed by Alexander
et al. (1976) and Chamberlain et al. (1984) were
directed toward one another or toward the ther-
apist. Nor did we know how the therapists in the
more successful families handled defensiveness
when it arose, as it most certainly must have
from time to time.
Common and distinctive features. A series
of studies by Friedlander and colleagues (Fried-
lander, Ellis, Raymond, Siegel, & Milford,
1987; Friedlander, Heatherington, & Wildman,
1991; Friedlander & Highlen, 1984; Fried-
lander, Highlen, & Lassiter, 1985) examined the
extent of similarity and dissimilarity in the in-
terventions of master theorists-therapists. In
Friedlander and Highlen (1984) and Friedlander
et al. (1985), the interventions of Nathan Ack-
erman, Murray Bowen, Don Jackson, and Carl
Whitaker were compared in BirdwhistelFs
(1969) Hillcrest Family Series, four films of
consultation interviews with one remarried fam-
ily (wife, husband, and 3 children). Like the
investigators of Carl Rogers, Albert Ellis, and
Fritz Perls in the well-known film series Three
Approaches to Psychotherapy (Shostrom,
1966), Friedlander and colleagues sought to
identify the interventions that distinguished
therapists with notably different theoretical on-
 394 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
entations. The assumption of this series of stud-
ies was that a microanalysis of the work of
master therapists could provide an important
perspective on the common and diverse aspects
of different approaches; by comparing experts'
work with a single family, one can attribute the
observed variations to differences in theoretical
approach rather than to the unique mix of family
and therapist.
In a subsequent, more extensive investiga-
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tion, Friedlander et al. (1987) compared the
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work of Salvador Minuchin and Carl Whitaker,
master therapists known for their theoretical
differences. Twelve representative sessions
were analyzed: six by Whitaker and six by
Minuchin. The interviews (most of which were
consultations) were selected to maximize diver-
sity in terms of family constellation, role and
age of identified patient, and presenting con-
cerns. In addition to identifying sources of con-
vergence and divergence in the two approaches,
the authors assessed the extent of therapist vari-
ability across families.
In two studies by Friedlander et al. (1985,
1987), a series of linguistic content analyses
were undertaken involving Pinsof's (1979,
1981, 1986) Family Therapist Coding System
and a measure of therapist response modes that
is not specific to family treatment. Results
showed, overall, remarkable similarities across
approaches as well as differences congruent
with theoretical differences. With respect to the
similarities, in both studies the therapists tended
to focus on individuals and dyads, particularly
the parental subsystem, and to be more con-
cerned with the present than either the future or
past. Relatively few references were made to
the family as an undifferentiated group, to ex-
tended family members, or to triangular rela-
tions among family members. In terms of re-
sponse modes, the Hillcrest therapists were
most similar in their use of requests and "infor-
mative directives" (Friedlander et al., 1985,
p. 171). They tended to avoid restatements, si-
lences, self-revealing, empathic, or confronta-
tive responses. In Friedlander et al. (1987),
Whitaker and Minuchin infrequently responded
with clarifications or reflections of feelings, en-
couragement, or reassurance, tending to rely
instead on requesting or providing information.
It is interesting that in both investigations, while
the therapists most often addressed themselves
to a single individual or subsystem, a sizable
proportion of interventions were "indirectly
routed, that is, addressed to someone other than
the target" of the intervention (Friedlander et
al., 1985, p. 177). The authors suggested that
indirectness may be an important strategy that
cuts across approaches to family therapy.
Friedlander et al. (1987) also observed the
extent of therapist variability across diverse
families. Despite the heterogeneity of families
sampled, results showed remarkable consis-
tency for both Whitaker and Minuchin. The
greatest variability was in the therapists' activ-
ity levels. Both therapists also varied across
families in terms of the extent of here-and-now
focus, the extent of directness and indirectness,
the amount of information provided to the fam-
ily, and the amount of focus on parental sub-
systems. The authors speculated that the factor
accounting for these differences across families
may be the therapist's judgment of the family's
readiness for change.
Another, more systemically based perspective
on theoretical convergence was provided by
content-free analyses of the Hillcrest films and
of the Minuchin and Whitaker consultations.
Interactional frequencies (who-talks-to-whom)
were subjected to multidimensional scaling
(MDS) to provide "a spatial representation of
the 'hidden' structure in the communication
patterns" (Friedlander & Highlen, 1984, p.
477). In contrast to the other, more traditional
comparative analyses of frequencies or propor-
tions of process variables, MDS provides as
output a geometric configuration—a spatial
map—in which distances between points are
derived from the observed measure of proxim-
ity or relatedness. For each interview a proxim-
ity matrix was generated, which consisted of the
proportion of interactions between each pair of
participants in the session (e.g., mother-father,
mother—therapist, father-therapist, and so on).
More frequent interactions were assumed to re-
flect greater interpersonal closeness; less fre-
quent interactions, more distance.
In the Hillcrest study (Friediander & Highlen,
1984), the four maps showed many similarities,
and correlations of the MDS solutions were
significantly positive, particularly the Acker-
man and Whitaker sessions (.75) and the Bowen
and Jackson sessions (.99). Interpretation of the
maps was based on the therapists' postsession
impressions of the family. Comparison of two
sessions by Minuchin and two by Whitaker
showed both therapists clearly in the midst of
the family and most closely aligned with the
problem clients and their parents (Friedlander et
al., 1987). Whereas the position of the therapists
 PROCESS OF FAMILY THERAPY 395

in the two MDS studies differed somewhat, in Palazzoli). The focus was the relational control
both investigations the major determinants of dynamics between therapists and family mem-
interpersonal closeness or distance seemed to be bers. Relational control is an interactional vari-
the extent of psychological disturbance and the able, reflecting how verbal messages are deliv-
nature of the subsystem alliances. ered and responded to; and relational control
Many (but not all) of the distinctive features patterns, based on the Family Relational Con-
of the interviews tended to be congruent with trol Communication Coding System (FRCCCS;
theoretical differences. In his Hillcrest inter- Friedlander & Heatherington, 1989; Heather-
view, Bowen made relatively few references to ington & Friedlander, 1987), are assumed to
the session itself, concentrating more on the reflect the reciprocal nature of the participants'
past and on the families of origin than did the social relationship (Ericson & Rogers, 1973).
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other Hillcrest therapists. While these findings As hypothesized, in both approaches comple-
were consistent with Bowen's insight-oriented mentary relational control patterns predomi-
multigenerational emphasis, one unexpected nated, with therapists from both camps most
finding was the relative infrequency of interpre- often assuming a "one-up" position and family
tations. Don Jackson, in line with his interac- members assuming a "one-down" position.
tional, pragmatic approach to family problems, Other FRCCCS indices showed considerable
emphasized the parental subsystem and focused divergence, however. Consistent with the re-
on dyadic and triadic relations more so than did spective theories, the systemic therapists en-
Bowen, Ackerman, or Whitaker. Whereas the gaged in proportionately more complementarity
spatial maps of Bowen's and Jackson's sessions than did the structural therapists, probably be-
suggested therapist alignment with the parents cause of their greater use of question and an-
and distance from the children, the alliances in swer sequences. By contrast, the structural ther-
the MDS maps with Whitaker, Ackerman, and apists engaged in more competitive symmetry
Minuchin were notably more unclear. Consis- with family members. Systemic therapists en-
tent with his psychodynamic heritage, Acker- couraged or permitted significantly less within-
man focused more on the unique experiences of family interaction, and structural therapists
individuals than on dyadic or triadic relations. It intervened in more overtly controlling and un-
is of interest, however, that few of Ackerman's balancing ways by, for example, ordering, in-
responses were geared toward the past; rather,
structing, interrupting, praising, and supporting
Ackerman led the group of Hillcrest thera-
family members either directly or indirectly.
pists in the use of here-and-now interventions.
Systemic therapists, as expected, used more
Whitaker, observed in both investigations, also
neutral indirect communications.
tended to comment on the here-and-now. In
contrast to the other therapists and consistent The conclusions of the studies just reviewed
with his writings, Whitaker commented less on need to be considered in light of several limita-
the past, focusing more on the present situation, tions. First, because all of the sessions analyzed
on the therapeutic system and his own reac- in this line of research were published or tran-
tions, and on the unique experiences of individ- scribed from videotapes made available to pro-
ual family members. Finally, compared with fessional audiences, the representativeness of
Whitaker, Minuchin focused more on the paren- each master therapist's behavior can be ques-
tal subsystem and used more confrontation, in- tioned. Second, these data do not provide infor-
terpretation, direct guidance, and advice. These mation about change over time, either within or
differences were seen as reflecting Minuchin's across sessions, or about the ultimate (or imme-
more explicit focus on executive functioning diate) effectiveness of the distinctive or com-
and his well-known techniques of reframing, mon features of these therapists' behaviors. As
challenging the family's reality, and activating Alexander (1988) suggested, different interven-
within-session change. tions are likely to be powerful at different points
In a more recent study, Friedlander et al. in treatment. Third, each of these studies reports
(1991) compared the consultative work of three frequencies or proportions of speech acts. As
leading structural therapists (Charles Fishman, other reviewers have pointed out (e.g., Pinsof,
Ron Liebman, and Salvador Minuchin) with 1989; Shoham-Salomon, 1990), information
those of three Milan systemic therapists (Luigi about the aggregate of variable X can be mis-
Boscolo, Gianfranco Cecchin, and Mara Selvini leading in the absence of immediate context.
 396 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
Treatment context. We located only two
studies that compared speech act variables in
different treatment contexts. First, Chamberlain
et al. (1984) examined differences in self-refer-
ral versus agency referral in 18 families who
completed a behavioral treatment for child man-
agement problems. Agency-referred families
were observed to engage in more resistant ver-
bal behaviors than did self-referred families. No
information was provided, however, about the
processes of change in those agency-referred
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families who were able to complete treatment
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successfully.
Second, Heatherington and Friedlander
(1990b) examined differences in relational con-
trol patterns using the FRCCCS in couple ver-
sus family contexts. The therapists were expe-
rienced staff at an outpatient family therapy
center of a large teaching hospital. Results
showed no meaningful differences by treatment
modality. Complementarity (i.e., therapist
one-up and family member one-down) was the
predominant control pattern in both contexts. It
would not be wise to conclude, however, that
there were no meaningful therapist—client dif-
ferences in the two treatment formats. Only a
single coding system was used, and it is likely
that there are differences in other, possibly more
salient, indexes of the therapeutic process.
Gender. Five investigations of the relation-
ship between participants' gender and therapeu-
tic processes have considered the degree to
which, early in treatment, male and female sex-
typed behaviors are observable in family treat-
ments. This question is important because if
stereotypically masculine and feminine behav-
iors tend to be modeled by family therapists and
expected of their clients (Luepnitz, 1988), ther-
apy may reinforce the traditional views of fam-
ily life that are particularly damaging to women.
Findings from two studies disconfirm this
traditionality hypothesis. First, with respect to
modes of expression, Newberry, Alexander, and
Turner (1991) reported that, in the first session
of Functional Family Therapy, male and female
student therapists did not differ in the extent of
overall structuring (a stereotypically masculine
behavior) or supportiveness (a stereotypically
feminine behavior) toward family members. In-
deed, female therapists in this study tended to
respond to client supportiveness with structur-
ing more so than did their male counterparts.
Second, in an earlier study of Functional Family
Therapy, male therapists in training spoke more
in the affective mode of experience than did
their female counterparts (Mas, Alexander, &
Barton, 1985).
These results should be juxtaposed against
other research, conducted in different settings
with more experienced therapists, in which the
findings were consistent with the traditionality
hypothesis. Shields and McDaniel (1992) found
that, in structural-strategic therapy, male thera-
pists tended to behave in a more instrumental,
directive manner by talking more and providing
more explanations when family members tried
to take charge or disagreed with them than did
female therapists. (No differences were ob-
served, however, in the retention rate of families
seen by male versus female therapists.) In
Heatherington and Friedlander's (1990b) early
sessions of systemic—strategic therapy, experi-
enced therapists of both genders tended to en-
gage in therapist one-up and family member
one-down complementarity (on the FRCCCS)
somewhat more frequently with female clients
than with male clients. Shields and McDaniel
did not, however, report differences in thera-
pists' behaviors by client gender, and Heather-
ington and Friedlander did not consider the gen-
der of the therapists, most of whom were men.
Nor did either research team analyze therapist
behaviors directed to husbands versus those di-
rected to wives within a given family.
When family members are the focus, evi-
dence from two studies suggests that early ses-
sions are characterized by interactions consis-
tent with traditional gender roles. First, Shields
and McDaniel (1992) found that family mem-
bers were more likely to disagree among them-
selves with female therapists than with male
therapists. With male therapists, family mem-
bers were more likely to make structuring state-
ments. The authors concluded that "[fjamily
members may elicit different behavior from
male versus female therapists because of their
own gender-based expectations" (Shields &
McDaniel, 1992, p. 149).
Second, in a study of marital therapy, Brown-
Standridge and Piercy (1988) examined hus-
bands' and wives' responses to the therapist's
use of reflections versus reframing. Thirteen
couples were seen by six experienced family
therapists; two early sessions from each treat-
ment were selected for coding. The Brown-
Standridge Marital Therapy Interaction Scale
was used to code client behaviors in the 20 s
surrounding reframing (i.e., challenge) and re-
 PROCESS OF FAMILY THERAPY
flection (i.e., understanding) identified as "ef-
fective" by the senior author and subsequently
confirmed by another observer.
Brown-Standridge and Piercy (1988) found
that when the husbands' behaviors were
"closed" (p. 210), the therapists tended to use
reflections; this was not the case, however,
when the wives' behaviors were closed. Follow-
ing therapist interventions, husbands tended to
respond more positively to reframing and wives
tended to respond more positively to reflecting.
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However, qualitative analyses of the therapists'
written responses to a series of questions about
their implicit decision rales for the use of re-
flection versus reframing showed that 80% of
the therapists denied having behaved differently
with husbands and wives.
Caution is necessary, however, in generaliz-
ing from these results because little information
was provided about the authors' criteria for
effective reframing and reflection. The study
was distinguished, on the other hand, in its
analysis of sequential behaviors and in its com-
bined use of qualitative and observational data.
Participant role. Two investigations con-
trasted the behaviors of parents and children in
family therapy. In Mas et al.'s (1985) study of
gender effects as well as in Friedlander et al.'s
(1985) comparison of the Hillcrest sessions,
parents tended to speak far more often than
children. The adolescents in Mas et al. ex-
pressed themselves in terms of agreement or
disagreement more so than did their parents,
and they tended to be more verbal with male
therapists than with female therapists. In the
Hillcrest interviews, the children's participa-
tion rates varied widely across therapists, as
did the degree to which they spoke about
parent-child, sibling, or marital relations in
the family. Compared with their parents, the
Hillcrest children made notably fewer refer-
ences to the past.
Only one of the studies that examined the
interaction of process variables and client role
took into account treatment outcome. Postner,
Guttman, Sigal, Epstein, and Rakoff (1971) re-
ported that in their group with good outcomes,
fathers were addressed more often. In the group
with poor outcomes, however, mothers tended
to be the primary targets of the therapists' in-
terventions. Overall, therapists (a) spoke signif-
icantly more often to parents than to children
and (b) tended to consistently address one par-
ent over the other.
397
Only two studies contrasted the behaviors of
therapists as a function of their role (i.e., ther-
apist vs. cotherapist, trainee vs. supervisor).
First, Dowling (1979) analyzed the verbal be-
haviors of five therapists who interacted in 10
different cotherapist pairs at three points in
treatment. Results showed that therapists be-
haved similarly with different cotherapists (and
with different families). Second, Pinsof (1979,
1986) compared the interventions of eight fam-
ily therapy trainees with those of their supervi-
sors. The procedure was unique in that the su-
pervisor observed the trainee's session (either
an intake or a second interview) from behind a
one-way mirror for 20 min, then joined the
trainee and conducted the remainder of the in-
terview with the trainee present but silent. Us-
ing his Family Therapist Coding System, Pinsof
(1979, 1986) compared the interventions of
trainees and supervisors and concluded that
trainees worked more intrapersonally and that
supervisors worked more interpersonally. That
is, whereas the trainees focused more on the
opinions and beliefs of individual family mem-
bers, the supervisors focused more on behav-
ioral sequences and family communication pat-
terns. The supervisors also tended to use a wider
range of responses: They were more active and
explicit, more here-and-now focused, and more
interpretive and supportive. These differences
cannot uniquely be attributed to therapist role,
however, because of differences in the observa-
tion situation as well as in therapist experience
and skill (Pinsof, 1979).
In addition to comparing the behaviors of
trainees and supervisors, Pinsof (1986) ob-
served changes in behavior common to both
groups over the course of one session. Trainees
and supervisors alike increasingly emphasized
the clients' behaviors and focused on the future,
on the parents, and on the therapy itself; they
also used more indirect and more cyclical inter-
ventions as the session progressed.
None of these investigations considered the
sequential responding of therapist-to-family
member, or vice versa, or the specific patterns
of interactions between and among family
members. Nor did any of these studies take into
account the functional role of family members
(e.g., parental child, homemaker, or income
provider). It may be that family members' func-
tional roles, which reflect differences in status
and power, are important predictors of family
therapy dynamics.
 398 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
Changes over treatment. In five studies,
changes in the frequency of client (Chamberlain
et al., 1984; Munton & Antaki, 1988; Winer,
1971) and/or therapist (Cline, Mejia, Coles,
Klein, & Cline, 1984; Postner et al., 1971) re-
sponse were observed over time. Sequences of
therapist-client interactions were only ob-
served in two case studies of successful struc-
tural family therapy (Laird & Vande Kemp,
1987; Raymond, Friedlander, Heatherington,
Ellis, & Sargent, 1993). The studies of family
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behavior are reviewed first, followed by those
This document is copyrighted by the American Psychological Association or one of its allied publishers.
involving therapist behavior and therapist-
client interactions.
First, Chamberlain et al. (1984) studied vari-
ability in client resistance and cooperativeness
in behavioral family therapy on the basis of
observations of six videotaped sessions at three
points in treatment. Resistance was defined as
interrupting or challenging the therapist, dem-
onstrating a negative attitude, pursuing an indi-
vidual agenda, disqualifying another, not pay-
ing attention, and so forth. The authors found
that early resistance predicted midtreatment
resistance. Indeed, the highest levels of resis-
tance tended to occur during the middle phase
of therapy. Furthermore, the more highly re-
sistant families had a greater dropout rate and
tended to be perceived as less successful by
their therapists.
Postner et al. (1971) also examined family
verbal behavior in relation to outcome. Twenty-
min excerpts were analyzed at four points in
treatment for 11 families. In addition to partic-
ipation rates, family members' speech acts were
coded with respect to three emotional states:
emergency (fear, anger, anxiety, sadness, and
dependence), welfare (happiness, joy, tender-
ness, love, sympathy, and support), and neutral
(information only). Outcome was identified as
"good" or "poor" on the basis of the indepen-
dent perceptions of three judges who observed
pre- and posttreatment interviews and rated
each family for overall change, affective in-
volvement, affective communication, and affec-
tive expression.
Results showed that, over the course of treat-
ment, family members tended to speak increas-
ingly among themselves and less frequently to
the therapist. Overall, the findings suggested
that the process of family therapy involves
enhanced affective involvement of family
members. Although variations in emotional re-
sponses during the therapy were not signifi-
cantly predictive of outcome, welfare state-
ments among family members tended to
increase over time, demonstrating changes in
family members' ability to "express affection,
sympathy, and pleasure" (Postner et al., 1971,
p. 463). Family members' speech also tended to
be less neutral and to involve increasing levels
of emergency emotions. The most significant
change in emotional expression tended to occur
between the second and sixth sessions.
Two investigations (Munton & Antaki, 1988;
Winer, 1971) were focused not on clients' emo-
tional states but on their cognitive change.
In the earlier study, Winer (1971) observed
changes in the frequency of / statements by
couples in a multiple family group treatment
led by Murray Bowen. The use of the / pro-
noun was assumed, based on Bowen's theory
(Bowen, 1978), to reflect an increase in differ-
entiation of self, that is, the ability to separate
and balance thinking and feeling and to tolerate
closeness and separateness from others. Winer
assumed that increases in / statements along
with decreases in the use of we, our, and us
pronouns would "reflect less intense, symbiotic
involvement in the family system" (p. 245).
Speech acts in the first two or three available
recordings of 4 couples were compared with
those in three later sessions. As predicted, a
greater proportion of / statements was observed
in the later sessions, with more we, our, and us
statements in earlier sessions. Further support-
ing Bowen's theory, results indicated that in the
early sessions the ratios of / to we, our, and us
pronouns by husbands and wives were highly
similar, "showing almost a mirror pattern"
(Winer, 1971, p. 241), whereas in later sessions
there were wide discrepancies, suggesting
greater differentiation between the spouses.
Munton and Antaki (1988) compared attribu-
tional changes in the speech acts of their most
successful versus their least successful families
(N = 10). The global outcome of brief therapy
(M = 7.7 sessions) was assessed by therapists.
Attributional statements were extracted and
coded from the first and last sessions of each
treatment. These attributions were then cate-
gorized on five dimensions: stable-unstable,
global-specific, internal-external, personal-
universal, and controllable—uncontrollable.
None of the authors' hypotheses was supported,
although two interesting observations were
noted. First, families with poor outcomes
tended to perceive their problems to be stable
 PROCESS OF FAMILY THERAPY
early and late in treatment more so than did the
families with good outcomes. Second, regard-
less of outcome, family members tended to
make more internal and personal attributions of
other family members over time. Munton and
Antaki speculated that attributional change does
not occur in "any straightforward way" (p. 96)
in therapy and that averaging across family
members or across families can obscure impor-
tant individual changes in attributions.
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With respect to therapist behavior, Postner et
This document is copyrighted by the American Psychological Association or one of its allied publishers.
al. (1971) found that therapists rarely spoke to
more than one family member at a time and that
therapists did not vary significantly in their
speech rate over the course of treatment, al-
though therapist variability across families was
more pronounced. Therapists spoke increas-
ingly more often in the group with good out-
comes, and they tended to focus increasingly on
a single family member, generally the most
verbal parent. With respect to type of response,
all interventions were categorized by observers
as either drive or interpretation on the basis of
intent. Drive was defined as the therapist's aim
to stimulate interaction, obtain information, or
provide support, and interpretation referred to
the therapist's intent to clarify underlying mo-
tives, further understanding, generalize, or sug-
gest alternative behaviors. The authors observed
a significant decrease in the drive to interpreta-
tion ratio by therapists overall; this change was
more marked in the group with good outcome
than in the group with poor outcome. In other
words, a change in the direction of fewer drive
responses relative to interpretation responses
may be predictive of successful treatment.
In a large-scale marital outcome study, Cline
et al. (1984) tested the degree to which changes
in couples' behaviors from early to late in ther-
apy could be predicted from therapist behaviors.
Seventy-seven couples were treated by 19 ex-
perienced male therapists, each of whom was
assigned 2 couples each from a low and a mid-
dle socioeconomic status (SES) group. Using
Alexander et al.'s (1976) rating system for ther-
apist modes of expression and a coding system
for client behavior that was modified from the
original Marital Interaction Coding System
(MICS; Hops, Wills, Patterson, & Weiss, 1972
[cited in Cline et al., 1984]), 10-min excerpts
were sampled from the first two and the last two
sessions in each treatment. Comparisons were
made of participants' behaviors (therapists,
wives, and husbands) within each of the SES
399
groups. The process data were analyzed by
correlating the early-to-late change scores in
the couples' behaviors (MICS) with therapist
modes of expression and behaviors averaged
across the two time periods. Outcome was
assessed posttherapy and at 3- and 6-month
follow-ups by means of several client reports of
marital adjustment and satisfaction. At termina-
tion therapists provided an evaluation of im-
provement or deterioration in 12 areas of mar-
ital functioning.
Results indicated notable differences between
the husbands and the wives within each SES
group. For couples in the middle SES group,
therapist directiveness was negatively corre-
lated with outcome at each assessment point.
Furthermore, directiveness was inversely asso-
ciated with increases in positive behaviors (e.g.,
acceptance, agreement, approval, and accepting
responsibility) over time. Couples in the middle
SES group tended to increase their expressions
of feelings when the therapists were less direc-
tive and when they used more reflections and
probes for affect. This pattern was, however,
notably more pronounced for husbands than for
wives.
The couples in the low SES group seemed to
have experienced the process differently. Ther-
apist directiveness was predictive of increased
positive behaviors on the part of these couples,
and directiveness predicted successful out-
come from the wives' perspective. For the hus-
bands, "directive questions that explore affect
and reflecting statements related to affect"
(Cline et al., 1984, p. 702) were most predictive
of outcome.
In summary, the major difference between the
two SES groups lay in how the husbands expe-
rienced the therapy, as the patterns were more
apparent for them than for their wives. Whereas
the husbands in the low SES group were seem-
ingly affected more by understanding the dy-
namics in their marriage without changing their
actual communication styles, husbands in the
middle SES group may have been helped by
expressing their feelings, so that gradually the
couple's communication style improved (Cline
et al., 1984).
In Cline et al.'s (1984) investigation, process
variables were correlated with one another or
used to predict outcome. Although therapist di-
rectiveness was significantly correlated with
positive client behavior for some couples, this
finding does not mean that directiveness was
 400 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
followed by positive client behavior. In only
two studies in the group that studied change
processes over time were sequences of behavior
observed. Both of these investigations (Laird &
Vande Kemp, 1987; Raymond et al, 1993)
were case studies in which well-known thera-
pists at the Philadelphia Child Guidance Clinic
treated families with an adolescent daughter
suffering from anorexia nervosa.
In the earlier research, Laird and Vande
Kemp (1987) tested several hypotheses about
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changes in Salvador Minuchin's responses to
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family members over time and changes in their
responses to him. Responses were identified as
either complementary or noncomplementary on
the basis of observers' coding of reciprocal ver-
bal exchanges between Minuchin and family
members in 20-min segments of an early, a
middle, and a late session. Interpersonal inter-
actions were identified on the basis of the cod-
ing of reciprocal speech acts involving the
Structural Analysis of Social Behavior (SASB;
Benjamin, 1974). Complementarity was defined
as (a) opposing behaviors with respect to focus
(one speaker focuses on self, the respondent
focuses on other) and (b) similar behaviors with
respect to affiliation and interdependence. The-
oretically, whereas complementary responses
are rewarding for both parties, noncomplemen-
tary responses are considered to be challenging;
in order to build trust and rapport in the initial
stage of therapy, therapists should respond in a
complementary fashion (Carson, 1969). How-
ever, to help clients modify their maladaptive
interpersonal styles, therapists should adopt a
noncomplementary style in the middle phase of
treatment.
Results supported Laird and Vande Kemp's
(1987) hypotheses that (a) Minuchin would re-
spond to family members with higher levels of
complementarity in the early and late stages of
treatment than in the middle stage and that (b)
therapist complementarity would be negatively
associated with immediate client change. Over-
all, these results indicated that Minuchin's non-
complementary behavior, particularly in the
middle stage of treatment, was predictive of
subsequent changes in family members' re-
sponses toward him. (Family members' re-
sponses toward one another were not observed.)
Indeed, the descriptive results suggested that
Minuchin was more variable in his responses in
the middle stage and used more "focus on self
responses in the termination phase. Across time,
his SASB responses tended to be "affirming,"
"understanding," "nurturing," "helping," and
"protecting." It is interesting that one finding
could be interpreted as supportive of the gender
traditionality hypothesis (see earlier section on
Gender). Laird and Vande Kemp (1987) ob-
served that Minuchin responded in a non-
complementary manner to both the mother and
the daughter with anorexia after these women
used either asserting or separating responses.
In the second case study (Raymond et al.,
1993), John Sargent, well-known for his inpa-
tient work with families who have members
with chronic anorexia, conducted (with a co-
therapist) 15 sessions of family treatment over a
3-week period. Based on the FRCCCS (Fried-
lander & Heatherington, 1989), relational con-
trol patterns between Sargent and each of 3 key
family members (mother, daughter, and father)
and among the 3 clients were observed, and
MDS spatial maps (cf. Friedlander & Highlen,
1984; Friedlander et al., 1987) of each session
were generated on the basis of all participants'
interactional frequencies.
Consistent with earlier research (Heathering-
ton & Friedlander, 1990b) on relational control
dynamics with the FRCCCS, therapist one-up
and family member one-down complementarity
predominated throughout this case.2 With the
identified patient, this pattern was observed
more frequently in the early and late phases of
treatment than in the middle, or restructuring,
stage. The MDS maps showed that Sargent
maintained a central position in the system
throughout treatment, with the cotherapist being
more peripheral. Hypothesized changes in with-
in-family alliances were not evident in the
maps, however.
Overall, Raymond et al.'s (1993) findings did
not confirm the majority of their theory-based
hypotheses, particularly those concerning
changes in family behavior over time. Further-
more, despite the structural emphasis on fam-
ily enactment (Minuchin, Rosman, & Baker,
1978), there was surprisingly little within-
family interaction throughout; family members
addressed each other, on average, only 22% of
the time.
2
Interpersonal complementarity and relational
control complementarity are not identical. In Fried-
lander's (1993) review of complementarity in brief
individual and family therapy, the similarities and
differences are discussed at length.
 PROCESS OF FAMILY THERAPY
A close inspection of the family's relational
control patterns, however, suggested that some
changes in the family's rigid communication
style may have taken place (Raymond et al.,
1993). Specifically, the parents were observed
to engage in more competitive symmetry over
time, possibly reflecting a struggle for control
between them. At the same time, the competi-
tive symmetry between the daughter with an-
orexia and each parent decreased over time.
Raymond et al. (1993) speculated that these
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shifts might reflect less detouring or conflict
avoidance on the part of the parents and a con-
sequent "'detriangling' of the symptomatic
child" (p. 323).
Raymond et al. (1993) also tested the hypoth-
esis that, because the goal of structural treat-
ment is to disrupt communication patterns that
reflect boundary violations or cross-genera-
tional triangulation, the therapist and cother-
apist would intervene immediately by inter-
preting or confronting these behaviors or by
educating or coaching the family toward more
functional communication. Based on the
FRCCCS, the following speech acts were iden-
tified: (a) attempts by the daughter to intervene
in her parents' conversations with each other,
(b) messages from the daughter in which the
daughter supported one parent while challeng-
ing the other, or (c) messages from either parent
in which the parent supported the daughter
while challenging the spouse. Surprisingly, only
three such instances were observed over the
course of the entire 15-session treatment. On
each of these occasions, however, the therapists
did respond immediately, as predicted. Their
interventions either "redirected the conversa-
tion, . . . provided information, direct guidance
or advice, o r . . . sought information from family
members in a highly structuring, one-up man-
ner" (Raymond et al., 1993, p. 322).
The question addressed in these seven studies
(how does change occur over time in successful
treatment) has been studied in a number of
ways. Unfortunately, however, because each in-
vestigator adopted a different perspective on the
therapeutic process, there is little accumulated
knowledge to answer this important question.
Only one study (Cline et al., 1984) used more
than a single coding system, but the categories
were global and atheoretical, and the interjudge
reliabilities were at best fair ( < .60) for the
majority of variables under study. Furthermore,
with a few exceptions, the coding systems used
401
have little known validity. In the absence of
validity information, the assumption that, for
example, increased usage of personal pronouns
(I, mine, etc.) reflects greater differentiation of
self (Winer, 1971) or that increased welfare
statements among family members (Postner et
al., 1971) signal greater closeness or better re-
lations should be questioned.
Both case studies of structural therapy did use
valid, theoretically based measures, the SASB
in Laird and Vande Kemp (1987) and the
FRCCCS in Raymond et al. (1993). Each inves-
tigation involved the treatment of a family who
had a child with anorexia by an expert structural
therapist. The degree of generalizability of the
results of these studies to other families, thera-
pists, and theoretical orientations is, however,
unknown.
Finally, in only one of the seven studies that
tested changes over time (Raymond et al., 1993)
was every session in the treatment analyzed in
entirety. Drawing conclusions about shifts over
time when short (10-20 min) segments are
sampled at two (Cline et al., 1984; Munton &
Antaki, 1988; Winer, 1971), three (Chamberlain
et al., 1984), or four (Postner et al., 1971) points
in time is questionable (Spector, Guttman,
Sigal, Rakoff, & Epstein, 1970). The method of
using proportions of therapist behaviors to pre-
dict proportions of client behaviors (Cline et al.,
1984; Postner et al., 1971) is also problematic
(Shoham-Salomon, 1990). Because this kind of
analysis does not take into account the context
of these behaviors or their sequential patterns
(i.e., therapist—client-therapist interactions), the
results can misleadingly suggest causation
(Pinsof, 1981).
Therapeutic Episodes
In research at the speech act level of the
therapy process, all behaviors occurring during
the sample—be it a segment, a session, or an
entire treatment—are observed. Frequencies or
proportions of these behaviors are compared or
used to predict treatment outcome. In research
at the episode level, by contrast, the assumption
is that not all speech acts are of equal impor-
tance. By limiting study to behaviors that
surround clinically meaningful moments, the
researcher hopes to elucidate the actual mecha-
nisms of therapeutic change (Greenberg, 1986;
Greenberg & Pinsof, 1986a).
 402 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
An early study of marital therapy demon-
strates the value of this approach. De Chenne
(1973) questioned whether clients experience
greater feeling in response to the therapist or in
response to their spouse. Tape recorded, hour-
long sessions with 9 couples were sampled from
a Catholic outpatient service. Trained raters ap-
plied the Experiencing Scale (Klein, Mathieu,
Kiesler, & Gendlin, 1969) to each client state-
ment. When experiencing levels were averaged
across speech acts, no differences were ob-
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served. However, a clinically and statistically
This document is copyrighted by the American Psychological Association or one of its allied publishers.
significant pattern was observed when each
client's "peak" moments of experiencing were
compared. The latter results supported De
Chenne's hypothesis. As predicted, greater
emotional experiencing followed therapist
statements than spousal statements.
In one variant on the events approach, behav-
iors that immediately precede or follow impor-
tant therapeutic moments are studied. In addi-
tion to De Chenne (1973), one study involved
frequent crying (Crits-Christoph et al., 1991),
one involved inappropriate laughter (Zuk,
Boszormenyi-Nagy, & Herman, 1963), one in-
volved noncompliance (Patterson & Forgatch,
1985), and one involved family conflict (Patter-
son & Chamberlain, 1988). In a second variant
on the events approach, effective sessions are
intensively studied, with the aim of identifying
clinically meaningful change processes. We
located three studies of this variety (Gale
& Newfield, 1992; Holloway, Wampold, &
Nelson, 1990; Johnson & Greenberg, 1988). In
still another variant on the events approach, task
analysis (Rice & Greenberg, 1984), the re-
searcher operationally defines a therapeutic ep-
isode with a clinically identifiable task that
is successfully resolved during the session
(Greenberg, 1984, p. 124). We located two such
research programs, one concerning the expres-
sion of affect in emotionally focused therapy
(EFT; Greenberg & Johnson, 1988) for couples
(Greenberg, Ford, Alden, & Johnson, 1993) and
one concerning family engagement in problem
solving (Friedlander, Heatherington, Johnson,
& Skowron, 1994; Heatherington & Fried-
lander, 1990a).
Important moments. In Crits-Christoph et
al.'s (1991) case study of family therapy,
"Suzie," a 17-year-old with superlabile diabe-
tes, exhibited a symptom of frequent, immature
crying that seemed related to her going into
diabetic acidosis. The 10-session family treat-
ment, conducted by Salvador Minuchin at the
Philadelphia Child Guidance Clinic, was geared
toward increasing Suzie's control over her cry-
ing and her physical condition. Twenty-five
400-word segments (immediately before ,and
immediately after a crying moment) were
compared with 27 control segments. All vid-
eotaped segments were transcribed and rated
on a variety of individual and interpersonal
indicators.
Compared with the control segments, in the
segments preceding Suzie's crying, the only
uniquely significant precipitant was a family
discussion about Suzie's difficulties, illness, or
shortcomings. Comparisons were also under-
taken of the pre- and postcrying moments. Re-
sults suggested that following her crying, Suzie
asserted her opinion more, her mother spoke
less, and the therapist tended to become more
active and assertive. Over the course of treat-
ment, the level of family discussion about
Suzie's difficulties increased, only to drop off
sharply at the end of treatment. At follow-up,
Suzie was reportedly asymptomatic and demon-
strated age appropriate maturity.
Crits-Christoph et al. (1991) hypothesized
that by reinforcing the daughter in her role of a
weak, sickly baby, the parents were able to
avoid their own conflicts. According to the au-
thors, in many families "a difficult social con-
text leads to the identified patient feeling bad
and unable to cope, which then may lead to the
symptom" (Crits-Christoph et al., 1991, p. 343).
The fact that no intrapsychic variables uniquely
predicted Suzie's crying moments was offered
as support for the family systems perspective on
individual symptomatology.
In Zuk et al.'s (1963) case study, a 23-year-
old woman with schizophrenia frequently ex-
hibited bizarre laughter that appeared to be
"unrelated in meaning to the social situation"
(p. 303). To determine whether the laughter was
precipitated by the woman's "intrapersonal fan-
tasies" (p. 303) or by the ongoing therapy situ-
ation, Zuk et al. (two of whom were the thera-
pists) calculated the frequency of laughter for
each family member along with the time inter-
val of the laughter, the "trigger person," and the
recipient of the laughter.
Results showed that, over the course of 13
sessions, the amount of laughter varied system-
atically by person, by time interval, and by
trigger. The mother and father tended to laugh
most in the first 15 min of the session, whereas
 PROCESS OF FAMILY THERAPY
the daughter laughed most in the third 15-min
interval. Zuk et al. (1963) concluded that the
seemingly bizarre laughter of the daughter with
schizophrenia was not devoid of meaning and
was, on some level, a reaction to the therapy
session. (The daughter was least anxious in the
initial 15-min segments, when structuring of the
session took place, but she was most anxious in
the last 15 min, when deeper thoughts and feel-
ings tended to be explored.) Alternatively, the
reversal of patterns of laughter between the
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parents and their daughter suggested that
"laughter was a device by which the family
members monitored each other's tension or
anxiety states" (Zuk et al., 1963, p. 312).
In a series of six case studies of behavior
therapy for serious child management problems,
Patterson and Forgatch (1985) coded all in-
stances of parental noncompliance (mothers
only). Results confirmed their hypotheses; In
the majority of cases, the conditional probabil-
ity of noncompliance following therapist teach
or confront interventions was significantly
higher than was the base-rate probability. In
contrast, in all 6 dyads, therapist support or
facilitate interventions were followed by de-
creases in noncompliance. Mixed results were
found for the therapist's use of reframe inter-
ventions. These responses were followed by
significantly increased noncompliance in 4 fam-
ilies but by significantly decreased noncompli-
ance in another family.
In a larger sample from the same child man-
agement project, Patterson and Chamberlain
(1988) identified moments of "mother and fa-
ther within-session conflict" (p. 217). The re-
sults of path analyses suggested that "forces
outside the therapy session such as parental
stressors, marital conflict, and depression ap-
pear to increase the within-session conflict
among family members" (Patterson & Cham-
berlain, 1988, p. 216). This is the only study we
located in which outside-of-therapy behaviors
were used to predict in-session behaviors. Of
more importance, perhaps, was that greater in-
session conflict was directly associated with
higher antisocial scores for the children (a com-
posite of teacher, parent, and child self-report
ratings and home observation data). Patterson
and Chamberlain concluded that an essential
aspect in the treatment of such children is to
design interventions that focus on reducing pa-
rental stressors and marital conflict outside the
session.
403
Effective sessions. Three studies of marital
therapy were located in which effective sessions
were intensively analyzed. The earliest investi-
gation was an observational study of brief EFT
with 6 couples. Johnson and Greenberg (1988)
examined change processes in the "best" ses-
sions, as rated by therapists. Three couples re-
ported improvement in marital satisfaction post-
treatment, whereas 3 couples reported minimal
improvement. All verbal statements in the latter
half of the six sessions were coded with respect
to quality of interaction on the SASB (Ben-
jamin, 1974) and level of experiencing on the
Experiencing Scale (Klein et al., 1969).
Comparisons showed proportionately more
affiliative and autonomous responses among the
more successful couples, along with higher lev-
els of emotional experiencing. Further analyses
showed that, in the successful group, the spouse
taking the "blaming position" (Johnson &
Greenberg, 1988, p. 179) scored significantly
higher on the Experiencing Scale and used
proportionately more affiliative, autonomous
responses. The latter results supported the au-
thors' theoretically based hypothesis that "soft-
ening" (Johnson & Greenberg, 1988, p. 181) is
an important change process in couples treat-
ment, one that may distinguish successful from
unsuccessful cases. In EFT, softening occurs
"when a blaming dominant spouse accesses vul-
nerability and asks for closeness or comfort
from a previously distant partner" (Johnson &
Greenberg, 1988, p. 176).
The two remaining studies of effective ses-
sions concerned systemic—strategic therapy.
First, Holloway et al. (1990) analyzed a suc-
cessful session with a paradoxical prescription
for insomnia. The therapist, Gerald Weeks, is
well-known for his work with paradox. His in-
tervention involved refraining the wife's insom-
nia to reflect the couple's interpersonal dynam-
ics. (An earlier prescription to change her
sleeplessness to voluntary control had been un-
successful.) Using a measure of "power and
involvement" in the manifest and latent content
of verbal behavior (Penman, 1980), Holloway
et al. coded all interactions during three phases
of the session: before, during, and after the
intervention. Base rates were obtained, and se-
quential analyses were conducted.
Results indicated differences in the couple's
interactions before and after the intervention as
well as changes in their interactional patterns
with the therapist. Specifically, the couple's
 404 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
negative symmetry was eliminated by the end
of the intervention, to be replaced by positive
symmetrical behaviors. The apparent power
struggle between Weeks and the husband "de-
escalated" (Holloway et al., 1990, p. 385)
following the intervention. Indeed, both part-
ners engaged in more deferential complementa-
rity with the therapist, suggesting a willingness
to collaborate with him. Holloway et al. con-
cluded that the effectiveness of the intervention,
as reflected in the observed interactional pat-
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terns, was due to the therapist "playing to [the
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husband's] need for power . . . to elicit a col-
laboration that facilitated rather than obstructed
the therapeutic endeavor" (p. 399). According
to Weeks, for 6 months following this session,
the wife's insomnia did not recur, and the ther-
apy shifted to the couple's underlying relation-
ship problems (Holloway et al., 1990).
Second, in contrast to Weeks's problem fo-
cus, a successful session of solution-focused
therapy conducted by Bill O'Hanlon was ana-
lyzed by Gale and Newfield (1992). Using con-
versation analysis to identify "the paralinguistic
features of the talk as well as the structural
sequencing of the various turn-takings in the
conversation" (p. 154), Gale and Newfield ex-
tracted themes to describe O'Hanlon's strate-
gies, the interpersonal dynamics of the session,
and the participants' expressed agendas. From
these themes the authors developed categories
that were then subjected to the scrutiny of other
researchers. Nine categories of therapist inter-
ventions, obtained by the use of this qualitative
method, reflected O'Hanlon's ways of focusing
the session on solutions. Specifically, he con-
strained the couple's dialogue by (a) pursuing a
response over many speaking turns, (b) clarify-
ing unclear references, (c) modifying an asser-
tion until receiving the expected response, (d)
posing and answering questions himself, (e) ig-
noring misunderstandings, (f) interrupting, (g)
reformulating, (h) incorporating an answer in
his question, and (i) using humor to switch from
a problem theme to a solution theme.
Change events. In contrast to Johnson and
Greenberg's (1988) research on effective ses-
sions, in more recent research Greenberg et al.
(1993) sought to identify specific change events
within sessions that could be linked to success-
ful outcome in EFT couples treatment. This
approach focuses on the expression of affect
and averages 8 to 10 sessions. Data for all three
investigations reported in Greenberg et al.
(1993) were drawn from a previously reported
outcome study.
In the first study, conflict events were iden-
tified by specific markers—SASB (Benjamin,
1974) codes indicating that the couple was en-
gaging in negative complementarity or negative
reciprocity—followed by a therapist interven-
tion focusing on needs or emotions. In a quasi-
experimental design, 20-min change events
were identified and coded in entirety beginning
with the operationally defined marker. Results
showed that couples' (N = 22) behaviors were
significantly more supportive, affirming, and
understanding in Session 7 than in Session 2,
with a significant reduction in "hostile control-
ling" behaviors later in treatment (Greenberg et
al., 1993, p. 83).
In the second study, a within-couple (N = 16)
design was used to compare conflict events in
"peak" versus "poor" EFT sessions (Greenberg
et al., 1993, p. 80). Sessions were selected on
the basis of clients' postsession ratings. The
marker for these conflict events was a sequence
of three "negative talk" speaking turns by the
couple, followed by a therapist response aimed
toward exploring one partner's underlying af-
fect. The event was defined as a 15-20-min
period beginning with the therapist intervention.
Results showed deeper experiencing levels in
the peak sessions, along with proportionately
more affiliative and self-focused positive state-
ments (e.g., "disclosing, expressing, approach-
ing, and enjoying"; Greenberg et al., 1993,
p. 83).
In the third study of the series, Greenberg et
al. (1993) isolated "intimate self-disclosure"
(p. 82) change events in sessions that had been
rated moderately positive by the couple and the
therapist. The event was defined as five speak-
ing turns by the spouse who was the recipient of
an intimate disclosure, preceded by a feeling-
based interchange between the therapist and
the disclosing spouse. Comparing the change
events with control segments that occurred prior
to the event, Greenberg et al. observed signifi-
cantly more affiliative responses in the change
events than in the control episodes and signifi-
cantly more disaffiliative responses in the con-
trol segments.
Taken together, the results of these three stud-
ies provide support for the major tenets of
EFT—that is, that change comes about through
the expression of underlying needs and feel-
ings, which, in turn, allows spouses to gradually
 PROCESS OF FAMILY THERAPY
become more responsive to one another
behaviorally.
Researchers interested in a different change
event, one dealing not with affective expression
but with interpersonal control, reached a similar
conclusion about the importance of emotional
disclosures. To illustrate how task analysis
could be used to study interpersonal behavior
change in structural therapy, Heatherington and
Friedlander (1990a) analyzed two consultation
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interviews by Salvador Minuchin. The authors
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described the therapeutic task in both sessions
as "commitment to engage" (Heatherington &
Friedlander, 1990a, p. 40) because, in each case,
the clinical work involved breaking an unpro-
ductive pursue—distance cycle that was hinder-
ing family members' ability to engage effec-
tively with one another in problem solving. In
both change events, the interpersonal impasse
(the marker) was significantly modified such
that the parents no longer pursued and the son
no longer distanced. Rather, each boy began to
express his feelings to his parent(s) voluntarily
and deeply. Observational coding of the fami-
ly's relational control dynamics based on the
FRCCCS (Friedlander & Heatherington, 1989)
in the two events showed that interactional pat-
terns changed notably over time. In one session,
for example, the initial competitive symmetry
between father and son shifted to complemen-
tarity, whereas the parents' interactions with
one another shifted from complementarity to
competitive symmetry.
In a subsequent field study, Friedlander et al.
(1994) proposed that sustaining engagement is a
change event common to many approaches to
family therapy. An inductive method was used
to operationally define family disengagement in
the marker phase of each session. Sustaining
engagement was operationalized as "a sequence
of speaking turns in which family members are
observably willing to disclose thoughts or feel-
ings on [a] designated topic, to share or coop-
erate, to show interest and involvement in the
discussion, or to be responsive and attentive
(i.e., emotionally present)" (Friedlander et al.,
1994, p. 442). Based on a qualitative compari-
son of four successful and four unsuccessful
sustaining engagement events, a conceptual
model of the process of change was created.
This model included a series of five interrelated
steps that seemed necessary for family members
to move from disengagement to sustained en-
gagement: acknowledgment of one's own con-
405
tribution to the interpersonal impasse, commu-
nication of thoughts and feelings about the
impasse, validation of those feelings by other
family members, development of new construc-
tions of one another's behavior, and recognition
of the potential benefits of engagement. The
authors described various strategies and inter-
ventions that the therapists in the successful
sample used to facilitate sustained engagement
among family members.
Critique. In the 11 studies reviewed above,
intensive analyses were conducted either of en-
tire sessions that master therapists perceived to
be effective (Gale & Newfield, 1992; Holloway
et al., 1990) or of theoretically important mo-
ments or episodes that occurred within sessions.
The latter were selected by the investigators,
who believed that something clinically mean-
ingful was occurring. Some of these moments
involved emotion—laughter (Zuk et al., 1963),
crying (Crits-Christoph et al., 1991), or peak
experiencing (De Chenne, 1973)—on the part of
a single family member. Other moments were
considered meaningful because the therapists
were working with problematic interpersonal
behaviors—resistance (Patterson & Forgatch,
1985), conflict (Greenberg et al., 1993; Johnson
& Greenberg, 1988; Patterson & Chamberlain,
1988), or disengagement (Friedlander et al.,
1994; Heatherington & Friedlander, 1990a).
The major issue to consider when critiquing
this kind of research is whether the therapeutic
processes described in these studies are, indeed,
meaningful (Pinsof, 1989). Only three of the
studies in this group (Friedlander et al., 1994;
Heatherington & Friedlander, 1990a; Greenberg
et al., 1993) could be considered change event
research (Greenberg, 1986) in the sense that (a)
specific family behaviors were markers (Rice &
Greenberg, 1984) for the therapist's interven-
tion and (b) these behaviors were observably
modified during the episode itself. To support
their conclusion that meaningful change had
taken place, Greenberg et al. (1993) contrasted
each successful disclosure episode with a con-
trol segment. Friedlander et al. (1994) com-
pared successful engagement events with un-
successful events, that is, those that began
similarly but concluded with no observable
change in behavior. With respect to outcome,
only Greenberg et al. (1993) selected sessions
for analysis based on family members' views of
their importance, and only Johnson and Green-
berg (1988) and Greenberg et al. (1993) ob-
 406 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
jectively assessed the ultimate success of the
treatments they observed. In the absence of
information about immediate or ultimate out-
comes, we cannot be certain that the episodes
selected by the other investigators were indeed
meaningful for the family members or that they
characterize what goes on in successful family
therapy (Pinsof, 1981).
One of the positive aspects of most of the
episode-based studies, particularly the more re-
cent ones, is that the theoretical approach of the
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therapy was clearly identified. Results of these
This document is copyrighted by the American Psychological Association or one of its allied publishers.
studies not only provide evidence to support
theoretical tenets—EFT in Greenberg et al.
(1993), structural therapy in Heatherington and
Friedlander (1990a), and strategic therapy in
Holloway et al. (1990)—but also support more
general systems notions (e.g., Crits-Christoph et
al., 1991; Patterson & Chamberlain, 1988; Zuk
et al., 1963) and provide information about
strategies to facilitate meaningful interpersonal
change in the therapy session itself (Friedlander
et al., 1994; Gale & Newfield, 1992; Greenberg
et al., 1993; Holloway et al., 1990).
Finally, for the most part, the coding systems
used in these studies were reliable, valid, and
theoretically meaningful, and two investigations
(Friedlander et al., 1994; Gale & Newfield,
1992) provide different models of conducting
clinically rich qualitative research. However,
since in all but two of the studies (Greenberg et
al., 1993; Patterson & Chamberlain, 1988)
fewer than 10 families were sampled, the au-
thors' claims should be considered cautiously.
Therapeutic Relationship
At the third, most global level of the process
is the therapeutic relationship. Despite the as-
sumption that the relationship between therapist
and family system is an essential component of
the therapeutic process, it has been virtually
ignored in the published empirical literature.
Furthermore, the ingredients of the relationship
considered to be most predictive of outcome by
individual theorists and researchers—empathy,
acceptance, unconditional regard, and so on—
have been rarely mentioned in the clinical liter-
ature. Rather than warm responsiveness, family
theorists have emphasized the systemic and
strategic aspects of the relationship, for exam-
ple, joining with the family (Minuchin &
Fishman, 1981) or attending to the coalitionary
process (Sluzki, 1975). Indeed, in the 1970s
prominent systemic theorists (e.g., Selvini-
Palazzoli, Boscolo, Cecchin, & Prata, 1978)
were warning family therapists to behave in a
strictly neutral fashion and to remain unrespon-
sive to family members' needs for approval and
liking.
Despite the conclusions of Gurman and Kni-
skern in their 1978 review of literature that "the
ability of the therapist to establish a positive
relationship with his or her clients, long a cen-
tral issue of individual therapy, receives the
most consistent support as an important out-
come-related therapist factor to marital and
family therapy" (p. 875), there have been only
six published studies at the relationship level of
the therapeutic process that met our inclusion
criteria.3 One investigation (Shapiro, 1974)
concerned therapist responsiveness, while the
others (Bourgeois, Sabourin, & Wright, 1990;
Heatherington & Friedlander, 1990b, 1990c;
Holtzworth-Munroe, Jacobson, DeKlyen, &
Whisman, 1989; Pinsof & Catherall, 1986;
Sigal, Rakoff, & Epstein, 1967) concerned col-
laboration—or the therapeutic alliance—as per-
ceived by therapists, family members, or both.
Responsiveness. A study of therapist re-
sponsiveness (Shapiro, 1974) is included in this
review because Shapiro investigated therapists'
perceptions of their relationship with a particu-
lar family, not their perceptions of themselves
as therapists in general (cf. Rice et al., 1974).
That is, Shapiro asked therapists who evaluated
families (N = 27) to complete a questionnaire
indicating their emotional responses to the fam-
ily as a whole. As predicted, greater responsive-
ness on the part of the therapist predicted con-
tinuance beyond the initial evaluation phase.
Families who were viewed less positively by the
therapists tended to reject treatment after this
phase.
Therapeutic alliance. Shapiro's (1974) con-
cern with therapists' responsiveness to the fam-
ily is unique among the published studies at the
relationship level of the therapeutic process.
The remaining studies in this section were con-
3
Many of the studies referenced by Gurman and
Kniskern (1978) were unpublished dissertations,
which we excluded from the present review because
of their relative inaccessibility. Others either did not
meet our inclusion criteria or were not at the rela-
tionship level of Greenberg's (1986) model of the
therapeutic process.
 PROCESS OF FAMILY THERAPY
cerned with collaboration rather than with emo-
tional involvement. In the earliest study of this
group, Sigal et al. (1967) sampled a heteroge-
neous group of 19 families, all but one of whom
were seeking help with a child. Therapists pro-
vided written perceptions of the patterns of col-
laboration in the session after the 2nd, 6th, and
12th interviews. Judges then used these descrip-
tions to score each family member's alliance
with every other family member and with the
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therapist on a 6-point scale (0 = resistance, 3 =
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cooperation without engagement, and 5 = ac-
tive engagement). A composite score was com-
puted and used as a predictor of individual and
family functioning 14 months after treatment
began. Results suggested that none of these
composite scores predicted outcome but that
collaboration did tend to improve over time.
While all of the "very high interactors" (Sigal et
al., 1967, p. 225) in Session 2 had successful
outcomes, 80% of the families who terminated
prematurely had scores in Session 2 that fell
below the median.
In a more recent study of marital therapy,
Holtzworth-Munroe et al. (1989) sought to de-
termine whether relational factors predicted
successful response to treatment. Thirty-two
White couples who were treated with a social
learning-based approach by 13 therapists who
varied in experience level completed a rating
form at the conclusion of each session and the
Dyadic Adjustment Scale (DAS; Spanier, 1976)
pre- and posttreatment. Therapists completed a
parallel version of the rating form after each
session. Results showed that, from the thera-
pists' perspective, successful outcome was re-
lated to their perceptions of having been effec-
tive in creating a collaborative atmosphere and
to their perceptions of the clients as "behaving
in a facilitative manner" (Holtzworth-Munroe et
al., 1989, p. 661). Similar results were found
from the clients' perspective. For both husbands
and wives, greater marital satisfaction posttreat-
ment was predicted from greater participation in
treatment and greater perceived collaboration
with therapeutic assignments.
The three remaining studies in this section
used a theoretically based instrument (Pinsof &
Catherall, 1986) to measure collaboration. Ex-
trapolating from Bordin's (1979) view of the
therapeutic alliance in individual psychother-
apy, Pinsof and Catherall (1986) conceptualized
the therapeutic alliance in family therapy as
multidimensional and occurring on multiple
407
levels. The dimensions refer to the nature of the
alliance as a strong emotional bond with mutu-
ally agreed upon goals and tasks. The tripartite
aspect of the alliance refers to the following
levels: (a) whole system alliance (therapist al-
lies with the family members as a group), (b)
subsystem alliance (therapist allies with various
subsystems, e.g., the marital dyad), and (c) in-
dividual alliance (therapist allies with each in-
dividual in the family). Theoretically, no single
level of the alliance should be considered in
isolation. When the three levels are attended to
simultaneously, a determination can be made as
to whether the alliance with the family is intact
(all family members feel positively toward
the therapist and the therapy) or split (there
is notable variability in individual family
members' feelings; Pinsof & Catherall, 1986,
p. 139).
In preliminary work developing their alliance
scale, which has parallel versions for individu-
als, couples, and families, Pinsof and Catherall
(1986) reported that clients, in general, tended
to rate their therapists quite favorably. Citing
unpublished research, the authors also reported
(a) significantly positive correlations between
alliance ratings and therapist-rated outcome and
(b) little variation in couples' ratings over the
first eight sessions of treatment.
Two subsequent investigations have used
Pinsof and CatheraH's (1986) alliance scales
(Bourgeois et al., 1990; Heatherington & Fried-
lander, 1990b, 1990c). Heatherington and
Friedlander (1990b, 1990c) administered either
the couple or the family version of the instru-
ment to all family members over age 10 imme-
diately after an early session of systemic-
strategic therapy. Four empirical questions were
addressed. First, results snowed that client rat-
ings were normally distributed, and no differ-
ences were observed between couples and fam-
ilies or between male and female participants.
Second, patterns of association were observed
between the alliance measures and the Session
Evaluation Questionnaire (Stiles, 1980), a well-
established measure of immediate therapeutic
impact. Among families, stronger bonds and
greater agreement on tasks were correlated with
smoothness and ease of the session. Among
couples, greater agreement on tasks was asso-
ciated with perceived depth or value of the
session. Third, the authors questioned how fre-
quently split alliances, as described by Pinsof
and Catherall (1986), occur in couples and fam-
 408 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
ily therapy. On the basis of a 1.0 standard de-
viation difference between individual family
members' ratings, 43% of couples and 75% of
families were classified as experiencing a split
alliance with the therapist. On the basis of a
more conservative decision rule (2.0 SDs), 14%
of couples and 42% of families were so classi-
fied. Fourth, the authors tested associations be-
tween client-therapist verbal interactions—that
is, complementarity and symmetry (as coded
on the FRCCCS; Friedlander & Heatherington,
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1989)—and family members' perceptions of the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
therapeutic alliance. Their predictions were not
supported, although one interesting result ap-
proached significance. Clients tended to view
their personal alliance with the therapist some-
what less favorably when they themselves were
more frequently in a complementary one-up
relational control position with the therapist
one-down.
Heatherington and Friedlander (1990c) con-
sidered speech acts within the context of the
alliance. By contrast, Bourgeois et al. (1990)
tested perceptions of the therapeutic alliance in
relation to client outcome. Assessing 63 mari-
tally distressed couples in time-limited group
treatment with a social learning and humanistic
focus, Bourgeois et al. (1990) reported that
Pinsof and Catherall's (1986) couples alliance
scale was significantly predictive of treatment
success as measured by the DAS and two au-
thor-constructed questionnaires: an individual-
ized measure of conflictual topics and a general
measure of marital happiness. In addition to
confirming the predictive validity of the alli-
ance scale (administered to all couples after
their third group session), Bourgeois et al. pro-
vided some important information about indi-
vidual client differences and therapists' percep-
tions of the alliance. Specifically, although
pretreatment marital distress was not predictive
of the quality of the alliance, either for the
couple or for the therapist, client gender was an
important predictor. Whereas for women alli-
ance scores contributed only moderately to one
aspect of outcome, marital adjustment (i.e., the
DAS), for men the perceived alliance signifi-
cantly predicted adjustment as well as two other
indexes of marital harmony. The authors inter-
preted their unexpected gender effect with re-
spect to the impact of traditional sex role so-
cialization on men's willingness to engage in
marital and group treatment. They concluded
that, for men to be successful, it is "important
for them to feel understood and for the tasks and
objectives to be clearly stated and agreed on in
the early sessions of the intervention program"
(Bourgeois et al., 1990, p. 613).
Critique. In the earliest studies of the rela-
tionship, Shapiro (1974) asked therapists to rate
their responsiveness to the family as a whole,
and Sigal et al. (1967) combined each family
member's collaboration score to create a single
variable. The relational measures in these early
studies were global and vague, with little psy-
chometric support. Furthermore, because evi-
dence from later studies (Bourgeois et al., 1990;
Heatherington & Friedlander, 1990c) in which a
more psychometrically sound measure was used
(Pinsof & Catherall, 1986) suggests that the
therapeutic alliance does not develop uniformly
for all members of the family, global family
ratings and combined scores can be misleading.
Averaging scores across sessions, as did Holtz-
worth-Munroe et al. (1989), also obscures in-
formation about variability in the developing
alliance for different family members.
Indeed, few investigators have assessed how
the relationship develops over time or how in-
dividual client or therapist differences affect the
developing therapeutic alliance. While some re-
sults suggest that client gender may play a part
in this process, none of the investigators who
considered client gender (Bourgeois et al.,
1990; Heatherington & Friedlander, 1990c;
Holtzworth-Munroe et al., 1989) took into ac-
count the therapist's gender. Consequently, lit-
tle information exists of how effective therapists
develop same- and opposite-sex alliances si-
multaneously when working with a couple or
family.
Implications
Despite the abundant outcome research, sur-
prisingly few family therapy process studies
have been published. Compared with the hun-
dreds—if not thousands—of process studies of
individual therapy, we located only 36 family
studies that met our inclusion criteria. Of these
investigations, which date from 1963, the ma-
jority (n = 19) are descriptive studies at the
speech act level of the therapeutic process. Only
5 of the speech act studies included an evalu-
ation of client outcome; 9 of them examined
the work of master theorists or therapists in
the absence of objective outcome information.
 PROCESS OF FAMILY THERAPY
Studies designed to test theories of change in
family systems are only now emerging. Indeed,
there are relatively fewer studies at the episode
or relationship level, levels that are arguably
more meaningful for the practicing family ther-
apist. In most of those investigations, speech
acts were observed within specific therapeutic
episodes or in relation to the therapeutic alliance
(see Table 1). No studies were located, how-
ever, in which all three levels in Greenberg's
(1986) process model were investigated simul-
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
taneously.
Although we organized the 36 process studies
by contextual unit, our major aim in conducting
this review was to synthesize and integrate the
substantive findings. The following are some
general conclusions about we do "know" about
the process of conjoint family therapy.
1. Consistent with the systems perspective,
there is some evidence to suggest (a) that when
individuals' symptoms are observed during
family therapy sessions, they occur in the con-
text of predictable interpersonal events (e.g.,
family disagreements; Crits-Christoph et al.,
1991; Zuk et al., 1963), and (b) that greater
stress outside of therapy is reflected in family
members' communications during the session
(Patterson & Chamberlain, 1988).
2. For the most part, different family therapy
approaches are reflected in different kinds of
therapeutic interventions and participant activ-
ity rates, although there may be more common-
alities across approaches than the clinical liter-
ature suggests (Friedlander & Highlen, 1984;
Friedlander et al., 1985, 1987, 1991).
3. Family therapists tend to be active and to
assume a dominant (Gale & Newfield, 1992;
Heatherington & Friedlander, 1990b), central
position in their work with families (Friedlander
et al., 1987; Raymond et al., 1993). Many of
their interventions are skillful indirect commu-
nications (Friedlander et al., 1985, 1987, 1991;
Holloway et al., 1990; Pinsof, 1986). Family
therapists tend to behave fairly consistently
with different families (Friedlander et al., 1987)
and with different cotherapists (Dowling,
1979).
4. While family therapists may not overtly
behave in gender stereotypic ways, some of the
more subtle, interactive aspects of their com-
munication patterns with family members do
reflect gender-based expectancies (Brown-
Standridge & Piercy, 1988; Heatherington &
Friedlander, 1990b; Shields & McDaniel,
409
1992). Men and women seem to experience the
therapeutic process differently (Bourgeois et al.,
1990; Cline et al., 1984).
5. Changes over the course of family therapy
as well as over time in a "good" session tend to
be affective (Cline et al., 1984; Greenberg et al.,
1993; Johnson & Greenberg, 1988; Postner et
al., 1971) and cognitive (Friedlander et al.,
1994; Winer, 1971) as well as behavioral (e.g.,
Sigal et al., 1967). These changes are observ-
able not only in interpersonal relations (Green-
berg et al., 1993; Johnson & Greenberg, 1988;
Heatherington & Friedlander, 1990a; Holloway
et al., 1990; Laird & Vande Kemp, 1987;
Raymond et al., 1993) but also within individ-
uals (Friedlander et al., 1994; Munton &
Antaki, 1988; Winer, 1971).
6. Although early family theorists did not
focus on emotional states, evidence at all levels
of the therapeutic process suggests that affec-
tive changes among family members are of cru-
cial significance in family therapy (Cline et
al., 1984; Greenberg et al., 1993; Johnson &
Greenberg, 1988; Postner et al., 1971).
7. Relatedly, family members' feelings about
the therapist (Bourgeois et al., 1990), and his or
her responsiveness toward them (Shapiro,
1974), seem to be important, but often over-
looked, sources of gain in family therapy.
8. As in individual therapy, the family's level
of cooperativeness, willingness to engage in
problem solving, and sense of collaboration
with the therapist are predictive of session ef-
fectiveness (Friedlander et al., 1994; Heather-
ington & Friedlander, 1990c; Holloway et al.,
1990), continuation in treatment, and therapeu-
tic outcome (Alexander et al., 1976; Chamber-
lain et al., 1984; Holtzworth-Munroe et al.,
1989; Shields et al., 1991). The strength of the
therapeutic alliance is not, however, identical
for all family members (Bourgeois et al., 1990;
Heatherington & Friedlander, 1990c; Pinsof &
Catherall, 1986).
In our search for relevant research, we found
studies in a wide range of journals representing
various literature bases, from human communi-
cations and counseling, clinical, and social psy-
chology to marital and family therapy proper.
While this diverse interest among scholars is
heartening, researchers in one discipline seem
not to be fully aware of the work of scholars in
other disciplines. The present review was un-
dertaken to identify, synthesize, and integrate
the findings from all of these sources and, in so
 410 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
doing, to offer guidelines for the advancement
of research on the process of change in family
therapy. In the concluding section of this arti-
cle, we provide several recommendations,
which are concerned not only with the sub-
stance of future efforts but also with methods
for conducting clinically relevant research on
family therapy.
What We Don't Know
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In the process of integrating the results from
the existing literature, we formulated several
generalizations about what there is yet to be
learned about effective family therapy. These
generalizations are presented below, along with
suggestions to redress the apparent gaps in the
literature.
What Do Family Members Do, Think, or
Feel in Effective Family Therapy?
In virtually all of the major theories of family
therapy, much more attention is paid to what
the therapist "does" to the clients to promote
change than to what family members "do"—
behaviorally, cognitively, or emotionally
(Kuehl et al, 1990; Reiss, 1988). This trend is
mirrored in the available research. Although
results from several studies suggest that various
therapeutic interventions affect family members
in predictable ways, few studies have been con-
cerned with describing the stages of successful
client performances. In the cognitive realm, for
example, several investigators have focused on
strategies such as paradox (Holloway et al.,
1990), interpretation (Postner et al., 1971), or
refraining (Brown-Standridge & Piercy, 1988)
for changing family members' beliefs about
their problems, but only one published study
has concerned itself with actual changes in
clients' belief systems (Munton & Antaki,
1988), and no studies have concerned the in-
teractional process that leads to such cognitive
changes.
One promising method for the identification
of processes of change that involve clients' be-
haviors as well as therapists' is the task analysis
paradigm (Rice & Greenberg, 1984), which has
recently been applied to couples (Greenberg et
al., 1993) and family therapy (Friedlander et al.,
1994; Heatherington & Friedlander, 1990a).
Clearly, more research is needed on specific
tasks in family therapy, so that family members'
behaviors that are most facilitative of enduring
change can be identified.
Relatedly, not much is known about effective
therapy from the family's perspective (Pinsof,
1989; Wynne, 1988). Most research on the cli-
ent's role in the family therapy change process
has been concerned with observable behavior
rather than with covert emotions and cognitions
(Pinsof, 1988). With few exceptions, research-
ers have analyzed families and family therapy
interactions objectively—-from above—just as
one might study, from some elevated platform,
the sequences of moves on a soccer field lead-
ing to a goal. For the most part, observer ratings
have been used to operationalize emotional
states (e.g., Johnson & Greenberg, 1988; Post-
ner et al., 1971), personality changes (Winer,
1971), resistance (Chamberlain et al., 1984),
collaboration (Friedlander et al., 1994; Sigal et
al., 1967), and intimacy (Greenberg et al.,
1993).
This preference for objective methods over
phenomenological ones makes sense given the
early theoretical work on the pragmatics of fam-
ily communication (e.g., Watzlawick, Beavin,
& Jackson, 1967) and the emphasis on observ-
able behavior in the systemic, structural, and
strategic therapies that evolved from these
theories. Certainly, observational studies have
provided much useful information about the
process of family therapy. Observer ratings,
however, provide only a single viewpoint. More
research is needed to discover how family mem-
bers themselves construe the effective ingredi-
ents of family therapy, that is, how they per-
ceive various therapeutic events as helping or
hindering the process of change (Wynne, 1988).
Indeed, there exist methodologies that can
provide answers to these questions. The method
of interpersonal process recall, which has fruit-
fully been applied to individual therapy by
Robert Elliott (1984), Clara E. Hill (Hill et al.,
1988), and Jack Martin (Martin, Martin, &
Slemon, 1987), among others, could be used to
study family members' perspectives on the pro-
cess of therapy. Alternatively, less labor-inten-
sive methods, such as postsession interviews or
questionnaires, could be used to provide an un-
derstanding about just what does and does
not work in family therapy from the family's
perspective.
 PROCESS OF FAMILY THERAPY
How Does Change Occur in the
Nonbehavioral Approaches?
As in individual therapy, the family therapy
approaches that focus on overt behaviors have
been the most researched. Our review suggests
that the bulk of research has been conducted
on the structural, strategic, and systemic thera-
pies (cf. Gurman et al., 1986), with relatively
less attention to the psychoanalytic, experien-
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tial, family-of-origin, or newer constructivist
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approaches.
There is, nonetheless, fertile material for
study in the nonbehavioral approaches (Gur-
man, 1988). The circular questioning tech-
niques, for example, that are popular in the
Milan and other constructivist therapies are eas-
ily identified. Theoretically, these therapies are
geared toward accomplishing certain tasks in
the session. Is there any evidence to suggest that
they do so? Even constructivist theorists who
eschew simple, linear prescriptions for success-
ful therapy have made statements that can
be operationalized and tested as hypotheses.
Anderson and Goolishian (1992), for example,
described "[t]he therapeutic conversation [as] a
two-way exchange, a criss-crossing of ideas . . .
in which new meanings are continually evolv-
ing toward the 'dis-solving' of problems" (p.
27). Indeed, is therapeutic discourse a "two-way
exchange, a criss-crossing of ideas"? Are "new
meanings" expressed by family members over
the course of therapy and, if so, how do these
meanings relate to the family's treatment goals?
Constructivist therapies are growing rapidly in
popularity yet remain virtually unstudied.
Diversity Issues in Family Therapy
With the exception of the continuing interest
in gender effects, there has been little or no
research to date on issues of diversity in family
therapy. In contrast to the relatively larger lit-
erature base on diversity in individual therapy
(e.g., Garfield, 1986), family therapists lack ba-
sic information about the demographics (race,
ethnicity, SES, or family structure) of family
therapy—who is referred for and who com-
pletes therapy (i.e., dropout rates), who is most
likely to benefit from or be harmed by family
therapy, and what family—therapist matchings
on demographic or cultural variables, if any,
facilitate progress in family therapy (Goldstein,
411
1988). These kinds of questions have tradition-
ally lent themselves to outcome research, yet
they are increasingly—and convincingly—be-
ing linked with process variables in individual
therapy (Sue & Zane, 1987). Recent process
research by Zane (personal communication,
April 1993), for example, suggests that the level
of early self-disclosure that is generally encour-
aged by therapists may be appropriate for Anglo
clients but is excessively intimate for some
Asian and Asian-American clients, who, by vir-
tue of their culture, tend to be particularly con-
cerned with "face" in relationships. To expect
similar therapeutic processes with clients of dif-
ferent cultural backgrounds may impede the
therapy, causing rifts in the alliance, premature
termination, or worse.
Many theorists are indeed concerned with
issues of diversity in family therapy (e.g.,
McGoldrick, Pearce, & Giordano, 1982;
Szapocznik & Kurtines, 1993), and their writ-
ings provide important sources from which to
identify testable hypotheses. Researchers inter-
ested in diversity would also do well to read and
carefully critique family theories, especially
with regard to how theorists' assumptions and
strategies may affect families from different
cultures (cf. Tamura & Lau, 1992). One obvious
question is how different styles of family ther-
apy (e.g., more or less active, directive, collab-
orative, strategic, interpretive, etc.) intersect
with the cultural or ethnic values that families
bring to the therapy room. It is reasonable to
expect that cultural values differentially affect
family members' expectations for the thera-
pist's behavior, their communication patterns in
the session, and their perceptions of the thera-
peutic alliance.
Regarding gender, the research reviewed here
suggests equivocal findings about bias in family
therapy. It is interesting to note that the least
overt and the most interactional measures
of verbal behavior (in, for example, Brown-
Standridge & Piercy, 1988) were more likely to
turn up evidence of gender differences in thera-
pist-family communications. Indeed, it would
be surprising if there were no such differences,
given evidence in sociolinguistics (Tannen,
1990), social psychology (Aries, 1987), and de-
velopmental psychology (e.g., Maccoby, 1990)
about the influence of gender on discourse pat-
terns in nontherapy contexts. Increased research
is needed in this area, including studies to ex-
amine the influence of gender on intrafamily
 412 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
interactions (e.g., husband-wife, mother-chil-
dren, father-children, and sister-brother) dur-
ing therapy, particularly as those family inter-
actions affect and are affected by the therapist's
behavior. The politics of gender in cotherapy is
a second important area for study. Despite the
popularity of cotherapy, the gender dynamics of
this interpersonal relationship have yet to be
studied. Finally, studies of gender in family
therapy should take into account interactions
with other salient variables like age (consider
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grandmothers) or family structure (consider les-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
bian mothers). Indeed, the very definition of
family is changing rapidly in U.S. culture, pos-
sibly more rapidly than the definition is chang-
ing in either family theory or family research.
How Do Therapeutic Interventions Affect
Family Members Simultaneously?
In working conjointly with family members,
therapists are challenged by complex demands
that are not present in individual therapy, one of
which is managing the multiperson conversa-
tion so as to keep it therapeutic rather than
destructive, another of which is establishing al-
liances with several individuals who are at odds
with each other. As well as demands, the com-
plexity of the family context also provides
unique opportunities for therapeutic interven-
tion—assessing in vivo enactments of problem-
atic family interactions, intervening indirectly
so as to soften a message and minimize resis-
tance, using family members as cotherapists,
and so forth.
Just as it takes beginning family therapists
some time to learn to handle the interpersonal
challenges (Pinsof, 1979) and to take advantage
of the opportunities afforded by conjoint treat-
ment, so does it take time for researchers to
appreciate the unique challenges of studying
family therapy processes. Designing creative
strategies for avoiding a singular focus on indi-
vidual behavior that is isolated from its social
context is perhaps the single most important
direction for future research on the family ther-
apy process (e.g., Pinsof, 1988; Steier, 1988;
Wynne, 1988).
Since Pinsof s 1981 review of family therapy
process research, there has been notable
progress in testing theory-based questions, in
developing measures, and in using methods and
analyses that are truly interactional in nature.
Yet more remains to be done. As one example,
consider the recent work on the therapeutic al-
liance. Despite recognition of its importance in
family therapy and the development of a self-
report instrument for its measurement (Pinsof &
Catherall, 1986), investigators have yet to dis-
cover what strategies are effective in creating a
strong alliance with a family group, whether
alliances with individual family members are
additive, or how therapists can effectively repair
split alliances in a family (Heatherington &
Friedlander, 1990c; Pinsof & Catherall, 1986).
Consistent with the recommendation to avoid
isolating individual behavior from its interper-
sonal context is a second recommendation: that
individual behaviors not be analyzed apart from
the ongoing stream of behaviors (Stanton,
1988). Snapshot studies in which a picture of
the process at one point in time is used to
predict client outcome are less useful than run-
ning videotapes, in which entire sessions or,
preferably, all sessions in a given treatment are
examined to predict intermediate and global
outcomes.
This recommendation underscores the need
for the use of sequential analysis (e.g., Bakeman
& Gottman, 1986; Wampold, 1989) to test hy-
potheses of the following variety: Given that the
therapist (or client) does A behavior, is B be-
havior likely to follow? If so, does B facilitate C
behavior in response, or D behavior by another
party? The need for sequential analyses of com-
munication has been raised in many earlier cri-
tiques of family therapy research (e.g., Gurman,
1988; Piercy & Sprenkle, 1990; Pinsof, 1981).
We raise it again here because of its importance:
Questions of sequence and pattern go to the
heart of the interactional process of effective
family therapy.
While the most popular sequential techniques
are limited to the detection of simple reciprocity
(A follows B), a careful qualitative analysis of
therapy sessions may reveal patterns of behav-
ior that unfold over longer periods of time and
in more complicated ways (e.g., Friedlander et
al., 1994; Gale & Newfield, 1992). A therapist,
for example, might listen to a mother's com-
plaints about her daughter and consistently re-
frame them in positive terms, terms that create
bonds between mother and daughter ("I see that
there are two women in this family who speak
their minds"). The cumulative effect of the se-
ries of interventions might be to prepare mother
and daughter to comply with an assignment
 PROCESS OF FAMILY THERAPY 413

requiring collaboration. Since patterns like
these unfold across sessions, entire therapies
need to be studied micro- and macroanalyti-
cally. Detection of important patterns calls for
innovative methodologies (Stanton, 1988). The
method of interpersonal process recall (men-
tioned earlier) might be used to complement
sequential analyses of observer ratings of the
process in order to locate significant episodes,
for example, those in which family members
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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Received June 28, 1993
Revision received December 14, 1993
Accepted December 19, 1993 •