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What We Do and Don't Know About The Process of Family
What We Do and Don't Know About The Process of Family
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 treatment for various psychological disorders.
considered an unusual, if not heretical, mode of Although outcome research was needed to es-
treatment, its popularity has been rapidly accel- tablish the efficacy of family treatment, and
erating. Family therapy is now routinely taught the evidence is indeed convincing (Gurman,
to students in all of the major mental health Kniskern, & Pinsof, 1986), such research
professions and to practitioners seeking to im- tends to be of little value to the practicing
prove their skills in professional workshops, therapist, who is concerned with effective
conferences, and free-standing training centers. strategies and interventions. Practitioners tend,
The process of family treatment is described, instead, to turn to theoretical or technical arti-
debated, and analyzed not only in practice-ori- cles, books, and workshops for such clinically
ented periodicals and books but also in well- relevant information.
respected journals of psychotherapy research. Another reason for the lack of knowledge
Despite the ever-growing popularity of fam- concerning interpersonal change processes is
ily therapy, little is known about how interper- that the overriding concern of theorists is what
sonal change actually comes about in this therapists should do to effect change (Kuehl,
context. One reason for this lack of knowl- Newfield, & Joanning, 1990). Rarely do theo-
edge may be because, to date, investigators rists discuss— or even comment on—what fam-
have emphasized the global efficacy of family ily members need to do. Furthermore, it is rare
for theorists to focus on processes common to
Myrna L. Friedlander, Julie Wildman, and Eliza- many therapeutic approaches. Instead, the con-
beth A. Skowron, Department of Counseling Psy- cern of most theorists is how to distinguish their
chology, University at Albany, State University of approach from others.
New York; Laurie Heatherington, Department of The purpose of this article is to redress these
Psychology, Williams College. imbalances (across all schools of family ther-
This article was presented in June 1993 at the apy) by reviewing the existing research on pro-
annual conference of the Society for Psychotherapy
Research in Pittsburgh, Pennsylvania. cesses of change in family therapy and by of-
Correspondence concerning this article should be fering recommendations for future research.
addressed to Myrna L. Friedlander, Department of We have made an attempt to provide a com-
Counseling Psychology, Education 220, University at prehensive review of all the published process
Albany, State University of New York, 1400 Wash- research on family therapy. Both computer-
ington Avenue, Albany, New York 12222. assisted and human searches were used to iden-
390
PROCESS OF FAMILY THERAPY 391
tify publications with empirical evidence (qual- levels, so that speech acts can be studied in the
itative as well as quantitative) on family treat- context of specific change events or episodes,
ments. Only studies of naturally occurring and each of these units can be "nested" within a
processes in family therapy were included in the study of the relational aspects of the therapy
review. Although there are a number of excel- (Greenberg, 1986). From this perspective, pro-
lent controlled studies of treatment components cess variable C is not only composed of other,
(e.g., Jacobson, 1984), these investigations were more microscopic process variables (A, B) but
designed to test the effectiveness of those com- is also, itself, a component of the therapeutic
ponents rather than to observe the naturally process (D) at a macroscopic level (e.g., Green-
unfolding process of change. Our intent was not berg, 1986; Greenberg & Pinsof, 1986a; Pinsof,
to disparage those important efforts but, rather, 1989; Shoham-Salomon, 1990).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
to highlight naturalistic process research in fam- We chose this schema to organize the review
ily therapy. for two reasons. First, this schema is particu-
To be included in the review, the study had to larly useful from the standpoint of practice.
focus on the actual in-session verbal behavior of Clinicians are best able to evaluate the conclu-
the participants or on their self-reported percep- sions of a given program of research when the
tions of in-session behaviors.1 Consequently, process unit is clearly specified. In other words,
we excluded retrospective studies of clients' the practical relevance of the finding that vari-
reactions (e.g., Beck & Jones, 1973; Greenberg, able A predicts variable B requires knowledge
James, & Conry, 1988; Kuehl et al., 1990; of the context (Greenberg, 1986; Heatherington,
Shapiro & Budman, 1973) as well as studies 1990). Consider the following hypothetical ex-
with only pre- and postmeasures of family be- ample. Speech act B (therapist confrontation) is
havior or other outside-of-therapy observations found to occur frequently in family therapy
(e.g., Seeman, Tittler, & Friedman, 1985), that sessions. It would be more useful to know,
is, those that typify outcome research. Studies however, that B follows A (therapist support)
of therapists' general or characteristic styles of significantly more often than chance. In addi-
behavior (e.g., Rice, Gurman, & Razin, 1974) tion, if the sequential relationship between A
were also excluded. Finally, while we recog- and B (support and confrontation) is found to
nize that family therapy is neither conceptually characterize specific, well-defined change epi-
nor practically limited to conjoint treatment sodes (C; e.g., challenging parents to work to-
(Gurman, 1988), we assume that in-session gether to set limits for their young children) in
processes are affected when more than a sin- the context of a supportive therapeutic relation-
gle client is present. Thus, for purposes of this ship (D), this finding is even more meaningful
review, we only included studies of conjoint for the practicing therapist. Indeed, in a recent
treatments involving two or more family survey of practitioners, Beutler, Williams, and
members. Wakefield (1993) found that the most strongly
In contrast to Pinsof's (1981) and Gurman et endorsed request was for "research that focuses
al.'s (1986) reviews of family therapy research, on therapist and/or client behaviors leading to
we excluded unpublished dissertations and con- important moments of change during psycho-
ference papers (e.g., Presser, Sigal, Mayero- therapy" (p. 56).
vitch, & Chayoga [cited in Pinsof, 1981]), as
well as articles reporting programs of instru-
ment development (e.g., Allred & Kersey, 1
In a case study of a single session, Scheflen
1977). Rather than organizing the review by (1973) developed an elaborate analysis of the coor-
investigator or by instrument, as have others dination of verbal and kinesic behaviors in a demon-
(e.g., Beutler & Crago, 1991; Greenberg & stration session with a mother and her daughter, who
Pinsof, 1986b; Pinsof, 1981), we focused on had schizophrenia. The therapists were Carl Whitaker
and Thomas Malone. While this is the sole study, to
three hierarchically ordered levels of in-session
our knowledge, in which nonverbal behaviors were
processes (Greenberg, 1986). We first reviewed analyzed in a family therapy context, the results are
investigations (a) at the speech act level, fol- not only exceptionally complex but also do not lend
lowed by studies of (b) therapeutic episodes themselves to drawing conclusions about the process
and, at the most global level, (c) the therapeutic of therapeutic change. As Pinsof (1981) noted in his
relationship. In this model of process research, review of Scheflen's work, the research was more
each unit or level is subsumed by successive ethnographic than psychological in nature.
392 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
Treatment Chamberlain et al. (1984)a structure the therapist and by more within-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
entations. The assumption of this series of stud- the target" of the intervention (Friedlander et
ies was that a microanalysis of the work of al., 1985, p. 177). The authors suggested that
master therapists could provide an important indirectness may be an important strategy that
perspective on the common and diverse aspects cuts across approaches to family therapy.
of different approaches; by comparing experts' Friedlander et al. (1987) also observed the
work with a single family, one can attribute the extent of therapist variability across diverse
observed variations to differences in theoretical families. Despite the heterogeneity of families
approach rather than to the unique mix of family sampled, results showed remarkable consis-
and therapist. tency for both Whitaker and Minuchin. The
In a subsequent, more extensive investiga- greatest variability was in the therapists' activ-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tion, Friedlander et al. (1987) compared the ity levels. Both therapists also varied across
This document is copyrighted by the American Psychological Association or one of its allied publishers.
work of Salvador Minuchin and Carl Whitaker, families in terms of the extent of here-and-now
master therapists known for their theoretical focus, the extent of directness and indirectness,
differences. Twelve representative sessions the amount of information provided to the fam-
were analyzed: six by Whitaker and six by ily, and the amount of focus on parental sub-
Minuchin. The interviews (most of which were systems. The authors speculated that the factor
consultations) were selected to maximize diver- accounting for these differences across families
sity in terms of family constellation, role and may be the therapist's judgment of the family's
age of identified patient, and presenting con- readiness for change.
cerns. In addition to identifying sources of con- Another, more systemically based perspective
vergence and divergence in the two approaches, on theoretical convergence was provided by
the authors assessed the extent of therapist vari- content-free analyses of the Hillcrest films and
ability across families. of the Minuchin and Whitaker consultations.
In two studies by Friedlander et al. (1985, Interactional frequencies (who-talks-to-whom)
1987), a series of linguistic content analyses were subjected to multidimensional scaling
were undertaken involving Pinsof's (1979, (MDS) to provide "a spatial representation of
1981, 1986) Family Therapist Coding System the 'hidden' structure in the communication
and a measure of therapist response modes that patterns" (Friedlander & Highlen, 1984, p.
is not specific to family treatment. Results 477). In contrast to the other, more traditional
showed, overall, remarkable similarities across comparative analyses of frequencies or propor-
approaches as well as differences congruent tions of process variables, MDS provides as
with theoretical differences. With respect to the output a geometric configuration—a spatial
similarities, in both studies the therapists tended map—in which distances between points are
to focus on individuals and dyads, particularly derived from the observed measure of proxim-
the parental subsystem, and to be more con- ity or relatedness. For each interview a proxim-
cerned with the present than either the future or ity matrix was generated, which consisted of the
past. Relatively few references were made to proportion of interactions between each pair of
the family as an undifferentiated group, to ex- participants in the session (e.g., mother-father,
tended family members, or to triangular rela- mother—therapist, father-therapist, and so on).
tions among family members. In terms of re- More frequent interactions were assumed to re-
sponse modes, the Hillcrest therapists were flect greater interpersonal closeness; less fre-
most similar in their use of requests and "infor- quent interactions, more distance.
mative directives" (Friedlander et al., 1985, In the Hillcrest study (Friediander & Highlen,
p. 171). They tended to avoid restatements, si- 1984), the four maps showed many similarities,
lences, self-revealing, empathic, or confronta- and correlations of the MDS solutions were
tive responses. In Friedlander et al. (1987), significantly positive, particularly the Acker-
Whitaker and Minuchin infrequently responded man and Whitaker sessions (.75) and the Bowen
with clarifications or reflections of feelings, en- and Jackson sessions (.99). Interpretation of the
couragement, or reassurance, tending to rely maps was based on the therapists' postsession
instead on requesting or providing information. impressions of the family. Comparison of two
It is interesting that in both investigations, while sessions by Minuchin and two by Whitaker
the therapists most often addressed themselves showed both therapists clearly in the midst of
to a single individual or subsystem, a sizable the family and most closely aligned with the
proportion of interventions were "indirectly problem clients and their parents (Friedlander et
routed, that is, addressed to someone other than 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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This document is copyrighted by the American Psychological Association or one of its allied publishers.
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 in the affective mode of experience than did
studies that compared speech act variables in their female counterparts (Mas, Alexander, &
different treatment contexts. First, Chamberlain Barton, 1985).
et al. (1984) examined differences in self-refer- These results should be juxtaposed against
ral versus agency referral in 18 families who other research, conducted in different settings
completed a behavioral treatment for child man- with more experienced therapists, in which the
agement problems. Agency-referred families findings were consistent with the traditionality
were observed to engage in more resistant ver- hypothesis. Shields and McDaniel (1992) found
bal behaviors than did self-referred families. No that, in structural-strategic therapy, male thera-
information was provided, however, about the pists tended to behave in a more instrumental,
processes of change in those agency-referred directive manner by talking more and providing
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
flection (i.e., understanding) identified as "ef- Only two studies contrasted the behaviors of
fective" by the senior author and subsequently therapists as a function of their role (i.e., ther-
confirmed by another observer. apist vs. cotherapist, trainee vs. supervisor).
Brown-Standridge and Piercy (1988) found First, Dowling (1979) analyzed the verbal be-
that when the husbands' behaviors were haviors of five therapists who interacted in 10
"closed" (p. 210), the therapists tended to use different cotherapist pairs at three points in
reflections; this was not the case, however, treatment. Results showed that therapists be-
when the wives' behaviors were closed. Follow- haved similarly with different cotherapists (and
ing therapist interventions, husbands tended to with different families). Second, Pinsof (1979,
respond more positively to reframing and wives 1986) compared the interventions of eight fam-
tended to respond more positively to reflecting. ily therapy trainees with those of their supervi-
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
However, qualitative analyses of the therapists' sors. The procedure was unique in that the su-
written responses to a series of questions about pervisor observed the trainee's session (either
their implicit decision rales for the use of re- an intake or a second interview) from behind a
flection versus reframing showed that 80% of one-way mirror for 20 min, then joined the
the therapists denied having behaved differently trainee and conducted the remainder of the in-
with husbands and wives. terview with the trainee present but silent. Us-
Caution is necessary, however, in generaliz- ing his Family Therapist Coding System, Pinsof
ing from these results because little information (1979, 1986) compared the interventions of
was provided about the authors' criteria for trainees and supervisors and concluded that
effective reframing and reflection. The study trainees worked more intrapersonally and that
was distinguished, on the other hand, in its supervisors worked more interpersonally. That
analysis of sequential behaviors and in its com- is, whereas the trainees focused more on the
bined use of qualitative and observational data. opinions and beliefs of individual family mem-
Participant role. Two investigations con- bers, the supervisors focused more on behav-
trasted the behaviors of parents and children in ioral sequences and family communication pat-
family therapy. In Mas et al.'s (1985) study of terns. The supervisors also tended to use a wider
gender effects as well as in Friedlander et al.'s range of responses: They were more active and
(1985) comparison of the Hillcrest sessions, explicit, more here-and-now focused, and more
parents tended to speak far more often than interpretive and supportive. These differences
children. The adolescents in Mas et al. ex- cannot uniquely be attributed to therapist role,
pressed themselves in terms of agreement or however, because of differences in the observa-
disagreement more so than did their parents, tion situation as well as in therapist experience
and they tended to be more verbal with male and skill (Pinsof, 1979).
therapists than with female therapists. In the In addition to comparing the behaviors of
Hillcrest interviews, the children's participa- trainees and supervisors, Pinsof (1986) ob-
tion rates varied widely across therapists, as served changes in behavior common to both
did the degree to which they spoke about groups over the course of one session. Trainees
parent-child, sibling, or marital relations in and supervisors alike increasingly emphasized
the family. Compared with their parents, the the clients' behaviors and focused on the future,
Hillcrest children made notably fewer refer- on the parents, and on the therapy itself; they
ences to the past. also used more indirect and more cyclical inter-
Only one of the studies that examined the ventions as the session progressed.
interaction of process variables and client role None of these investigations considered the
took into account treatment outcome. Postner, sequential responding of therapist-to-family
Guttman, Sigal, Epstein, and Rakoff (1971) re- member, or vice versa, or the specific patterns
ported that in their group with good outcomes, of interactions between and among family
fathers were addressed more often. In the group members. Nor did any of these studies take into
with poor outcomes, however, mothers tended account the functional role of family members
to be the primary targets of the therapists' in- (e.g., parental child, homemaker, or income
terventions. Overall, therapists (a) spoke signif- provider). It may be that family members' func-
icantly more often to parents than to children tional roles, which reflect differences in status
and (b) tended to consistently address one par- and power, are important predictors of family
ent over the other. therapy dynamics.
398 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
Changes over treatment. In five studies, cantly predictive of outcome, welfare state-
changes in the frequency of client (Chamberlain ments among family members tended to
et al., 1984; Munton & Antaki, 1988; Winer, increase over time, demonstrating changes in
1971) and/or therapist (Cline, Mejia, Coles, family members' ability to "express affection,
Klein, & Cline, 1984; Postner et al., 1971) re- sympathy, and pleasure" (Postner et al., 1971,
sponse were observed over time. Sequences of p. 463). Family members' speech also tended to
therapist-client interactions were only ob- be less neutral and to involve increasing levels
served in two case studies of successful struc- of emergency emotions. The most significant
tural family therapy (Laird & Vande Kemp, change in emotional expression tended to occur
1987; Raymond, Friedlander, Heatherington, between the second and sixth sessions.
Ellis, & Sargent, 1993). The studies of family Two investigations (Munton & Antaki, 1988;
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
early and late in treatment more so than did the groups. The process data were analyzed by
families with good outcomes. Second, regard- correlating the early-to-late change scores in
less of outcome, family members tended to the couples' behaviors (MICS) with therapist
make more internal and personal attributions of modes of expression and behaviors averaged
other family members over time. Munton and across the two time periods. Outcome was
Antaki speculated that attributional change does assessed posttherapy and at 3- and 6-month
not occur in "any straightforward way" (p. 96) follow-ups by means of several client reports of
in therapy and that averaging across family marital adjustment and satisfaction. At termina-
members or across families can obscure impor- tion therapists provided an evaluation of im-
tant individual changes in attributions. provement or deterioration in 12 areas of mar-
ital functioning.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
al. (1971) found that therapists rarely spoke to Results indicated notable differences between
more than one family member at a time and that the husbands and the wives within each SES
therapists did not vary significantly in their group. For couples in the middle SES group,
speech rate over the course of treatment, al- therapist directiveness was negatively corre-
though therapist variability across families was lated with outcome at each assessment point.
more pronounced. Therapists spoke increas- Furthermore, directiveness was inversely asso-
ingly more often in the group with good out- ciated with increases in positive behaviors (e.g.,
comes, and they tended to focus increasingly on acceptance, agreement, approval, and accepting
a single family member, generally the most responsibility) over time. Couples in the middle
verbal parent. With respect to type of response, SES group tended to increase their expressions
all interventions were categorized by observers of feelings when the therapists were less direc-
as either drive or interpretation on the basis of tive and when they used more reflections and
intent. Drive was defined as the therapist's aim probes for affect. This pattern was, however,
to stimulate interaction, obtain information, or notably more pronounced for husbands than for
provide support, and interpretation referred to wives.
the therapist's intent to clarify underlying mo- The couples in the low SES group seemed to
tives, further understanding, generalize, or sug- have experienced the process differently. Ther-
gest alternative behaviors. The authors observed apist directiveness was predictive of increased
a significant decrease in the drive to interpreta- positive behaviors on the part of these couples,
tion ratio by therapists overall; this change was and directiveness predicted successful out-
more marked in the group with good outcome come from the wives' perspective. For the hus-
than in the group with poor outcome. In other bands, "directive questions that explore affect
words, a change in the direction of fewer drive and reflecting statements related to affect"
responses relative to interpretation responses (Cline et al., 1984, p. 702) were most predictive
may be predictive of successful treatment. of outcome.
In a large-scale marital outcome study, Cline In summary, the major difference between the
et al. (1984) tested the degree to which changes two SES groups lay in how the husbands expe-
in couples' behaviors from early to late in ther- rienced the therapy, as the patterns were more
apy could be predicted from therapist behaviors. apparent for them than for their wives. Whereas
Seventy-seven couples were treated by 19 ex- the husbands in the low SES group were seem-
perienced male therapists, each of whom was ingly affected more by understanding the dy-
assigned 2 couples each from a low and a mid- namics in their marriage without changing their
dle socioeconomic status (SES) group. Using actual communication styles, husbands in the
Alexander et al.'s (1976) rating system for ther- middle SES group may have been helped by
apist modes of expression and a coding system expressing their feelings, so that gradually the
for client behavior that was modified from the couple's communication style improved (Cline
original Marital Interaction Coding System et al., 1984).
(MICS; Hops, Wills, Patterson, & Weiss, 1972 In Cline et al.'s (1984) investigation, process
[cited in Cline et al., 1984]), 10-min excerpts variables were correlated with one another or
were sampled from the first two and the last two used to predict outcome. Although therapist di-
sessions in each treatment. Comparisons were rectiveness was significantly correlated with
made of participants' behaviors (therapists, positive client behavior for some couples, this
wives, and husbands) within each of the SES finding does not mean that directiveness was
400 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
followed by positive client behavior. In only his SASB responses tended to be "affirming,"
two studies in the group that studied change "understanding," "nurturing," "helping," and
processes over time were sequences of behavior "protecting." It is interesting that one finding
observed. Both of these investigations (Laird & could be interpreted as supportive of the gender
Vande Kemp, 1987; Raymond et al, 1993) traditionality hypothesis (see earlier section on
were case studies in which well-known thera- Gender). Laird and Vande Kemp (1987) ob-
pists at the Philadelphia Child Guidance Clinic served that Minuchin responded in a non-
treated families with an adolescent daughter complementary manner to both the mother and
suffering from anorexia nervosa. the daughter with anorexia after these women
In the earlier research, Laird and Vande used either asserting or separating responses.
Kemp (1987) tested several hypotheses about In the second case study (Raymond et al.,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
changes in Salvador Minuchin's responses to 1993), John Sargent, well-known for his inpa-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
family members over time and changes in their tient work with families who have members
responses to him. Responses were identified as with chronic anorexia, conducted (with a co-
either complementary or noncomplementary on therapist) 15 sessions of family treatment over a
the basis of observers' coding of reciprocal ver- 3-week period. Based on the FRCCCS (Fried-
bal exchanges between Minuchin and family lander & Heatherington, 1989), relational con-
members in 20-min segments of an early, a trol patterns between Sargent and each of 3 key
middle, and a late session. Interpersonal inter- family members (mother, daughter, and father)
actions were identified on the basis of the cod- and among the 3 clients were observed, and
ing of reciprocal speech acts involving the MDS spatial maps (cf. Friedlander & Highlen,
Structural Analysis of Social Behavior (SASB; 1984; Friedlander et al., 1987) of each session
Benjamin, 1974). Complementarity was defined were generated on the basis of all participants'
as (a) opposing behaviors with respect to focus interactional frequencies.
(one speaker focuses on self, the respondent Consistent with earlier research (Heathering-
focuses on other) and (b) similar behaviors with ton & Friedlander, 1990b) on relational control
respect to affiliation and interdependence. The- dynamics with the FRCCCS, therapist one-up
oretically, whereas complementary responses and family member one-down complementarity
are rewarding for both parties, noncomplemen- predominated throughout this case.2 With the
tary responses are considered to be challenging; identified patient, this pattern was observed
in order to build trust and rapport in the initial more frequently in the early and late phases of
stage of therapy, therapists should respond in a treatment than in the middle, or restructuring,
complementary fashion (Carson, 1969). How- stage. The MDS maps showed that Sargent
ever, to help clients modify their maladaptive maintained a central position in the system
interpersonal styles, therapists should adopt a throughout treatment, with the cotherapist being
noncomplementary style in the middle phase of more peripheral. Hypothesized changes in with-
treatment. in-family alliances were not evident in the
Results supported Laird and Vande Kemp's maps, however.
(1987) hypotheses that (a) Minuchin would re- Overall, Raymond et al.'s (1993) findings did
spond to family members with higher levels of not confirm the majority of their theory-based
complementarity in the early and late stages of hypotheses, particularly those concerning
treatment than in the middle stage and that (b) changes in family behavior over time. Further-
therapist complementarity would be negatively more, despite the structural emphasis on fam-
associated with immediate client change. Over- ily enactment (Minuchin, Rosman, & Baker,
all, these results indicated that Minuchin's non- 1978), there was surprisingly little within-
complementary behavior, particularly in the family interaction throughout; family members
middle stage of treatment, was predictive of addressed each other, on average, only 22% of
subsequent changes in family members' re- the time.
sponses toward him. (Family members' re-
sponses toward one another were not observed.) 2
Interpersonal complementarity and relational
Indeed, the descriptive results suggested that control complementarity are not identical. In Fried-
Minuchin was more variable in his responses in lander's (1993) review of complementarity in brief
the middle stage and used more "focus on self individual and family therapy, the similarities and
responses in the termination phase. Across time, differences are discussed at length.
PROCESS OF FAMILY THERAPY 401
A close inspection of the family's relational have little known validity. In the absence of
control patterns, however, suggested that some validity information, the assumption that, for
changes in the family's rigid communication example, increased usage of personal pronouns
style may have taken place (Raymond et al., (I, mine, etc.) reflects greater differentiation of
1993). Specifically, the parents were observed self (Winer, 1971) or that increased welfare
to engage in more competitive symmetry over statements among family members (Postner et
time, possibly reflecting a struggle for control al., 1971) signal greater closeness or better re-
between them. At the same time, the competi- lations should be questioned.
tive symmetry between the daughter with an- Both case studies of structural therapy did use
orexia and each parent decreased over time. valid, theoretically based measures, the SASB
Raymond et al. (1993) speculated that these in Laird and Vande Kemp (1987) and the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
shifts might reflect less detouring or conflict FRCCCS in Raymond et al. (1993). Each inves-
avoidance on the part of the parents and a con- tigation involved the treatment of a family who
sequent "'detriangling' of the symptomatic had a child with anorexia by an expert structural
child" (p. 323). therapist. The degree of generalizability of the
Raymond et al. (1993) also tested the hypoth- results of these studies to other families, thera-
esis that, because the goal of structural treat- pists, and theoretical orientations is, however,
ment is to disrupt communication patterns that unknown.
reflect boundary violations or cross-genera- Finally, in only one of the seven studies that
tional triangulation, the therapist and cother- tested changes over time (Raymond et al., 1993)
apist would intervene immediately by inter- was every session in the treatment analyzed in
preting or confronting these behaviors or by entirety. Drawing conclusions about shifts over
educating or coaching the family toward more time when short (10-20 min) segments are
functional communication. Based on the sampled at two (Cline et al., 1984; Munton &
FRCCCS, the following speech acts were iden- Antaki, 1988; Winer, 1971), three (Chamberlain
tified: (a) attempts by the daughter to intervene et al., 1984), or four (Postner et al., 1971) points
in her parents' conversations with each other, in time is questionable (Spector, Guttman,
(b) messages from the daughter in which the Sigal, Rakoff, & Epstein, 1970). The method of
daughter supported one parent while challeng- using proportions of therapist behaviors to pre-
ing the other, or (c) messages from either parent dict proportions of client behaviors (Cline et al.,
in which the parent supported the daughter 1984; Postner et al., 1971) is also problematic
while challenging the spouse. Surprisingly, only (Shoham-Salomon, 1990). Because this kind of
three such instances were observed over the analysis does not take into account the context
course of the entire 15-session treatment. On of these behaviors or their sequential patterns
each of these occasions, however, the therapists (i.e., therapist—client-therapist interactions), the
did respond immediately, as predicted. Their results can misleadingly suggest causation
interventions either "redirected the conversa- (Pinsof, 1981).
tion, . . . provided information, direct guidance
or advice, o r . . . sought information from family
members in a highly structuring, one-up man- Therapeutic Episodes
ner" (Raymond et al., 1993, p. 322).
The question addressed in these seven studies In research at the speech act level of the
(how does change occur over time in successful therapy process, all behaviors occurring during
treatment) has been studied in a number of the sample—be it a segment, a session, or an
ways. Unfortunately, however, because each in- entire treatment—are observed. Frequencies or
vestigator adopted a different perspective on the proportions of these behaviors are compared or
therapeutic process, there is little accumulated used to predict treatment outcome. In research
knowledge to answer this important question. at the episode level, by contrast, the assumption
Only one study (Cline et al., 1984) used more is that not all speech acts are of equal impor-
than a single coding system, but the categories tance. By limiting study to behaviors that
were global and atheoretical, and the interjudge surround clinically meaningful moments, the
reliabilities were at best fair ( < .60) for the researcher hopes to elucidate the actual mecha-
majority of variables under study. Furthermore, nisms of therapeutic change (Greenberg, 1986;
with a few exceptions, the coding systems used Greenberg & Pinsof, 1986a).
402 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
An early study of marital therapy demon- ment, conducted by Salvador Minuchin at the
strates the value of this approach. De Chenne Philadelphia Child Guidance Clinic, was geared
(1973) questioned whether clients experience toward increasing Suzie's control over her cry-
greater feeling in response to the therapist or in ing and her physical condition. Twenty-five
response to their spouse. Tape recorded, hour- 400-word segments (immediately before ,and
long sessions with 9 couples were sampled from immediately after a crying moment) were
a Catholic outpatient service. Trained raters ap- compared with 27 control segments. All vid-
plied the Experiencing Scale (Klein, Mathieu, eotaped segments were transcribed and rated
Kiesler, & Gendlin, 1969) to each client state- on a variety of individual and interpersonal
ment. When experiencing levels were averaged indicators.
across speech acts, no differences were ob- Compared with the control segments, in the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
the daughter laughed most in the third 15-min Effective sessions. Three studies of marital
interval. Zuk et al. (1963) concluded that the therapy were located in which effective sessions
seemingly bizarre laughter of the daughter with were intensively analyzed. The earliest investi-
schizophrenia was not devoid of meaning and gation was an observational study of brief EFT
was, on some level, a reaction to the therapy with 6 couples. Johnson and Greenberg (1988)
session. (The daughter was least anxious in the examined change processes in the "best" ses-
initial 15-min segments, when structuring of the sions, as rated by therapists. Three couples re-
session took place, but she was most anxious in ported improvement in marital satisfaction post-
the last 15 min, when deeper thoughts and feel- treatment, whereas 3 couples reported minimal
ings tended to be explored.) Alternatively, the improvement. All verbal statements in the latter
reversal of patterns of laughter between the half of the six sessions were coded with respect
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
negative symmetry was eliminated by the end (1993) were drawn from a previously reported
of the intervention, to be replaced by positive outcome study.
symmetrical behaviors. The apparent power In the first study, conflict events were iden-
struggle between Weeks and the husband "de- tified by specific markers—SASB (Benjamin,
escalated" (Holloway et al., 1990, p. 385) 1974) codes indicating that the couple was en-
following the intervention. Indeed, both part- gaging in negative complementarity or negative
ners engaged in more deferential complementa- reciprocity—followed by a therapist interven-
rity with the therapist, suggesting a willingness tion focusing on needs or emotions. In a quasi-
to collaborate with him. Holloway et al. con- experimental design, 20-min change events
cluded that the effectiveness of the intervention, were identified and coded in entirety beginning
as reflected in the observed interactional pat- with the operationally defined marker. Results
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
terns, was due to the therapist "playing to [the showed that couples' (N = 22) behaviors were
This document is copyrighted by the American Psychological Association or one of its allied publishers.
husband's] need for power . . . to elicit a col- significantly more supportive, affirming, and
laboration that facilitated rather than obstructed understanding in Session 7 than in Session 2,
the therapeutic endeavor" (p. 399). According with a significant reduction in "hostile control-
to Weeks, for 6 months following this session, ling" behaviors later in treatment (Greenberg et
the wife's insomnia did not recur, and the ther- al., 1993, p. 83).
apy shifted to the couple's underlying relation- In the second study, a within-couple (N = 16)
ship problems (Holloway et al., 1990). design was used to compare conflict events in
Second, in contrast to Weeks's problem fo- "peak" versus "poor" EFT sessions (Greenberg
cus, a successful session of solution-focused et al., 1993, p. 80). Sessions were selected on
therapy conducted by Bill O'Hanlon was ana- the basis of clients' postsession ratings. The
lyzed by Gale and Newfield (1992). Using con- marker for these conflict events was a sequence
versation analysis to identify "the paralinguistic of three "negative talk" speaking turns by the
features of the talk as well as the structural couple, followed by a therapist response aimed
sequencing of the various turn-takings in the toward exploring one partner's underlying af-
conversation" (p. 154), Gale and Newfield ex- fect. The event was defined as a 15-20-min
tracted themes to describe O'Hanlon's strate- period beginning with the therapist intervention.
gies, the interpersonal dynamics of the session, Results showed deeper experiencing levels in
and the participants' expressed agendas. From the peak sessions, along with proportionately
these themes the authors developed categories more affiliative and self-focused positive state-
that were then subjected to the scrutiny of other ments (e.g., "disclosing, expressing, approach-
researchers. Nine categories of therapist inter- ing, and enjoying"; Greenberg et al., 1993,
ventions, obtained by the use of this qualitative p. 83).
method, reflected O'Hanlon's ways of focusing In the third study of the series, Greenberg et
the session on solutions. Specifically, he con- al. (1993) isolated "intimate self-disclosure"
strained the couple's dialogue by (a) pursuing a (p. 82) change events in sessions that had been
response over many speaking turns, (b) clarify- rated moderately positive by the couple and the
ing unclear references, (c) modifying an asser- therapist. The event was defined as five speak-
tion until receiving the expected response, (d) ing turns by the spouse who was the recipient of
posing and answering questions himself, (e) ig- an intimate disclosure, preceded by a feeling-
noring misunderstandings, (f) interrupting, (g) based interchange between the therapist and
reformulating, (h) incorporating an answer in the disclosing spouse. Comparing the change
his question, and (i) using humor to switch from events with control segments that occurred prior
a problem theme to a solution theme. to the event, Greenberg et al. observed signifi-
Change events. In contrast to Johnson and cantly more affiliative responses in the change
Greenberg's (1988) research on effective ses- events than in the control episodes and signifi-
sions, in more recent research Greenberg et al. cantly more disaffiliative responses in the con-
(1993) sought to identify specific change events trol segments.
within sessions that could be linked to success- Taken together, the results of these three stud-
ful outcome in EFT couples treatment. This ies provide support for the major tenets of
approach focuses on the expression of affect EFT—that is, that change comes about through
and averages 8 to 10 sessions. Data for all three the expression of underlying needs and feel-
investigations reported in Greenberg et al. ings, which, in turn, allows spouses to gradually
PROCESS OF FAMILY THERAPY 405
become more responsive to one another tribution to the interpersonal impasse, commu-
behaviorally. nication of thoughts and feelings about the
Researchers interested in a different change impasse, validation of those feelings by other
event, one dealing not with affective expression family members, development of new construc-
but with interpersonal control, reached a similar tions of one another's behavior, and recognition
conclusion about the importance of emotional of the potential benefits of engagement. The
disclosures. To illustrate how task analysis authors described various strategies and inter-
could be used to study interpersonal behavior ventions that the therapists in the successful
change in structural therapy, Heatherington and sample used to facilitate sustained engagement
Friedlander (1990a) analyzed two consultation among family members.
Critique. In the 11 studies reviewed above,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
described the therapeutic task in both sessions intensive analyses were conducted either of en-
as "commitment to engage" (Heatherington & tire sessions that master therapists perceived to
Friedlander, 1990a, p. 40) because, in each case, be effective (Gale & Newfield, 1992; Holloway
the clinical work involved breaking an unpro- et al., 1990) or of theoretically important mo-
ductive pursue—distance cycle that was hinder- ments or episodes that occurred within sessions.
ing family members' ability to engage effec- The latter were selected by the investigators,
tively with one another in problem solving. In who believed that something clinically mean-
both change events, the interpersonal impasse ingful was occurring. Some of these moments
(the marker) was significantly modified such involved emotion—laughter (Zuk et al., 1963),
that the parents no longer pursued and the son crying (Crits-Christoph et al., 1991), or peak
no longer distanced. Rather, each boy began to experiencing (De Chenne, 1973)—on the part of
express his feelings to his parent(s) voluntarily a single family member. Other moments were
and deeply. Observational coding of the fami- considered meaningful because the therapists
ly's relational control dynamics based on the were working with problematic interpersonal
FRCCCS (Friedlander & Heatherington, 1989) behaviors—resistance (Patterson & Forgatch,
in the two events showed that interactional pat- 1985), conflict (Greenberg et al., 1993; Johnson
terns changed notably over time. In one session, & Greenberg, 1988; Patterson & Chamberlain,
for example, the initial competitive symmetry 1988), or disengagement (Friedlander et al.,
between father and son shifted to complemen- 1994; Heatherington & Friedlander, 1990a).
tarity, whereas the parents' interactions with The major issue to consider when critiquing
one another shifted from complementarity to this kind of research is whether the therapeutic
competitive symmetry. processes described in these studies are, indeed,
In a subsequent field study, Friedlander et al. meaningful (Pinsof, 1989). Only three of the
(1994) proposed that sustaining engagement is a studies in this group (Friedlander et al., 1994;
change event common to many approaches to Heatherington & Friedlander, 1990a; Greenberg
family therapy. An inductive method was used et al., 1993) could be considered change event
to operationally define family disengagement in research (Greenberg, 1986) in the sense that (a)
the marker phase of each session. Sustaining specific family behaviors were markers (Rice &
engagement was operationalized as "a sequence Greenberg, 1984) for the therapist's interven-
of speaking turns in which family members are tion and (b) these behaviors were observably
observably willing to disclose thoughts or feel- modified during the episode itself. To support
ings on [a] designated topic, to share or coop- their conclusion that meaningful change had
erate, to show interest and involvement in the taken place, Greenberg et al. (1993) contrasted
discussion, or to be responsive and attentive each successful disclosure episode with a con-
(i.e., emotionally present)" (Friedlander et al., trol segment. Friedlander et al. (1994) com-
1994, p. 442). Based on a qualitative compari- pared successful engagement events with un-
son of four successful and four unsuccessful successful events, that is, those that began
sustaining engagement events, a conceptual similarly but concluded with no observable
model of the process of change was created. change in behavior. With respect to outcome,
This model included a series of five interrelated only Greenberg et al. (1993) selected sessions
steps that seemed necessary for family members for analysis based on family members' views of
to move from disengagement to sustained en- their importance, and only Johnson and Green-
gagement: acknowledgment of one's own con- berg (1988) and Greenberg et al. (1993) ob-
406 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
jectively assessed the ultimate success of the process (Sluzki, 1975). Indeed, in the 1970s
treatments they observed. In the absence of prominent systemic theorists (e.g., Selvini-
information about immediate or ultimate out- Palazzoli, Boscolo, Cecchin, & Prata, 1978)
comes, we cannot be certain that the episodes were warning family therapists to behave in a
selected by the other investigators were indeed strictly neutral fashion and to remain unrespon-
meaningful for the family members or that they sive to family members' needs for approval and
characterize what goes on in successful family liking.
therapy (Pinsof, 1981). Despite the conclusions of Gurman and Kni-
One of the positive aspects of most of the skern in their 1978 review of literature that "the
episode-based studies, particularly the more re- ability of the therapist to establish a positive
cent ones, is that the theoretical approach of the relationship with his or her clients, long a cen-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
cerned with collaboration rather than with emo- levels. The dimensions refer to the nature of the
tional involvement. In the earliest study of this alliance as a strong emotional bond with mutu-
group, Sigal et al. (1967) sampled a heteroge- ally agreed upon goals and tasks. The tripartite
neous group of 19 families, all but one of whom aspect of the alliance refers to the following
were seeking help with a child. Therapists pro- levels: (a) whole system alliance (therapist al-
vided written perceptions of the patterns of col- lies with the family members as a group), (b)
laboration in the session after the 2nd, 6th, and subsystem alliance (therapist allies with various
12th interviews. Judges then used these descrip- subsystems, e.g., the marital dyad), and (c) in-
tions to score each family member's alliance dividual alliance (therapist allies with each in-
with every other family member and with the dividual in the family). Theoretically, no single
level of the alliance should be considered in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
cooperation without engagement, and 5 = ac- isolation. When the three levels are attended to
tive engagement). A composite score was com- simultaneously, a determination can be made as
puted and used as a predictor of individual and to whether the alliance with the family is intact
family functioning 14 months after treatment (all family members feel positively toward
began. Results suggested that none of these the therapist and the therapy) or split (there
composite scores predicted outcome but that is notable variability in individual family
collaboration did tend to improve over time. members' feelings; Pinsof & Catherall, 1986,
While all of the "very high interactors" (Sigal et p. 139).
al., 1967, p. 225) in Session 2 had successful In preliminary work developing their alliance
outcomes, 80% of the families who terminated scale, which has parallel versions for individu-
prematurely had scores in Session 2 that fell als, couples, and families, Pinsof and Catherall
below the median. (1986) reported that clients, in general, tended
In a more recent study of marital therapy, to rate their therapists quite favorably. Citing
Holtzworth-Munroe et al. (1989) sought to de- unpublished research, the authors also reported
termine whether relational factors predicted (a) significantly positive correlations between
successful response to treatment. Thirty-two alliance ratings and therapist-rated outcome and
White couples who were treated with a social (b) little variation in couples' ratings over the
learning-based approach by 13 therapists who first eight sessions of treatment.
varied in experience level completed a rating Two subsequent investigations have used
form at the conclusion of each session and the Pinsof and CatheraH's (1986) alliance scales
Dyadic Adjustment Scale (DAS; Spanier, 1976) (Bourgeois et al., 1990; Heatherington & Fried-
pre- and posttreatment. Therapists completed a lander, 1990b, 1990c). Heatherington and
parallel version of the rating form after each Friedlander (1990b, 1990c) administered either
session. Results showed that, from the thera- the couple or the family version of the instru-
pists' perspective, successful outcome was re- ment to all family members over age 10 imme-
lated to their perceptions of having been effec- diately after an early session of systemic-
tive in creating a collaborative atmosphere and strategic therapy. Four empirical questions were
to their perceptions of the clients as "behaving addressed. First, results snowed that client rat-
in a facilitative manner" (Holtzworth-Munroe et ings were normally distributed, and no differ-
al., 1989, p. 661). Similar results were found ences were observed between couples and fam-
from the clients' perspective. For both husbands ilies or between male and female participants.
and wives, greater marital satisfaction posttreat- Second, patterns of association were observed
ment was predicted from greater participation in between the alliance measures and the Session
treatment and greater perceived collaboration Evaluation Questionnaire (Stiles, 1980), a well-
with therapeutic assignments. established measure of immediate therapeutic
The three remaining studies in this section impact. Among families, stronger bonds and
used a theoretically based instrument (Pinsof & greater agreement on tasks were correlated with
Catherall, 1986) to measure collaboration. Ex- smoothness and ease of the session. Among
trapolating from Bordin's (1979) view of the couples, greater agreement on tasks was asso-
therapeutic alliance in individual psychother- ciated with perceived depth or value of the
apy, Pinsof and Catherall (1986) conceptualized session. Third, the authors questioned how fre-
the therapeutic alliance in family therapy as quently split alliances, as described by Pinsof
multidimensional and occurring on multiple 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- for them to feel understood and for the tasks and
viation difference between individual family objectives to be clearly stated and agreed on in
members' ratings, 43% of couples and 75% of the early sessions of the intervention program"
families were classified as experiencing a split (Bourgeois et al., 1990, p. 613).
alliance with the therapist. On the basis of a Critique. In the earliest studies of the rela-
more conservative decision rule (2.0 SDs), 14% tionship, Shapiro (1974) asked therapists to rate
of couples and 42% of families were so classi- their responsiveness to the family as a whole,
fied. Fourth, the authors tested associations be- and Sigal et al. (1967) combined each family
tween client-therapist verbal interactions—that member's collaboration score to create a single
is, complementarity and symmetry (as coded variable. The relational measures in these early
on the FRCCCS; Friedlander & Heatherington, studies were global and vague, with little psy-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Studies designed to test theories of change in 1992). Men and women seem to experience the
family systems are only now emerging. Indeed, therapeutic process differently (Bourgeois et al.,
there are relatively fewer studies at the episode 1990; Cline et al., 1984).
or relationship level, levels that are arguably 5. Changes over the course of family therapy
more meaningful for the practicing family ther- as well as over time in a "good" session tend to
apist. In most of those investigations, speech be affective (Cline et al., 1984; Greenberg et al.,
acts were observed within specific therapeutic 1993; Johnson & Greenberg, 1988; Postner et
episodes or in relation to the therapeutic alliance al., 1971) and cognitive (Friedlander et al.,
(see Table 1). No studies were located, how- 1994; Winer, 1971) as well as behavioral (e.g.,
ever, in which all three levels in Greenberg's Sigal et al., 1967). These changes are observ-
(1986) process model were investigated simul- able not only in interpersonal relations (Green-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
doing, to offer guidelines for the advancement tasks in family therapy, so that family members'
of research on the process of change in family behaviors that are most facilitative of enduring
therapy. In the concluding section of this arti- change can be identified.
cle, we provide several recommendations, Relatedly, not much is known about effective
which are concerned not only with the sub- therapy from the family's perspective (Pinsof,
stance of future efforts but also with methods 1989; Wynne, 1988). Most research on the cli-
for conducting clinically relevant research on ent's role in the family therapy change process
family therapy. has been concerned with observable behavior
rather than with covert emotions and cognitions
What We Don't Know (Pinsof, 1988). With few exceptions, research-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
How Does Change Occur in the 1988). These kinds of questions have tradition-
Nonbehavioral Approaches? ally lent themselves to outcome research, yet
they are increasingly—and convincingly—be-
As in individual therapy, the family therapy ing linked with process variables in individual
approaches that focus on overt behaviors have therapy (Sue & Zane, 1987). Recent process
been the most researched. Our review suggests research by Zane (personal communication,
that the bulk of research has been conducted April 1993), for example, suggests that the level
on the structural, strategic, and systemic thera- of early self-disclosure that is generally encour-
pies (cf. Gurman et al., 1986), with relatively aged by therapists may be appropriate for Anglo
less attention to the psychoanalytic, experien- clients but is excessively intimate for some
Asian and Asian-American clients, who, by vir-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
approaches.
There is, nonetheless, fertile material for cerned with "face" in relationships. To expect
study in the nonbehavioral approaches (Gur- similar therapeutic processes with clients of dif-
man, 1988). The circular questioning tech- ferent cultural backgrounds may impede the
niques, for example, that are popular in the therapy, causing rifts in the alliance, premature
Milan and other constructivist therapies are eas- termination, or worse.
ily identified. Theoretically, these therapies are Many theorists are indeed concerned with
geared toward accomplishing certain tasks in issues of diversity in family therapy (e.g.,
the session. Is there any evidence to suggest that McGoldrick, Pearce, & Giordano, 1982;
they do so? Even constructivist theorists who Szapocznik & Kurtines, 1993), and their writ-
eschew simple, linear prescriptions for success- ings provide important sources from which to
ful therapy have made statements that can identify testable hypotheses. Researchers inter-
be operationalized and tested as hypotheses. ested in diversity would also do well to read and
Anderson and Goolishian (1992), for example, carefully critique family theories, especially
described "[t]he therapeutic conversation [as] a with regard to how theorists' assumptions and
two-way exchange, a criss-crossing of ideas . . . strategies may affect families from different
in which new meanings are continually evolv- cultures (cf. Tamura & Lau, 1992). One obvious
ing toward the 'dis-solving' of problems" (p. question is how different styles of family ther-
27). Indeed, is therapeutic discourse a "two-way apy (e.g., more or less active, directive, collab-
exchange, a criss-crossing of ideas"? Are "new orative, strategic, interpretive, etc.) intersect
meanings" expressed by family members over with the cultural or ethnic values that families
the course of therapy and, if so, how do these bring to the therapy room. It is reasonable to
meanings relate to the family's treatment goals? expect that cultural values differentially affect
Constructivist therapies are growing rapidly in family members' expectations for the thera-
popularity yet remain virtually unstudied. pist's behavior, their communication patterns in
the session, and their perceptions of the thera-
peutic alliance.
Diversity Issues in Family Therapy Regarding gender, the research reviewed here
suggests equivocal findings about bias in family
With the exception of the continuing interest therapy. It is interesting to note that the least
in gender effects, there has been little or no overt and the most interactional measures
research to date on issues of diversity in family of verbal behavior (in, for example, Brown-
therapy. In contrast to the relatively larger lit- Standridge & Piercy, 1988) were more likely to
erature base on diversity in individual therapy turn up evidence of gender differences in thera-
(e.g., Garfield, 1986), family therapists lack ba- pist-family communications. Indeed, it would
sic information about the demographics (race, be surprising if there were no such differences,
ethnicity, SES, or family structure) of family given evidence in sociolinguistics (Tannen,
therapy—who is referred for and who com- 1990), social psychology (Aries, 1987), and de-
pletes therapy (i.e., dropout rates), who is most velopmental psychology (e.g., Maccoby, 1990)
likely to benefit from or be harmed by family about the influence of gender on discourse pat-
therapy, and what family—therapist matchings terns in nontherapy contexts. Increased research
on demographic or cultural variables, if any, is needed in this area, including studies to ex-
facilitate progress in family therapy (Goldstein, amine the influence of gender on intrafamily
412 FRIEDLANDER, WILDMAN, HEATHERINGTON, AND SKOWRON
interactions (e.g., husband-wife, mother-chil- Yet more remains to be done. As one example,
dren, father-children, and sister-brother) dur- consider the recent work on the therapeutic al-
ing therapy, particularly as those family inter- liance. Despite recognition of its importance in
actions affect and are affected by the therapist's family therapy and the development of a self-
behavior. The politics of gender in cotherapy is report instrument for its measurement (Pinsof &
a second important area for study. Despite the Catherall, 1986), investigators have yet to dis-
popularity of cotherapy, the gender dynamics of cover what strategies are effective in creating a
this interpersonal relationship have yet to be strong alliance with a family group, whether
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with other salient variables like age (consider split alliances in a family (Heatherington &
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