P
Pairs Enrichment Program
Mo Therese Hannah1,2 and Rita DeMaria3,4
1
Siena College, Loudonville, NY, USA
2
Advanced Clinician, Imago Relationship
Therapy/Imago Relationships International,
Glen Ellyn, IL, USA
3
Couple and Family Therapy Program, Jefferson
University, Philadelphia, PA, USA
4
Post-Graduate MFT Certificate Program,
Council for Relationships,
Philadelphia, PA, USA
Name of the Model
Practical Application of Intimate Relationship
Skills (PAIRS)
Introduction
PAIRS is a comprehensive relationship education
program that serves as a bridge between marriage
education/enrichment (primary and secondary
intervention) and marital therapy (tertiary inter-
vention). The model integrates marital enrich-
ment, education, and therapeutic treatment in the
support of healthy couple relationships (DeMaria
2003). PAIRS focuses on the essential role that
primary relationships play in shaping our thoughts
and feelings which in turn has a powerful impact
© Springer Nature Switzerland AG 2019
J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy,
https://doi.org/10.1007/978-3-319-49425-8
on how we view ourselves and perceive and
respond to other human beings.
With its broad focus and appeal, the PAIRS
program is suitable for couples in relatively
healthy, non-distressed relationships who wish to
deepen their intimacy, as well as for distressed
couples experiencing significant relationship dif-
ficulties (DeMaria 2005; Greenberg and Johnson
1988; Hawley and Olson 1995; Wampler 1982;
Zimpher 1988). It is systematic and comprehen-
sive in that it targets all of the major areas of
relationship functioning that are usually addressed
collectively by other existing relationship pro-
grams (Turner and Gordon 1995). These core
areas include improving intimacy and communi-
cation, training in conflict resolution and emo-
tional literacy, and enhancing sensuality and
sexuality. PAIRS thus provides for couples
instruction and practice in the mental, emotional,
and behavioral skills associated with healthy rela-
tionship functioning. The PAIRS program is a
group-based psychoeducational model. The pro-
gram is delivered in a variety of formats of differ-
ing lengths, including 1-day, 2-day, 8-week, and
16-week courses. The longest format consists of
120 h of instruction.
Prominent Associated Figures
Seminal thinkers who contributed to the core
concepts and practices of the PAIRS program
2100
include Lori Gordon, Virginia Satir, Dan Casriel,
George Bach, and Michele Baldwin. These indi-
viduals were representative of the then-current
state of theoretical frameworks for understand-
ing couple dynamics and interventions. Lori Gor-
don developed PAIRS as an integration of
mainstream theories and clinical approaches
drawn from the fields of human relations, family
therapy, and communications theory (Gordon
and Frandsen 1993). Through her incorporation
of these diverse, well-established perspectives,
Gordon targeted the specific attitudes, behaviors,
and emotions that require change if couples
are to enjoy a loving, passionate, and intimate
relationship.
Theoretical Framework
Like other integrative marital education/therapy
programs, PAIRS targets multiple areas of per-
sonal and relational functioning: emotions, behav-
ior, and cognitions. Uniquely in PAIRS, special
emphasis is given to the core theoretical concept
of bonding (Gordon and Frandsen 1993). The
emphasis on bonding was influenced by Casriel
(1972) who formulated “the road of happiness”
(Casriel 1983), which guided the development
of PAIRS. According to PAIRS, bonding is a
process involving both physical and emotional
closeness, and the quality of bonding between
romantic partners predicts their ability to under-
stand and express emotions and to experience a
secure sense of attachment to one another. Only
under the condition of secure bonding can part-
ners take the risk of engaging in emotional and
psychological self-examination and intimate shar-
ing, which allows them to move together toward
healthy behavioral, attitudinal, and emotional
changes. The attention of the PAIRS program to
bonding foreshadowed Johnson’s (1986) attention
to the importance of emotional bonds for couples,
which was then followed by Greenberg and John-
son (1988), who used bonding as a strong theo-
retical foundation for emotional focused couples
therapy.
Theory of Change and Rationale for the
Model. The guiding paradigm for the PAIRS
Pairs Enrichment Program
course is based on the “the road of happiness,”
proposed by Casriel in his early work (1972).
The concept was adopted and elaborated
as The Relationship Road Map by PAIRS found-
er, Lori Gordon (1992). The Relationship Road
Map follows an emotionally focused-cognitive-
behavioral model and highlights that emotions
have logic to them: people are motivated to seek
pleasure and avoid pain (Casriel 1983). When one
associates his or her partner with pain, he/she
will tend to avoid the partner. On the other hand,
if the partner is a source of pleasure, the other
will naturally seek him or her out. The PAIRS
Curricula (Gordon 1992) outlined a comprehen-
sive model for change emphasizing the critical
importance of helping couples generate psycho-
logical, emotional, physical, and sexual pleasure
and was further elaborated by DeMaria and
Hannah (2003) in collaboration with PAIRS
Leaders. The PAIRS Curriculum was included as
an application for low-income couples as part of
federal initiative (Gordon et al. 2007).
Populations in Focus
Conventional clinical thinking is that only
healthy, non-distressed couples can benefit
from PAIRS and similar enrichment programs
(Hunt et al. 1998). However, according to several
authors, distressed couples can also gain from
participating in marital enrichment programs
(Blanchard et al. 2009; DeMaria 1998, 2005;
Durana 1997; Giblin 1986; Hawley and Olson
1995; Mattson et al. 1990). In particular, Giblin’s
(1986) meta-analysis revealed that distressed cou-
ples participating in marriage enrichment pro-
grams experienced positive effects.
DeMaria (2005) found that 67% of the couples
who enrolled in the PAIRS program were
devitalized based on Olson and Fowers’ (1993)
couple typology for five couple types, which
include vitalized, harmonious, traditional, con-
flicted, and devitalized couples. Using the Dyadic
Adjustment Scale (Spanier 1976), the most widely
used self-report measure of couple functioning,
these same couples were also highly distressed.
Characteristically, devitalized couples report very
Pairs Enrichment Program
low relationship satisfaction and have difficulty
with communication (or low to no communica-
tion) as well as difficulty with conflict resolution.
These couples are also low in sexual satisfaction
and have the lowest scores across all dimensions
of the typology. Olson and collaborators (Allen
and Olson 2001; Garrett and Olson 2006: Olson
2011) found similarities in the couple typology
for African-American, Hispanic, and White cou-
ples, and research continues on cultural adapta-
tions for the PREPARE-ENRICH inventories.
Strategies and Techniques Used in
Model
The PAIRS program runs for 120 h over
the course of 16 weeks, including four weekends.
The core strategies taught in the program are
communication, problem-solving and conflict res-
olution skills, exercises to increase emotional and
physical bonding, enhancing sexual satisfaction,
and developing a relationship vision (Berger and
Hannah 1999; DeMaria and Hannah 2003;
Gordon 1992; Turner and Gordon 1995).
PAIRS covers the following concepts and
processes that emphasize alleviation of distress
and enhancement of emotional and physical con-
nection. There are seven basic components to the
program:
1. The Relationship Road Map, based on
Casriel’s (1983) “road of happiness,” provides
a key concept that emphasizes the interplay
between thoughts, behavior, and emotion and
is designed to heal pain and change fixated
behaviors through emotional expression and
bonding.
2. Emotional Literacy, in which participants learn
to become more adept at reading, interpreting,
and expressing emotions.
3. Communication and Conflict Resolution,
whereby couples learn how to listen and
speak in ways that deepen their level of con-
fiding and gain tools to express and resolve
conflicts constructively.
4. Family Systems, an approach which has cou-
ples engage in exercises and strategies for
2101
deepening their understanding of the structure
and functioning of their own families of origin.
5. Bonding and Emotional Re-education, used
to facilitate self-exploration and to encourage
new emotional, cognitive, and behavioral
experiences for both partners.
6. Sensuality and Sexuality, which is focused
on enhancing pleasure in the couple’s
relationship.
7. Contracting: Clarifying Expectations and
Needs, which serves as the culmination of
everything that is covered in the entire PAIRS
program, allowing participants the opportunity
to integrate their new learnings.
The core techniques taught and practiced in
the full-scale PAIRS program include the Daily
Temperature Reading, Congruent Communica-
tion, the Negative Emotional Infinity Loop and
Emotional Allergies, the Emotional Jug, Emo-
tional and Physical Bonding, Fair Fight for
Change, Self Awareness and Family Genograms,
Sexuality, and Behavioral Contracting (Gordon
1992).
Research About the Model
The PAIRS model has had many clinical appli-
cations through psychoeducational programs P
conducted with distressed and non-distressed
couples (DeMaria 2005; Guerney and Maxson
1990; Hsueh et al. 2012). Early research on
change mechanisms of PAIRS focused primar-
ily on the bonding and emotional expressive-
ness (BEL) segment, which revealed that BEL
is a key element in inducing change, as is con-
gruent with other findings that support affective
interventions (Durana 1994). Durana (1996a, b,
c) conducted pre-, post-, and follow-up studies
of participants and discovered positive impacts.
Additional effectiveness studies have demon-
strated that the PAIRS program improves couple
functioning in a range of populations, including
distressed and non-distressed couples in a vari-
ety of cultural and socioeconomic communities
(Durana 1996a; Hsueh et al. 2012; Peluso
2011).
2102
Case Example
Jessica and Frank are a couple in their mid-40s
who have been married for 20 years. In the early
part of their marriage, they postponed having chil-
dren to complete their advanced degrees and to
“find themselves.” For a decade, they were very
happy in their relationship.
It was after the birth of their daughter, Alexa,
that things began to go steadily downhill. Alexa
was a colicky baby who did not sleep through the
night. Jessica, exhausted by the baby’s crying and
demands to nurse, found herself growing more
and more tired, stressed out, and curt with her
husband. Frank, for his part, did his best to com-
pensate by taking on more of the housework and
grocery shopping; after a few months exercising
patience, he finally blurted out that he no longer
enjoyed living with “his new wife.” Jessica would
respond with her own angry comebacks.
The couple’s marital distress did not keep
them from having another baby when Alexa
was a toddler. The couple’s excitement over
the arrival of their son, Joshua, provided a tem-
porary retrieve from their misery. Unlike that of
Alexa, Joshua’s babyhood went relatively
smoothly; he slept through the night starting at
around 3 months of age, and he did not experi-
ence the colic and irritability that plagued
Alexa’s infancy. Nonetheless, the relative tran-
quility of bringing up baby Joshua was not
matched by any lasting improvements in the
quality of the parents’ marriage. The couple
managed to co-parent fairly well together, with
relatively little conflict; they shared a belief in
authoritative parenting, and both were devoted
to raising their children to be healthy and pro-
ductive adults. That was, however, where their
relationship harmony ended: they fought, some-
times viciously, about almost everything else,
including money, sex, and in-laws.
By the time their kids were teens, Jessica
noticed a romantic text emerge on her husband’s
smartphone. Jessica confronted Frank about the
matter and threatened divorce if Frank did not end
his inappropriate interactions with a coworker.
Frank finally agreed that he and his wife should
seek out some form of marital therapy.
Pairs Enrichment Program
Frank and Jessica heard about the PAIRS
program from a couple they knew who had gone
through a difficult time in their own marriage
several years earlier. This couple claimed that
PAIRS had “literally saved their relationship.”
After signing up for the full 120-h program, they
arrived at the first group meeting feeling some-
what hesitant and embarrassed over their predica-
ment. But they quickly discovered, upon hearing
from the other couples in the group, that they were
not alone in their struggles. Several other couples
revealed that they, too, had been negatively
affected by an affair. This led the couple to feel
safer and more open to receiving what PAIRS had
to offer.
The first part of the course focused on styles
of communication. Frank was surprised to realize
that he avoided sharing his feelings with Jessica.
Jessica learned that she tended to ignore prob-
lems and issues in her relationship with Frank
while focusing predominantly on her children.
They attended a communication and conflict man-
agement weekend workshop, where they began to
really listen deeply to each other. Over the course
of the weekend, they learned a variety of tech-
niques for resolving differences, even long-
standing ones.
The next part of the PAIRS course addressed
the importance of partners’ understanding and
sharing their most vulnerable emotions – their
fears, sorrows, hopes, and joys. In this segment,
they learned about the negative infinity loop – the
never-ending conflict that plagues distressed cou-
ples, in which partners repeat the same destructive
cycles over and over again, resulting in further
wear and tear on their relationship. In the PAIRS
course, they began to learn how to nurture their
relationship. They also explored how the emo-
tional and behavioral patterns of their respective
families of origin were being reenacted in their
relationship. Frank and Jessica were experiencing
a paradigm shift about themselves, their marriage,
and the affair. In small groups, they shared with
others and listened about their families, their lives,
their hopes, and dreams, as well as their failures
and heartbreaks. Jessica was able to share her pain
and loneliness with other women. Frank was able
to learn from other men who struggled to be
Pairs Enrichment Program
faithful. For the first time in his life, Frank told
another person about his father’s affairs. He expe-
rienced support and caring from other men in
ways he had never before experienced.
Within the safe structure of the PAIRS week-
end program on sexuality, Frank and Jessica
delved into the vulnerable topic of Frank’s affair
and how it had affected their sexual relationship.
During the weekend, they examined their attitudes
and hidden struggles revolving around giving and
receiving pleasure.
By this point, Frank and Jessica were
re-committed to their marriage. They had set up
boundaries around Frank’s affair-work relationship.
Frank decided that he would look for another job.
Frank recognized that the stress of work and his
unrecognized needs for connection and safety with
Jessica were at least part of the reason he “crossed
the line.” For her part, Jessica came to understand
that Frank longed for her to be more sexually pas-
sionate and recognized that, in her family of origin,
affection and sexuality had been taboo.
As the course neared the end, couples were
given the opportunity to make concrete plans for
their future relationship. As part of this process,
Frank and Jessica identified specific and concrete
goals that they wished to achieve as individuals
and as a couple. In the final segment of the course,
they collaborated in creating a script for their new
and much improved relationship. With their
PAIRS course completion certificates in hand,
they were now fully equipped and capable of
actualizing the kind of relationship they had
always hoped to have.
Cross-References
▶ Attachment Theory
▶ Behavioral Couple Therapy
▶ Circle of Security: “Understanding Attachment
in Couples and Families”
▶ Cognitive Behavioral Couple Therapy
▶ Communication Training in Couple and Family
Therapy
▶ Contracting of Goals in Couple and Family
Therapy
▶ Dyadic Adjustment Scale
2103
▶ Emotion in Couple and Family Therapy
▶ Family of Origin
▶ Guided Imagery in Couple and Family Therapy
▶ Modeling in Couple and Family Therapy
▶ Pairs Enrichment Program
▶ Prepare/Enrich Enrichment Program
▶ Problem-Solving Family Therapy
▶ Problem-Solving Skills Training in Couple and
Family Therapy
▶ Restructuring the Bond in Emotion-Focused
Therapy
▶ Sexuality in Couples
References
Allen, W. D., & Olson, D. H. (2001). Five types of African
American marriages based on ENRICH. Journal of
Marital and Family Therapy, 27(3), 301–314.
Berger, R., & Hannah, M. (1999). Preventive approaches
to coupled therapy. New York: Taylor & Francis.
Blanchard, V., Hawkins, A. J., Baldwin, S. A., &
Fawcett, E. B. (2009). Investigating the effects of mar-
riage and relationship education on couples’ communi-
cation skills: A meta-analytic study. Journal of Family
Psychology, 23(2), 203–214. American Psychological
Association.
Casriel, D. (1972). A scream away from happiness.
New York: Grosset & Dunlap.
Casriel, D. (1983). The relationship road map (Videotaped
lecture). Falls Church: PAIRS Foundation.
DeMaria, R. (1998). Satisfaction, couple type, divorce P
potential, conflict styles, attachment patterns, and
romantic and sexual satisfaction of married couples
who participated in a marital enrichment program
(PAIRS) (Unpublished doctoral dissertation), Bryn
Mawr College, Bryn Mawr.
DeMaria, R. (2005). Distressed couples and marriage
education. Family Relations, 54(2), 242–253.
DeMaria, R., & Hannah, M. (2003). Building intimate
relationships: Clinical applications of the PAIRS
program. New York: Brunner Routledge.
Durana, C. (1994). The use of bonding and emotional
expressiveness in the PAIRS training: A psychoedu-
cational approach for couples. Journal of Family
Psychotherapy, 5(2), 65–81.
Durana, C. (1996a). A longitudinal evaluation of the effec-
tiveness of the PAIRS psychoeducational program for
couples. Family Therapy, 23, 11–36.
Durana, C. (1996b). Bonding and emotional re-education
of couples in the PAIRS training: Part I. The American
Journal of Family Therapy, 24(3), 269–280.
Durana, C. (1996c). Bonding and emotional re-education
of couples in the PAIRS training: Part II. The American
Journal of Family Therapy, 24(4), 315–328.
2104 Pakman, Marcelo

Durana, C. (1997). Enhancing marital intimacy through Wampler, K. S. (1982). The effectiveness of the Minnesota
psychoeducation: The PAIRS program. The Family Couple Communication Program: A review of
Journal, 5(3), 204–215. research. Journal of Marital and Family Therapy, 8,
Garrett, J., & Olson, D.H. (2006) ENRICH couple typology 345–356.
and Hispanic and Caucasian married couples. Zimpher, D. G. (1988). Marriage enrichment programs:
Unpublished manuscript, Life Innovations, A review. Journal for Specialists in Group Work, 13,
Minneapolis. 44–53.
Giblin, P. (1986). Research and assessment in marriage and
family enrichment: A meta-analysis study. Journal of
Psychotherapy and the Family, 2, 79–95.
Gordon, L. H. (1992). Training manual and curriculum
guide, Vols. I and II. Falls Church: PAIRS Foundation.
Gordon, L., & Frandsen, J. (1993, 2001). Passage to Inti- Pakman, Marcelo
macy (Revised Edition). Fireside, Falls Church, VA.
Gordon, L., DeMaria, R., Haggerty, V., & José Nesis1 and Rodrigo Morales Martínez2
Hayes, E. (2007). PAIRS SHM facilitator’s guide and 1
curriculum for managers, facilitators, and family sup-
Ministry of Justice and Human Rights, Buenos
port staff. Weston: PAIRS Foundation. Aires, Argentina
2
Greenberg, L. S., & Johnson, S. (1988). Emotionally Universidad Alberto Hurtado, Santiago, Chile
focused couples therapy. New York: Guilford Press.
Guerney, B., & Maxson, P. (1990). Marital and family
enrichment research: A decade review and look
ahead. Journal of Marriage and the Family, 52, Introduction
1127–1135.
Hawley, D. R., & Olson, D. H. (1995). Enriching newly- Marcelo Pakman, MD, is an Argentinian medical
weds: An evaluation of three enrichment programs. The
American Journal of Family Therapy, 23, 129–147.
doctor with extensive experience and interna-
Hsueh, J., Alderson, D. P., Lundquist, E., tional prestige in psychotherapy, community psy-
Michalopoulos, C., Gubits, D., Fein, D., & chiatry, and systemically oriented family therapy.
Knox, V. (2012). The supporting healthy marriage His work, which has been called an “anthropology
evaluation: Early impacts on low-income families.
New York: MDRC.
of therapeutic praxis,” articulates the relationships
Hunt, R., Hof, L., & DeMaria, R. (1998). Marriage enrich- between epistemology, philosophy, and art on one
ment, preparation, mentoring and outreach. New York: side and clinical practices as well as social inter-
Taylor & Francis. ventions in issues as diverse as work with minor-
Johnson, S. (1986). Bonds or bargains: Relationship para-
digms and their significance for marital therapy.
ities, immigrants, and ethnic dissonance, on the
Journal of Marital and Family Therapy, 12, 259–267. other. He is considered a leading figure in the
Mattson, D. L., Christensen, O. J., & England, J. T. (1990). theoretical-clinical field of systemic therapy and
The effectiveness of a specific marital enrichment pro- has, for over 25 years, given conferences, semi-
gram: Time. Individual Psychology, 46(1), 88–92.
Olson, D. (2011). FACES IV and circumplex model.
nars, and workshops all around the globe, as well
Journal of Marital and Family Therapy, 3(1), 64–80. as written books and articles translated into sev-
Olson, D. H., & Fowers, B. J. (1993). Five types of mar- eral languages.
riage: An empirical typology based on ENRICH. The
Family Journal, 1(3), 196–207.
Peluso, P. ( 2011). Relationship education impact reports,
PAIRS Foundation for the U.S. Department of Health
Career
and Human Services, Administration for Children and
Families. http://evaluation.pairs.com/reports/pairs0505 Pakman graduated with honors from the medical
10.pdf. school of the University of Buenos and completed
Spanier, G. B. (1976). Measuring dyadic adjustment:
his psychiatry residence in the by then same city’s
New scales for assessing the quality of marriage and
similar dyads. Journal of Marriage and the Family, main children’s hospital. On top of a solid
38, 15–28. psychoanalytic formation, he showed an early
Turner, L., & Gordon, L. H. (1995). PAIRS (Practical interest in theoretical and clinical systemic devel-
Application of Intimate Relationship Skills): An inte-
opments while teaching developmental psychol-
grative approach to intimate relationship change
through a psychoeducational program. Journal of Cou- ogy. A comprehensive and thorough reading of
ples Therapy, 5(1–2), 37–53. the clinical and philosophical bases of systemic
Pakman, Marcelo
thought gave fruit to a synthesis that forever
left its mark on the international systemic scene.
Pakman was invited by Heinz von Foerster to the
third Gordon Conference on Cybernetics, where
he met other major protagonists of that field.
Pakman’s Spanish edition, with his extensive
commentaries of von Foerster’s collected papers
(1991), disseminated in detail the relationship
between cybernetics and therapy for the large com-
munity of Spanish-speaking therapists. He migrated
to the United States in 1989, where he joined Carlos
Sluzki’s team and, in the year 2000, took over the
direction of the intensive courses on systemic ther-
apy in Spanish where many Latin American thera-
pists were trained. From 1994 to 1999, Pakman
presided over the Human Rights Committee of the
American Family Therapy Academy, institution
where he would later become Vice President
(2001–2002). He also served as Vice President for
the American Society for Cybernetics from 1995 to
1998. Furthermore, he has been a member of the
editorial board of multiple professional journals in
America and Europe.
Contributions
His clinical work with individuals and families, as
well as in community mental health, elicited a
philosophical investigation of the epistemologi-
cal, ontological, and ethical-political bases of psy-
chotherapeutic practices, particularly those with a
systemic orientation. Thus, he delivered a critical
analysis of the clinical trends that, explicitly or
implicitly, reproduce positivist philosophies as
well as those resulting from the linguistic turn.
His critique, both substantial and rigorous, with-
out disregarding the rich philosophical heritage of
these traditions, questions their reductionist con-
sequences by showing how systemic psychother-
apy has tended to either ignore all cultural,
linguistic, and social factors or, on the contrary,
fall into a dictatorship of linguistic meaning as
part of what Pakman has called “dominant micro-
politics.” In both cases, he remarks the exclusion
of the singularity and the materiality of lived
experiences at the center of processes of discon-
tinuous change.
2105
Rather than breaking away from systemic
thinking, Pakman reinterprets the bases of it,
mainly of Gregory Bateson (Pakman 2004) and
of Heinz von Foerster, in light of new theoretical
developments that integrate a philosophical,
social, artistic, and clinical perspective. In his
works, Pakman elaborates aspects of the philoso-
phy of meaning of Jean-Luc Nancy, the event
philosophy of Alain Badiou, the political philos-
ophy of Giorgio Agamben, and the transversal
analysis on power by Michel Foucault.
In Palabras que Permanecen, Palabras por
Venir. Micropolítica y Poética en Psicoterapia
(2011), and in Texturas de la Imaginación. Más
allá de la Ciencia Empírica y el Giro Lingüístico
(2014), Pakman develops a “critical-poetic”
stance in psychotherapy, characterized by (a) a
critical view on dominant micropolitics, distanc-
ing himself from the forces that capture people,
through stereotypical scripts, in a dominant sub-
jectivity practice; (b) a movement from the lin-
guistic meaning as the epicenter of psychotherapy,
toward the dimension of sense, understood as the
material and singular presence configured prior to
the meaning making allowed by speech, in what
Pakman calls an ecology of the lap, which
exceeds, during our lives, any act of linguistic
representation; (c) and, finally, an interest in
poetic events: inflection points in psychotherapy
in which, through an imaginative process – under- P
stood as a work with the singular, material, and
sensual textures that the images of the worlds that
we inhabit appear in – a difference appears, in the
Batesonian sense, that surprises a person with
regard to their self or dominant continuity.
Pakman’s critical-poetic work transcends tra-
ditional therapeutic spaces, opening up to the
microcommunities arising around singular poetic
events. Through its resistance to the hegemony of
established meanings, it allows him to tackle
social topics related to forms of racial, cultural,
political, and religious domination.
In El Sentido de lo Justo (2018), Pakman
begins to critically explore the ethical and moral
perspectives arising from dominant micropolitics
and proposes, in an antithetical fashion, that he
calls “a sense of the just,” a notion that roots every
ethical and moral practice to the dimension of
2106
sense and singular presence. This permits
questioning explicit and implicit norms when
confronting ethical and moral crises, both in the
clinic and in broader domains.
Cross-References
▶ Bateson, Gregory
▶ Micropolitics and Poetics in Couple and Family
Therapy
▶ Second-Order Cybernetics in Family Systems
Theory
▶ Torture in Couple and Family Therapy
▶ Von Foerster, Heinz
References
Pakman, M. (2004). On imagination: Reconciling knowl-
edge and life or what does ‘Gregory Bateson’ stand for?
Family Process, 43(4), 413–423.
Pakman, M. (2011). Palabras que permanecen,
palabras por venir. Micropolítica y poética en
psicoterapia. Barcelona: Gedisa.
Pakman, M. (2014). Texturas de la imaginación. Más allá
de la ciencia empírica y el giro lingüístico. Barcelona:
Gedisa.
Pakman, M. (2018). El sentido de lo justo. Para una ética
del cambio, el cuerpo y la presencia. Barcelona:
Gedisa.
Von Foerster, H. [Ed. Pakman, M.]. (1991). Las semillas de
la cibernética. Barcelona: Gedisa.
Palo Alto Group, The
Wendel Ray
University of Louisiana Monroe, Monroe, LA,
USA
Introduction
The term “Palo Alto Group” refers to Gregory
Bateson and his research associates in Palo Alto,
California, or to Don D. Jackson, M.D., and his
early coworkers at the Mental Research Institute
(MRI), or both, since their personnel and research
overlap. This term is convenient for referring to a
Palo Alto Group, The
number of researchers and clinicians jointly inter-
ested in examining behavior (especially symp-
tomatic or deviant behavior) as a function of
communication and interaction in social systems,
studied initially in the family. There is, however,
not a specific organization named “The Palo Alto
Group.” Along with basic shared interests and
approaches among these researchers and clini-
cians, certain differences and changes over time
have also existed.
Prominent Associated Figures and
Contributions
Bateson’s original research group included John
H. Weakland and Jay Haley when the group began
in late 1952 and ended in June 1961. Psychiatrist
Dr. Jackson joined in early 1954, and William F. Fry,
M.D., also a psychiatrist, participated at various
periods (Fry 1962, 1963). Initial research focused
on the general nature of communication, especially
the existence of different levels of messages and
paradoxes – a view explicitly guided by the Theory
of Logical Types in Whitehead and Russell’s
Principia Mathematica (1903). This combination
of theoretical interest and intensive study of actual
communication led progressively to: (1) a concern
with the multiplicity of messages in all communi-
cation and how the various messages frame or
qualify one another; (2) examination of the peculiar
communication of schizophrenics, and comprehen-
sion of this as “unlabeled metaphor,” (3) inquiries
on how such communication might have been
learned, especially in family contexts, and
(4) application of a cultural anthropology method-
ology (Weakland 1951, 1967, 1975) to analyze
family interaction, with a shifting of focus from
learning derived from past experiences to the
nature of interaction in the present moment, out
of which emerges shared “reality.” This shift of
attention to current interaction and study of
recorded interviews with schizophrenics and their
families led to formulation of “family homeosta-
sis,” as a conceptual tool for grasping the interac-
tional nature of behavior qua behavior and a
potential to attempt to reinstate the status quo
when proposed change is experienced as too
Palo Alto Group, The
threatening (Jackson 1957). This led to the
“double-bind theory,” in which schizophrenic
behavior is seen as a response to a communication
pattern involving two incongruent messages of
different levels, and where comment on this incon-
gruence or escape from the field is prohibited
(Bateson et al. 1956).
Thus, interest in the nature of communication
and its behavioral influence resulted in viewing of
symptoms which focused primarily on observable
current interaction in family systems rather than on
inferences as to special mental or biochemical
qualities of separate individuals, or unobservable
childhood experiences. This further led to beginning
efforts at conjoint family therapy of schizophrenia –
the application of this interactional viewpoint to
treatment (Jackson and Weakland 1961).
In October 1958, Dr. Don D. Jackson founded
the Mental Research Institute (MRI) as a center for
building on the theoretical and practical foundations
laid by the Bateson group, which was nearing the
end of its joint work. Through research, treatment,
and training programs, the MRI has continued to
work toward broadening the scope of the interac-
tional viewpoint on behavior – to look at other
behaviors in addition to schizophrenia, and other
groups in addition to the family – and toward
increasing the effectiveness of its practical applica-
tion. An overview of the interactional approach and
its significance is given in Watzlawick, Beavin, and
Jackson, Pragmatics of Human Communication
(1967). An extensive review of the work and ideas
of the Bateson group is given by Haley, with com-
ments by Bateson and Weakland, in C. Sluzki and
D. Ransom, editors, Double Bind: The Foundation
of the Communicational Approach to the Family
(1976), and in Weakland’s paper, “One thing leads
to another,” in C. Wilder-Mott and J. Weakland
(Eds.), Rigor & Imagination: Essays from the Leg-
acy of Gregory Bateson (1981), and in Ray and
Simms (2016). Continued application of the Inter-
actional View and continued study of actual com-
munication led to the development of the MRI Brief
Therapy model of problem formation and problem
resolution (Fisch et al. 2009; Ray and Watzlawick
2005; Weakland et al. 1974; Watzlawick et al. 1974;
Fisch, Weakland, & Segal, 1982; Weakland and Ray
1995).
2107
Enduring Contributions
The Palo Alto Group intentionally chose not to
use conventional presuppositions of intrapsychic
psychology and biology and instead applied Cul-
tural Anthropology Methodology (Weakland
1951) and observations introduced by Harry
Stack Sullivan in his Interpersonal Theory of Psy-
chiatry (1953) to intentionally shift the focus of
attention to behavior as emerging from the inter-
action between people in the current moment of
exchanges, which, in effect, were understood as
efforts to define the nature of the relationship.
Many of the precepts of the Interactional View
and related techniques of action that are now
accepted across a wide spectrum of theories and
models were introduced by the Palo Alto Group in
addition to Family Homeostasis and the Double
Bind, which include:
• The vital importance of an intentional shift in
primary data from the nature of the individual
to the nature of the relationship between people
interacting in the present moment.
• The vital relevance of context in
comprehending and attributing meaning to
behavior.
• Observer imposed punctuation, where attribu-
tion of meaning is often different from the
vantage point of different participants, and P
from the perspective of an observer. For exam-
ple, one spouse may complain that the problem
is that the other spouse nags, while the other
spouse being accused of nagging may say they
are compelled to nag because the other spouse
hides behind a smart phone and will not
respond. Both are partially “correct,” but all-
to-often with limited capacity to take into
account their own behavior as a part in the
exchange (Bateson and Jackson 1964).
• Close attention is given to how people qualify
their own messages verbally and nonverbally.
Often comments about the nature of the rela-
tionship being exchanged at the command
level reveal themselves in how messages are
exchanged, usually out of the awareness of
participants (Jackson 1965a; Watzlawick
et al. 1967).
2108
• Following Bateson’s lead, the complementary
dichotomy of report and command facilitates
rapid understanding of behavior exchanges.
“Every communication bit conveys informa-
tion of a factual nature which, presumably,
can be evaluated in terms of truth and falsity,
and can be dealt with logically as the ‘object’
of communication; this is the communication
report; e.g., ‘the streets are icy,’ or a shake of
the head. In addition to this report . . . the same
communication bit also conveys a command
which indicates how this information is to be
taken. . . . [in] human communication
[in] which the command aspect can be para-
phrased, “this is how I define the relationship
in which this report takes place, i.e., this is how
you are to see me in relation to you” (Jackson
1965a, p. 7). Exchanges of behaviors are
understood as explicit and implicit attempts to
define the nature of the relationship. Further,
difficulties in living emerge from such strug-
gles to define the nature of the relationship
(Bateson 1972).
• Family Rules. According to Jackson, “the
major assertion of the [current interaction
focused] theory to be outlined here is that the
family is a rule-governed system: that its mem-
bers behave among themselves in an orga-
nized, repetitive manner and that this
patterning of behaviors can be abstracted as a
governing principle of family life” (1965a,
p. 6). In relationships, people behave as though
following rules; once these repeating
exchanges are understood, they become the
focus of efforts made to evoke change. The
marital quid pro quo is one such rule
(Jackson 1965b).
• Circular or recursive causality in distinction
from lineal causality logic.
• A nonpathological, nonnormative view of
human behavior (set forth by Jackson, “the
individual does the best he can at any given
moment. . . The terms ‘lazy,’ ‘stubborn,’ ‘no
will power’ are not merely descriptive, but
imply moral censure and an unspoken ‘he
could do better if he wanted to.’ Hence. . .
certain dynamic interpersonal processes over
Palo Alto Group, The
which the individual has no control are respon-
sible for his character traits” (1952,
pp. 391–394). The implication of adopting a
nonpathological, nonnormative view is pro-
found. “If one assumes that the truly abnormal
is produced by pathological cells, one need
have little guilt about man’s inhumanity to
man” (Jackson 1967, p. 30)
• “Reality” is constructed, emerging from pat-
terns of interaction. In intimate relationships,
such repetitions reveal the interconnected and
context contingent nature of behavior qua
behavior.
• Intentional shifting verb tense from “to be” to
“to seem” to move away from a language-
based illusion of objective reality.
• First- and second-order cybernetics. Jay
Haley and John Weakland frequently said
that in supervision, when they were describ-
ing a patient’s behavior, Don Jackson would
ask, “What did you do to bring that about.”
Jackson emphasized that the therapist is
actively part of the situation, articulating
what is called a first- and second-order cyber-
netic view: “Over and over again it has been
necessary to learn the lesson that the observer
influences the observed . . . In the field of
mental health, we have not only to reckon
with the natural effect of the observers’ own
bias but we also have to deal with a second
variable: the effect of this bias on the patient”
(pp. 5–6).
• In evoking change, promotion of insight was
recognized as inconsequential, reframing
replaced interpretation, the difference between
injunctive and descriptive language was artic-
ulated, giving direct and indirect behavioral
tasks gained importance, and the essential
role of positive connotation promoted
(Jackson 1961; Watzlawick 1986).
George Orwell (1946) once wrote, “To see
what is in front of one’s nose needs a constant
struggle.” The fruits of one such constant strug-
gle is found in the contributions of the Palo Alto
Group during and continued by various group
members subsequent to the project. The basic
Palo Alto Group, The
premises of communication theory set forth in
the research and publications of the Palo Alto
Group contributed to the creation of a radically
alternative way of understanding behavior qua
behavior, constituting the enduring legacy of the
Interactional View. This uncompromisingly
relationship and contextual view contributed to
the launching of marriage and family therapy
and brief therapy, and found immediate rele-
vance across a wide spectrum of sciences from
ecological to biological, to behavioral.
References
Bateson, G. (1972). Steps to an ecology of mind.
New York: Ballantine Books.
Bateson, G., & Jackson, D. (1964). Social factors and
disorders of communication. Some varieties of patho-
genic organization. In Disorders of communication
(Vol. 42, pp. 270–283). Baltimore: Research Publica-
tions, A.R.N.M.D.
Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956).
Toward a theory of schizophrenia. Behavioral Science,
1(4), 251–264.
Bateson, G., Weakland, J., & Haley, J. (1976). Comments
on Haley’s “history”. In C. Sluzki & D. Ransom (Eds.),
Double bind – The foundation of the communicational
approach to the family (pp. 105–110). New York:
Grune & Stratton.
Fisch, R., Ray, W., & Schlanger, K. (Eds.). (2009).
Focused problem resolution – Selected papers of the
MRI brief therapy center. Phoenix: Zeig, Tucker,
Theisan, Ltd.
Fry, W. (1962, September). The marital context on an
anxiety syndrome. Family Process, 1(2), 245–252.
Fry, W. (1963). Sweet madness: The study of humor. Palo
Alto: Pacific Books.
Jackson, D. (1952, June). The relationship between the
referring physician and the psychiatrist. California
Medicine, 76(6), 391–394.
Jackson, D. (1957). The question of family homeostasis.
The Psychiatric Quarterly Supplement, 31(part 1),
79–90.
Jackson, D. (1960). Introduction. In D. Jackson (Ed.), The
etiology of schizophrenia (pp. 3–20). New York: WW
Norton.
Jackson, D. (1961). Interactional psychotherapy. In
M. Stein (Ed.), Contemporary psychotherapies
(pp. 256–271). New York: The Free Press of Glenco.
Jackson, D. (1965a). The study of the family. Family
Process, 4(1), 1–20.
Jackson, D. (1965b, June). Family rules, marital quid pro
quo. Archives of General Psychiatry, 12, 589–594.
2109
Jackson, D. (1967). The myth of normality. Medical Opin-
ion & Review, 3(5), 28–33.
Jackson, D., & Weakland, J. (1961). Conjoint family
therapy – Some considerations on theory, technique &
results. Psychiatry, 24(Suppl. #2), 30–45.
Orwell, G. (1946, March 22). In front of your nose. London
Tribune, London.
Ray, W. (Ed.). (2005). Essays at the dawn of an era – Don
D. Jackson, MD, selected papers volume I. Phoenix:
Zeig, Tucker, Theisan, Ltd.
Ray, W., & Watzlawick, P. (2005). The Interactional
Approach – Enduring Conceptions from the Mental
Research Institute. Journal of Brief Therapy, 6(1),
1–20.
Ray, W. (Ed.). (2009). Interactional theory in the practice
of therapy – Don D. Jackson, MD, selected papers
volume II. Phoenix: Zeig, Tucker, Theisan, Ltd.
Ray, W., & Simms, M. (2016). Embracing complexity –
Living legacy of Gregory Bateson’s research team.
Cybernetics of Human Knowing, 23(3), 29–57.
Sluzki, C., & Ransom, D. (Eds.). (1976). Double bind: The
foundation of the communicational approach to the
family. New York: Grune & Stratton.
Sullivan, H. S. (1953). Conceptions of modern psychiatry
(2nd ed.). New York: W. W. Norton & Co.
Watzlawick, P. (1986). The use of behavior prescriptions in
psychotherapy. In Family Therapy Evolving, Proceed-
ings of the 8-th International Delphic Symposium,
April 22–25, 1985, The Athenian Institute of
Anthropos (pp. 31–34).
Watzlawick, P., & Jackson, D. (1964/2009). On
human communication. In W. Ray & G. Nardone
(Eds.), Paul Watzlawick – Insight may cause blind-
ness & other essays. Phoenix: Zeig, Tucker,
Theisan, Ltd.
Watzlawick, P., Beavin-Bavelas, J., & Jackson, D. (1967).
Pragmatics of human communication. New York: P
W. W. Norton & Co.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change –
Principles of problem formation & problem resolution.
New York: W. W. Norton & Co.
Weakland, J. (1951). Method in cultural anthropology.
Philosophy of Science, 18, 55–69.
Weakland, J. (1967). Communication & behavior. Ameri-
can Behavioral Scientist, 10(8), 1–3.
Weakland, J. (1975). The Palo Alto Group (unpublished
draft).
Weakland, J., & Ray, W. (Eds.). (1995). Propagations –
Thirty years of influence from the mental research
institute. New York: Haworth Press.
Weakland, J., Fisch, R., Watzlawick, P., & Bodin,
A. (1974, June). Brief therapy – Focysed problem
resolution. Family Process, 13(2), 141–168.
Whitehead, A., & Russell, B. (1903). Principia
mathematica. Cambridge: The Cambridge University
Press.
Wilder-Mott, C., & Weakland, J. (1981). Rigor & imagi-
nation: Essays from the legacy of Gregory Bateson.
New York: Praeger.
2110
Papernow, Patricia
Scott W. Browning
Chestnut Hill College, Philadelphia, PA, USA
Name
Papernow, Patricia
Introduction
Patricia L. Papernow, Ed.D., is an internation-
ally known clinician, teacher, consultant, and
author on stepfamily relationships. She is the
Director of the Institute for Stepfamily Educa-
tion and a psychologist in private practice in
Hudson, MA.
Career
Patricia Lee Papernow was born in San Diego,
California. During her childhood, her family
moved across country to Philadelphia and then
back again to Los Angeles. She completed her
undergraduate degree at Harvard University,
magna cum laude, and her doctorate at Boston
University where she received the Practitioner-
Teacher Award for Outstanding Applied
Scholarship.
Dr. Papernow began her career strongly
rooted in preventive mental health, a commit-
ment she has carried through to the present. In
her first job in the field, she was part of a team
researching citizen participation in community
mental health. From 1971 to 1973, she devel-
oped the preventive education arm of a program
for troubled adolescents. Over the next 10 years,
she developed and became the first Director of
Community Training Resources. CTR trained
clinicians to bring skill-oriented workshops on
parenting, conflict management, stress, aging,
and other mental health concerns to clergy,
teachers, day care workers, elder care providers,
nurses, etc. The National Institute of Mental
Papernow, Patricia
Health named CTR as a “national best” preven-
tive mental health program.
For the last four decades, Dr. Papernow has
been deeply engaged bringing awareness and
understanding to the intense and often complex
challenges of stepfamily dynamics. She is cur-
rently the Director of the Institute for Stepfamily
Education, dedicated to bringing evidence-
informed guidance for healthy thriving stepfamily
relationships to clinicians, stepfamily members,
and others in a position to be helpful (school
personnel, mediators, family lawyers, PCPs, pedi-
atricians, day care providers, etc.). As a clinician,
Dr. Papernow now works primarily in the internal
family systems model, also integrating her train-
ing in preventive mental health, couple and family
therapy, gestalt, attachment, trauma, and interper-
sonal neurobiology.
Contributions to the Profession
Dr. Papernow has devoted most of her profes-
sional career to illuminating the fundamental dif-
ferences between stepfamilies and first-time
families and to sharing best practices for meeting
the often-significant challenges this family form
creates for intimate relationships (2013, 2015b).
To quote Dr. Papernow, “Few clinicians receive
adequate training in working with the intense and
often complex dynamics facing stepfamilies. . . .
As a result, many . . . rely on their training in first-
time family models. This is not only often
unhelpful, but all too often inadvertently destruc-
tive” (Papernow 2018a, p. 26).
Dr. Papernow is the author of two of the lead-
ing books on stepfamilies and dozens of articles
and book chapters. Her second book, Surviving
and Thriving in Stepfamily Relationships: What
Works and What Doesn’t, has been called a classic
in the field. It is one of only two clinical books
written about stepfamilies in the last 25 years. Her
first book, Becoming a Stepfamily: Stages of
Development in Remarried Families (1993), also
a landmark contribution to the field, provided the
first model of stepfamily development over time.
Dr. Papernow teaches and consults to clinicians all
over the USA and the world; makes herself
Papernow, Patricia
available to print, radio, and television media; and
regularly contributes to guest blogs that bring
evidence-informed guidance to the public about
meeting stepfamily challenges.
Dr. Papernow’s work integrates four decades
of clinical practice with key findings from the
growing and increasingly sophisticated body of
stepfamily scholarship, to provide a framework of
five challenges and three levels of intervention for
working with the challenges of stepfamily rela-
tionships. The five challenges are as follows:
(1) Children in stepfamilies struggle with losses,
loyalty binds, and the pace of change.
Because parents and stepparents are usually
thrilled to have found each other, the adults
often need help understanding and meeting
children’s needs for empathic attunement
and for proceeding slowly.
(2) Insider/outsider positions in stepcouples are
intense, and stepfamily structure keeps them
“stuck.” Stepparents often occupy a “stuck
outsider” position. Parents are often “stuck
insiders.” The resulting feelings (rejection
and alienation for stepparents, feeling torn,
anxious, and inadequate for parents) can cre-
ate painful rifts for stepcouples.
(3) Parenting tasks divide parents and steppar-
ents: Stepparents are often pulled toward
more authoritarian parenting and parents
toward more permissive parenting, when
what children actually need is “authoritative”
parenting.
(4) Stepfamilies must build a new family culture
while respecting already-established cultures.
Cultures are shared within parent-child and
ex-spouse relationships, not within step
relationships.
(5) Ex-spouses are part of the family. Children in
stepfamilies have another parent, dead or
alive, who is not part of the nuclear
household.
Papernow has also contributed a three-level
framework for intervention:
I. Psychoeducational (information about what
is normal, what works, and what does not);
2111
II. Interpersonal (creating connection and
empathy)
III. Intrapsychic/intergenerational (healing
family-of-origin wounds that may intensify
stepfamily challenges).
Dr. Papernow’s latest work focuses on the
increasing numbers of late-life stepcouples
formed after “gray divorce,” where normal
stepfamily challenges “are sometimes even
intensified by decades-long ex-spouse and
parent-child relationships, as well as by multi-
ple intergenerational layers of extended fam-
ily” (Papernow 2018b, p. 53).
In recognition of the importance of her work,
along with her colleague Dr. Scott Browning,
Dr. Papernow was awarded the 2017 APA
Award for Distinguished Contribution to Family
Psychology from APA’s Division 43.
Cross-References
▶ Browning, Scott
▶ Internal Family Systems in Family Therapy
▶ Parenting in Families
▶ Stepfamilies in Couple and Family Therapy
P
References
Papernow, P. L. (2013). Surviving and thriving in stepfam-
ily relationships: What works and what doesn’t.
New York: Routledge.
Papernow, P. L. (2015a). Suteppu famiri wo ikani iki,
hagukumuka: Umakuikukoto ikanaikoto. [Surviving
and thriving in stepfamily relationships: What works
and what doesn’t.] (trans: Nakamura, S., Ohnishi, M. &
Yoshikawa, Y.). Tokyo: Kongo Shuppan.
Papernow, P. L. (2015b). Therapy with couples in step-
families. In A. Gurman, J. Lebow, & D. Snyder (Eds.),
Clinical handbook of couple therapy (4th ed.,
pp. 467–488). New York: Guilford.
Papernow, P. L. (2018a). Clinical guidelines for working
with stepfamilies: What individual, couple, child, and
family therapists need to know. Family Process, 57(1).
https://doi.org/10.1111/famp.12321.
Papernow, P. L. (2018b). Recoupling in mid-life and
beyond: From love at last to not so fast. Family Pro-
cess, 57(1). https://doi.org/10.1111/famp.12315.
2112
Papp, Peggy
Billy Benson
The Ackerman Institute for the Family, New York
City, NY, USA
Name
Peggy Papp, LCSW (1923 –)
Introduction
Peggy Papp is a world renowned family thera-
pist whose work spans over four decades. In that
time, she has contributed extensively to the
field’s understanding of gender and power and
has demonstrated particular interest in themes
and belief systems within families. She is best
known for her work in family sculpting and
couple’s choreography. She has written numer-
ous articles and books throughout her career and
is most notably the author of The Process of
Change, the co-author of The Invisible Web:
Gender Patterns in Family Relationships, and
the editor of Couples on the Fault Line: New
Directions for Therapists. Her publications
have been translated into several different lan-
guages, and she has presented extensively in the
United States, Europe, South America, China,
and Israel.
Career
Ms. Papp received her MSW at Hunter College,
School of Social Work, in New York City. She
later founded The Gender and Depression Project
at the Ackerman Institute, which explored the
relationship between gender and how depressive
symptoms are experienced within a couple.
Ms. Papp has worked extensively with other pro-
fessionals who were peers and colleagues at given
times, including collaborations with Jay Haley,
Salvador Minuchin, Evan Imber-Black, Olga
Silverstein, Betty Carter, and Mara Selvini
Papp, Peggy
Palazzoli. She is currently both a senior faculty
member and a co-director of the Adolescent Pro-
ject at Ackerman. She maintains a private practice
in New York City.
Ms. Papp has received numerous awards
throughout her career, including the American
Association for Marriage and Family Therapy’s
Lifetime Achievement Award, as well as the
University of Utah’s Distinguished Alumni
Award. She has been honored by the American
Family Therapy Academy for her work in the
Women’s Project in Family Therapy.
Contributions to Profession
One of Ms. Papp’s major contributions to the field
of family therapy has been her identification and
use of themes within a system, so as to understand
the presenting problem clearly as part of a larger
family drama. She understands themes to be
embedded in a different form of logic than reduc-
tionist, conventional thinking, one that is broader
in scope and open to solutions that are previously
unacknowledged by the therapist and family. By
identifying central themes that operate within a
family system, the therapist is able to design and
implement effective interventions in a collabora-
tive manner that has the potential to help the
family clarify priorities and prioritize family
strengths and resources.
A second contribution to the field has been
her use of paradoxical intervention in situations
where a family presents with a pattern of behav-
ior that is unresponsive to traditional, goal-
directed interventions. An example is the utili-
zation of a consultation group who acts as a
“Greek chorus” to underline the therapist’s
intentions within the therapy room to the family,
and who comments on risks associated with any
change in the family system. Other paradoxical
interventions she has highlighted in her work
include attempting to redefine or prescribe a
problem, as well as encouraging the family to
not move too quickly towards change, i.e.
restraining change.
A third contribution to the field has been her
use and development of family sculpting and
Paradox in Strategic Couple and Family Therapy
couple’s choreography. Ms. Papp has utilized
family sculpting to reveal each family member’s
perception of family relationships and interac-
tions. She does so first by asking family member
to arrange the others in a model, or sculpture,
which represents their view of family function-
ing. This is in turn is followed by her request of
each member to sculpt their ideal family rela-
tionships and functioning. Couples choreogra-
phy, as developed by Ms. Papp, is similar to
family sculpting in its attempt to bypass verbal
language and other explanatory techniques,
though it is specific to couples’ relationships.
Couples choreography uses metaphor, symbols,
and fantasies to demonstrate the experience
within the relationship of each partner. The cou-
ple then acts out the problem between the sym-
bolic forms and finds a metaphorical solution,
thereby offering the couple a new language and
solutions.
Cross-References
▶ Ackerman Institute for the Family
▶ American Association for Marriage and Family
Therapy (AAMFT)
▶ American Family Therapy Academy (AFTA)
▶ Creativity in Couple and Family Therapy
▶ Feminism in Couple and Family Therapy
▶ Gender in Couple and Family Therapy
▶ Reflecting Team in Couple and Family Therapy
▶ Restraining in Couple and Family Therapy
▶ Second-Order Change in Couple and Family
Therapy
▶ Women’s Project, The
References
Papp, P. (1980). The Greek chorus and other techniques of
paradoxical therapy. Family Process, 19, 45–57.
Papp, P., & Imber-Black, E. (1996). Family themes: Trans-
mission and transformation. Family Process, 35, 5–20.
Papp, P., Schienkman, M., & Malpas, J. (2013). Breaking
the mold: Sculpting impasses in couples’ therapy. Fam-
ily Process, 52, 43–55.
Peggy Papp, LCSW. (2017). Retrieved December 11, 2017,
from http://www.ackerman.org/peggy-papp-lcsw/
2113
Paradox in Strategic Couple
and Family Therapy
James Ruby
The Family Institute at Northwestern University,
Evanston, IL, USA
Name of the Intervention
Paradox in Strategic Couple and Family Therapy
Synonyms
Paradoxical interventions; Paradoxical techniques
Introduction
Paradoxical interventions are therapeutic tech-
niques that play an important role in couple and
family therapy, particularly within communica-
tion, strategic, and systemic therapy. The couple
or the family is often exposed to contradictory or
counterintuitive instructions from the family ther-
apist. By introducing these types of instructions,
the clients are placed in a situation that is not
resolved by means of logic, sometimes called a P
double bind (Bateson et al. 1963). The couple or
family is forced to change their ways of under-
standing. This is often referred to as second-order
change, which will be discussed in more detail
later in this article.
Theoretical Framework
Gregory Bateson, Jay Haley, Don Jackson, John
Weakland, and others within the Mental Research
Institute in Palo Alto, California, helped transform
the nature of family work by integrating Milton
Erickson’s understandings of change in psycho-
therapy into a systemic approach to working with
family systems. While Erickson never actually
proposed a process by which families would
engage in psychotherapy, many of his ideas
2114
related to diagnosis and formulating interventions
have been integrated by family theorists (Zeig and
Lankton 1988). Erickson utilized hypnotherapy
and was known for making therapeutic impacts
through some of the most counterintuitive
approaches to working with his clients (Watzlawick
et al. 1974).
Erickson’s hypnotherapy has often been
viewed through a skeptical lens due to
glamourized, Las Vegas style, understandings of
hypnosis. Haley (1985) and Watzlawick et al.
(1974) highlighted Erickson’s conceptualizations
of his clients in building their own understandings
of client resistance to behavioral change. Rather
than seek out the potential causes of a patient’s
resistance to change, Erickson would encourage it
and even suggest noncompliance. In doing so, he
was engaging in a hypnotherapeutic suggestion
that assumed if resistance is accepted and encour-
aged by the therapist, clients will eventually give
up and their resistance will cease. For instance,
if clients expressed in a session that they were not
sure if they could say everything that might need
to be said in a session, Erickson would suggest
that the clients should feel comfortable not shar-
ing that information. In fact, he would encourage
them not to do so until they felt completely com-
fortable with him. Now, the only way the clients
can avoid engaging in a resistant posture with
the therapist is to share the reserved information
with her/him.
Watzlawick et al. (1974) added to Erickson’s
ideas of resistance. They suggested that the
therapist engage in a cognitive relabeling, or a
reframing, of the client resistance. In the face of
resistance, reframing requires attributing positive
attributes to the otherwise problematic behaviors.
These proposed positive attributes would not
be obvious to the clients, but the therapist’s rec-
ognition of the potential value of the resistance
stirs something within the clients. In the earlier
example, the clients’ resistance to sharing infor-
mation might be reframed to be critical thinking
or seeking clarity before expressing oneself. Now,
the clients have been offered a new lens through
which to see their experience.
The Mental Research Institute group was
quick to recognize that an individual family
Paradox in Strategic Couple and Family Therapy
member’s behavior is best understood within the
family context (Haley 1973, 1976). As such, it
was important to know how a family member’s
actions influenced or supported the existing fam-
ily system (Evans 1989). With that understanding
in mind, it becomes the family therapist’s respon-
sibility to initiate what should happen in the ther-
apeutic encounter and to develop plans for solving
family problems. Jay Haley’s (1973) strategic
therapy attempts to introduce a level of complex-
ity into the life of a family so that they envision
specific options from which to choose, the end
result being that the therapeutic intervention
will bring more connectedness in the family and
encourage individuals to be more responsible for
one another. Adding complexity to a system that is
experiencing complex problems is an expression
of a paradoxical intervention.
One of the Mental Research Institute’s
most enduring strategies was the introduction of
paradoxical interventions into the family therapy
environment. Mozdzierz et al. (1976) provided
a useful definition of paradoxical interventions:
“seemingly self-contradictory and sometimes
even absurd therapeutic interventions which are
always constructively rationalizable, although
sometimes very challenging, and which join
rather than oppose symptomatic behavior while
containing qualities of empathy, encouragement,
and humor” (p. 169). Haley (1963, 1973, 1976)
recognized that clients would often resist the fam-
ily therapist’s attempts at leading the process and
would also resist attempts to change the family
dynamic. This resistance could manifest itself in
active or passive ways. The goal of the paradox-
ical technique was to harness the forces of resis-
tance and use the energy to produce change, in
spite of the resistance. The belief was that placing
therapy clients into a bit of a double bind would
produce change in their presenting situations
where prior direct attempts at change had been
unsuccessful (Cullin 2014).
While Milton Erickson’s theories of change
informed this strategy, so did Albert Adler’s indi-
vidual psychology approach to therapy. Many
have suggested that Adler was the first prominent
figure to integrate and write about paradoxical
techniques in psychotherapy (West et al. 1997).
Paradox in Strategic Couple and Family Therapy
Adler frequently “prescribed the symptom” as a
means of defusing the client’s resistance to the
directive influence of the therapist. While the
therapist’s words suggested that the client should
continue problematic behavior(s), the actual mes-
sage was one of challenge to the client to do
something different. All the while, the therapist
was responding in an empathic way, prioritizing
client welfare (Haley 1976).
The resulting changes would typically fit into
one of two categories, first-order change or
second-order change (Haley 1976). Strategic fam-
ily therapy defines first-order change as being a
temporary removal of presenting symptoms.
Unfortunately, this type of change is not often
long lasting. Second-order change, on the other
hand, moves beyond simple symptom removal.
There is repair of the family system’s patterns
of functioning involved in this sort of change.
Paradoxical techniques are designed to bring
about second-order change in a family system.
Bateson suggested humans have a preoccupa-
tion with controlling their behavior (1972). Thus,
clients coming for therapy often need a major
epistemological shift, or a new frame of reference
for seeing the world around them. Second-order
change suggests that clients are able to see things
from a perspective that doesn’t necessarily have
to reinforce their prescribed ways of viewing
the world. Paradoxical interventions often under-
mine the previously held assumptions and ways of
being in clients and their systems. Direct chal-
lenges to assumptions that maintain problematic
ways of being are often met with great resistance,
but paradoxical interventions help loosen the hold
and lessen the power of those assumptions
(Bateson 1972).
Rationale for the Strategy or
Intervention
At the foundation of paradoxical techniques is an
understanding that problems are best understood
as unique opportunities. This represents a signif-
icant cognitive reframe for both the therapist
and the family members (Tennen and Affleck
1991). By conceptualizing the problem as an
2115
opportunity, families are invited to embrace a
more hopeful posture and begin to explore inter-
nal and external resources that they might never
have imagined available to them.
Description of the Strategy or
Intervention
The paradoxical interventions used by the thera-
pist typically come from one of two directions, a
one-down position or a one-up position. The one-
down position is designed to elevate the family
member(s) to a role of expert on their problem(s),
and the therapist is placed in a less than expert role
(Fisch and Schlanger 1999). This positioning
requires the family to take on more responsibility
for change and challenges their perceptions
of being helpless or incompetent. The therapist
does not jeopardize their competence when
using the one-down position but simply promotes
the family members to a place of personal agency
and efficacy. The paradox lies in the positioning as
much as in the specific directives because families
that enter counseling often feel like anything
but experts.
The one-up position places the therapist in
the expert, or consultant, role. The therapist
essentially prescribes the actions that the family
members are to carry out. In particular, family P
members are asked to do more of whatever symp-
tomatic behavior that is part of their presenting
problem(s). This is often called “prescribing
the symptom.” Asking families to do this, the
therapist is placing them in a double bind, where
if they follow the directions of the therapist, they
are revealing that they are in control of the behav-
ior(s). However, very likely, they have expressed
to the therapist that they feel out of control, hence
the double bind. If the family agrees to do more
of what is not working, they prove to the therapist
and themselves that they are in a position to influ-
ence their family’s functioning (Watzlawick et al.
1974). If they do not act in accordance to the
therapist’s direction(s), the family remains in a
state of suffering.
Another type of paradoxical intervention is
often referred to as going slow. Going slow
2116
requires the family to decrease their pace of
improvement and focus on the smallest incre-
ments of change (Fisch et al. 1982). In other
words, the family is encouraged to slow their
efforts at trying to improve because the therapist
is concerned that other problems might pop up if
the family’s issues are addressed too quickly
(Fisch et al. 1982). Once again, by complying
with the directive, the family reveals their own
capacity at control. Typically, however, families
refuse the directive and increase their efforts at
improving things. In defying the family therapist’s
suggestion, they move forward and address their
presenting symptoms on their own. The paradox
occurs when the family members’ lives improve
by ignoring the directions of the therapist.
Often, the “going slow” intervention is paired
with what some have called the “dangers of
improvement” (Fisch et al. 1982). The dangers
of improvement approach is seen when a therapist
shares how it might be common for others in
the clients’ lives to resent the clients simply due
to the fact that they are attempting to improve
themselves by making positive adjustments in
their lives. This intervention is designed to
increase the clients’ motivation for therapy and
to encourage them to do whatever might be nec-
essary to achieve their therapy goal(s) (Fisch
et al. 1982).
A similar construction is the “be spontaneous”
intervention. In the be spontaneous paradox,
an individual or a family is asked to do something
deliberately that would normally only come about
spontaneously (Segal and Kahn 1986). Similar to
the other two examples, families ultimately betray
their positions of helplessness or powerlessness
by engaging in trying something new or creative.
Interestingly enough, Watzlawick (2010)
identified a paradox that resides within the use
of paradoxical interventions. According to
Watzlawick, several therapists foster a naïve
assumption that any unique or unusual request
qualifies as paradoxical therapy. Because of this
misunderstanding, paradoxical interventions are
often met with suspicious scrutiny and unfounded
criticism. It is important to remember, though,
that not every trick or clever exercise a therapist
might utilize is based on sound theoretical
Paradox in Strategic Couple and Family Therapy
understandings and they cannot truly be consid-
ered paradoxical interventions.
Case Example
The following is an example of how a paradoxical
intervention might be useful in family work.
A couple comes to therapy and speaks of the
difficulties in their marriage. The have recently
become empty nesters, and they are not sure if
they can remain together any longer. They com-
municate that they have stayed together for the
children, a common phrase heard in couple’s
work. The therapist using a paradoxical approach
responds by saying that for many people, staying
together for the children would not be enough, so
the couple must have some significant personal
resources within them to endure as they have.
This reframe of the time spent together shifts
the focus to resources rather than deficits.
The couple responds that while the therapist
might be correct, they have also endured a long-
standing hostility toward each other. Paradoxi-
cally, the therapist recognizes this as a potential
sign of the couple’s loyalty. In fact, the couple
remaining hostile (prescribing the symptom)
might be a way of keeping enough distance
between one another, which could allow the
partners to reduce the pain or hurt they might
otherwise experience. By prescribing, or at least
reframing the motivation behind, the symptom the
therapist opens up additional possibilities and
even finds possible value in the actions that
brought the couple to therapy in the first place.
The family therapist monitors the outcomes
of their paradoxical directive and might push the
paradox even further until the couple rebels
or desired change occurs within the couple’s
relationship.
Ethical Concerns
It should be noted that soon after their promotion
by the Mental Research Institute, some criticized
paradoxical interventions as manipulative or
unethical (Ascher and Efran 1978), while others
Paradox in Strategic Couple and Family Therapy
suggested that they were only appropriate after a
clearly defined treatment plan was outlined by the
therapist (Brown and Slee 1986; Hunsley 1988).
The paradoxical intervention was viewed as
appropriate only in as much as it supported larger
therapeutic goals and could be clearly connected
to the desired outcomes. Others have suggested
that consent for using such interventions should
be secured from clients prior to their use, but
some would argue that securing consent for use
of paradoxical interventions sabotages their effec-
tiveness (Foreman 1990).
Conclusion
Strategic family therapy and the use of paradoxi-
cal interventions have found wide appeal for
individuals from cultural groups that embrace
individualistic assertions and do not feel bound
to more collectivistic approaches of decision-
making (Mozdzierz et al. 2010). Commitments
to family and community might make some fam-
ilies resist participating in paradoxical techniques.
The brief and strategic nature of the paradoxical
interventions has been useful for the managed
care environment, however, and might be a
benefit for those with limited time or resources
(Goldenberg et al. 2017). That being said, a recent
survey discovered that less than 5% of active
psychotherapists actively integrate paradoxical
techniques into their work (Cook et al. 2010).
References
Ascher, L. M., & Efran, J. (1978). Use of paradoxical
intervention in a behavioral program for sleep onset
insomnia. Journal of Consulting and Clinical Psychol-
ogy, 46, 547–550.
Bateson, G. (1972). Steps to an ecology of mind.
New York: Ballentine.
Bateson, G., Jackson, D., Haley, J., & Weakland, J. H.
(1963). A note on the double bind – 1962. Family
Process, 2, 1–4.
Brown, J. E., & Slee, P. T. (1986). Paradoxical strategies:
The ethics of intervention. Professional Psychology:
Research and Practice, 17, 487–491.
Cook, J. M., Biyanova, T., Elhai, J., Schnurr, P. P., &
Coyne, J. C. (2010). What do psychotherapists really
do in practice? An internet study of over 2,000
2117
practitioners. Psychotherapy: Theory, Research, Prac-
tice, Training, 47(2), 260–267.
Cullin, J. (2014). On learning and teaching family therapy.
Australian and New Zealand Journal of Family Ther-
apy, 34, 352–369. https://doi.org/10.1002/anzf.1037.
Evans, T. D. (1989). Brief therapy: The tradition of
individual psychology compared to MRI. Individual
Psychology, 45, 48–56.
Fisch, R., & Schlanger, K. (1999). Brief therapy with
intimidating cases: Changing the unchangeable. San
Francisco: Jossey-Bass.
Fisch, R., Weakland, J. H., Watzlawick, P., & Segal,
L. (1982). The tactics of change: Doing therapy briefly.
San Francisco: Jossey-Bass.
Foreman, D. (1990). The ethical use of paradoxical inter-
ventions in psychotherapy. Journal of Medical Ethics,
16(4), 200–205.
Goldenberg, I., Stanton, M., & Goldernberg, H. (2017). Fam-
ily therapy: An overview (9th ed.). Boston: Cengage.
Haley, J. (1963). Strategies of psychotherapy. New York:
Grune and Stratton.
Haley, J. (1973). Uncommon therapy: The psychiatric
techniques of Milton H. Erickson, M.D. New York:
W.W. Norton.
Haley, J. (1976). Problem solving therapy. San Francisco:
Jossey-Bass.
Haley, J. (Ed.). (1985). Conversations with Milton
H. Erickson, M.D.: Vol. 1: Changing individuals.
New York: Triangle Press.
Hunsley, J. (1988). Conceptions and misconceptions
about the context of paradoxical therapy. Professional
Psychology: Research and Practice, 19, 553–559.
Mozdzierz, G. J., Macchitelli, F. J., & Lisiecki, J. (1976).
The paradox in psychotherapy: An Adlerian perspec-
tive. Journal of Individual Psychology, 32, 169–184.
Mozdzierz, G. J., Peluso, P. R., & Lisiecki, J. (2010).
Evidence-based psychological practices and thera- P
pist training. Journal of Humanistic Psychology,
51(4), 439–464. https://doi.org/10.1177/
0022167810386959.
Segal, L., & Kahn, J. (1986). Brief family therapy. Individ-
ual Psychology: The Journal of Adlerian Theory,
Research and Practice, 42(4), 545–555.
Tennen, H., & Affleck, G. (1991). Paradox-based treat-
ments. In C. R. Snyder & D. R. Forsyth (Eds.), Hand-
book of social and clinical psychology: The health
perspective (pp. 624–643). Elmsford: Pergamon.
Watzlawick, P. (2010). The use of behavior prescriptions
in psychotherapy. Journal of Systemic Therapies,
29(4), 35–39.
Watzlawick, P., Weakland, J. H., & Fisch, R. (1974).
Change: Principles of problem formation and problem
resolution. New York: W. W. Norton & Company.
West, J., Main, F., & Zarski, J. (1997). The paradoxical
prescription in individual psychology. In J. Carlson &
S. Slavik (Eds.), Techniques in Adlerian psychology.
Washington, DC: Accelerated Development.
Zeig, J. K., & Lankton, S. R. (1988). Developing
Ericksonian therapy: State of the art. Bristol: Brunner/
Mazel.
2118
Paradoxical Directive in
Couple and Family Therapy
Linna Wang
Alliant International University, San Diego,
CA, USA
Name of Concept
Paradoxical Directive
Synonyms
Invariant prescription; Paradoxical intervention;
Prescribing the symptom
Introduction
The Webster dictionary definition of the word
“paradox” is “a statement that is seemingly con-
tradictory or opposed to common sense and yet is
perhaps true.” Many think paradox is something
mysterious. Actually, everyday life is peppered
with paradoxical statements. “You have to spend
money to make money,” “I spank you because
I love you,” “Less is more,” and “It has to get
worse before it gets better,” are just a few exam-
ples. As one can see, these statements put two
contradicting elements in one statement. At first
glance, these statements do not make sense, yet to
give it a thought, they are sort of true.
Paradoxical Directive is one of the hall
mark interventions in Strategic Family Therapy.
Strategic family therapists are interested in
generating changes in behavior and solve specific
problems. They are known to design novel inter-
vention strategies to direct clients to solve prob-
lems. There are two types of directives: direct
directives (given when the therapist can go
straight forward and tell client what to do, usually
in the form of good advice) and indirect directives
(given when the therapist does not have enough
authority and has to work around to get the desired
change). Paradoxical Directive is an indirect
Paradoxical Directive in Couple and Family Therapy
directive and is the most controversial yet most
powerful and most elegant amongst all the direc-
tives of strategic therapy.
Paradoxical directive puts clients in a bind that
at first may seem to be nonsensical and illogical.
Yet while in this bind, clients will achieve specific
therapeutic goals no matter what they do. The
most commonly known paradoxical directive is
“prescribe the symptom.”
Theoretical Context for Concept
Strategic Family Therapy is considered by many
as more pragmatic than theoretical, and most of
the strategic therapy writings are indeed about
techniques. It is very much influenced by Milton
Erickson, and its theoretical roots are deeply
connected to researches of theorists of Mental
Research Institute (MRI), such as Paul
Watzlawick and Don Jackson.
Milton Erickson broke away from the psychi-
atric foundations of his time. He viewed the
unconscious mind as having the wisdom to solve
problems and heal, rather than destructive. The
therapist’s job was to help patients to gain access
to that wisdom. Instead of devoting lengthy effort
to interpret patients’ behavior, Erickson focused
on the symptoms, developed different ways,
including paradoxical interventions, to change
people’s behavior and solve their problems
as quickly as possible. Influenced by Milton
Erickson, the strategic therapists believe that peo-
ple can make rapid changes once the therapist gets
the change process started. The therapists, rather
than the clients, should take on the responsibility
for changes by designing strategies and directing
clients to behavioral actions. Their goal is to help
clients to solve their problems by whatever means
that works.
Researchers of MRI group took a similar prag-
matic approach to understand human communi-
cation and its function in problem formation and
problem solving. They believed that it is impossi-
ble to accurately understand how the unconscious
mind works. The effort to understand “why” or
intention of human behavior is just an unverifiable
guess work. They adopted the concept of “black
Paradoxical Directive in Couple and Family Therapy
box” from the field of telecommunication as an
analogy of the “why.” It is impossible to know the
inner work of the box from the outside, and any
effort to get into the box (crack it open) will
destroy the box and its content. Instead of trying
to understand what is going on inside the black
box, sometimes it is much more efficient to bypass
the black box entirely, focus only on the observ-
able relationship between what goes into (input)
and what comes out of (output) the black box. The
sequence or pattern, rather than the intention, of
human behavior can provide much more useful
inforamtion. Symptoms are no longer viewed as
an expression of intrapsychic conflict but some
kind of input into the family system (Watzlawick
et al. 1967).
Similar to intrapsychic dynamics, past experi-
ence was also viewed by MRI researchers as an
unreliable explanation of the current behavior.
The intrapsychic dynamics and past experiences
assume only secondary importance in understand-
ing human behavior. MRI group focused exclu-
sively on the here and now, the behavior
sequences, the circular causality of human inter-
actions (the output of one black box may be the
input of another black box), and the interaction
between symptoms and its context (Watzlawick
et al. 1967). Instead of “why,” they focused on
“what for” or the function of symptoms. The
intensely pragmatic research focus on human
interaction leads to MRI group’s simple yet pow-
erful principles of problem formation and problem
solution. Problem becomes a problem when
(1) people persistently attempt to solve a problem
that has no solutions (therefore regular annoying
difficulties in life are turned into problems);
(2) problems result from flawed family hierarchy
and/or boundaries; and (3) problems result from
family members’ attempts to protect or control
each other, thus serve a function in the family
(Nichols and Schwartz, 1991). Problem solutions
are equally pragmatic and situated in here and
now, following a four-step procedure: (1) clearly
define the problem in concrete terms; (2) investi-
gate solutions that have been attempted; (3) clearly
define desired outcome in concrete terms; and
(4) design and implement a plan to produce the
desired outcome (Watzlawick et al. 1974).
2119
People usually attempt to solve their prob-
lems with common sense and logical solutions.
Commonsensical and logical solution is to do
the opposite of the problem (Watzlawick et al.
1974). For example, put on a jacket when cold.
When the logical solution does not solve the
problem, people tend to increase the solution’s
frequency and intensity (put on another jacket if
still cold after the first one), more of the same.
Commonsensical and logical solutions work
well when the problem and solution is linear.
When the problems are misconceived (e.g.,
applying first-order change to problems that
require second order change; the sense of chill
is not due to the ambient temperature but a
symptom of some physical illness), the repeated
commonsensical and logical solution itself
becomes the problem. This is the time when
people are trapped in the insane situation: do
the same thing again and again and expect dif-
ferent outcomes. This is the time when paradox-
ical directive works well: its very nature of
being counterintuitive and seemingly illogic
gets people out of the trap created by their own
logic solutions, get people to do something dif-
ferent, something that they have not tried
before. Even in the case of prescription of symp-
toms, clients are actually not repeating the same
symptomatic pattern. Some aspects of the symp-
tom or something in the context of the symptom P
are changed. Clients are doing something dif-
ferent even though they may appear to be
repeating the same symptom.
Description
Informed by Milton Erickson and MRI group,
Haley mapped out eight stages to create a suc-
cessful paradoxical directive clinically:
(1) establish a relationship that’s defined as to
bring about change, (2) the problem needs to be
defined clearly, (3) the goals need to be defined
clearly, (4) there needs to be a plan, although the
plan may be left implicit to clients, (5) gracefully
take the responsibility away from the person
who is designated by the family to solve the
problem, (6) give the directive, (7) observe
2120
clients’ response and continue to encourage
compliance to the directive, and (8) therapist
avoid accept credit (Haley 1987).
When clients seek for help, the relationship
(Stage 1) is usually implicit but may need to
be emphasized. Stage 2, the therapist needs
to intensely investigate how the problem
was formed, what strategies that clients
have attempted, client’s motivation for change
(resistance to change is also a motivation), and
the context in which the problem is a problem.
This investigation unveils the repeated rational
and logical solutions (more of the same) that
clients have already tried but failed to solve the
problem; unearths the drive or motivation that
therapist can utilize to increase client’s compli-
ance to follow the directive; identifies the func-
tion of the problem; and provide information
about what element in the context (e.g., mean-
ing, function, time, location, sequence, fre-
quency, etc. of the symptom) that can be
manipulated and changed. Stage 3, goals have
to be very specific and clear. The desired change
may not be the elimination of the problem but to
change some aspects of the problem. For exam-
ple, the goal for the boy who masturbated exces-
sively as well as in the public may be to
masturbate only in private, not in public. With
clearly defined problem and goals, the therapist
can plan-ahead (Stage 4) and develop a para-
doxical directive to move families through
stages of change. Whatever the task may be, it
needs to be simple enough so that family can
do it.
One person is usually designated by the fam-
ily as the authority to solve the presenting prob-
lem or control the person doing the problem. If
the problem is solved, this designated person
would lose his/her authority and lose part of
his/her function in the family. Therefore he/she
may resist or even sabotage the change. Stage
5 is to gracefully take this function away from
the authority person and help him/her to take on
some other functions in the family.
Strategic family therapy does not believe
insight would lead to change. When giving direc-
tives in Stage 6, the therapist only needs to tell
Paradoxical Directive in Couple and Family Therapy
clients what to do, not the rationale behind the
strategy. In Stage 7, the therapist needs to observe
clients’ responses to the paradoxical directive.
If clients improved, the therapist should discour-
age that by defining the improvement as not
cooperating. When improvement occurs, the ther-
apist should avoid accepting the credit for the
change (Stage 8), as therapist’s need to take credit
will lead to clients’ relapse. One way to avoid
accepting credit is the therapist being puzzled by
the changes.
Paradoxical directive is to shift the logic to
create a bind in which clients are given different
options. The freedom to choose eliminates the
need to resist. Clients gain the power of control,
and they gain something desirable regardless
which options they choose. For example, a par-
adoxical directive to an alcoholic who presents
himself as helplessly enslaved by the addiction
and wants to stop drinking may be: “Why do you
want to do that? Don’t you see how much you
benefit from drinking? Look, your wife makes
excuses for you when you miss work. Your
annoying teenagers leave you alone. You’ve
got it made, man! Why don’t you give it a seri-
ous thought before you make this decision?”
Here, against the logic, drinking is reframed as
actually good and desirable, a reasonable
choice. This statement also brings to light the
function of the symptom, and the man is not a
helpless victim but a beneficiary of drinking.
The client is directed to choose, between stop
or not to stop drinking (logically a helpful per-
son should give him only one option, stop drink-
ing). If the client chooses to stop drinking, he
would engage in the behavior that he desires. He
would also know what’s ahead of him (he’ll lose
the benefit of drinking. He will have to deal with
his employment responsibilities, and he’ll have
to deal with his teenagers.) If he chooses not to
stop drinking, his drinking behavior takes on
different meanings (the drinking is a voluntary
behavior, and he made a conscientious decision
to continue benefiting from this behavior). Even
if client chooses not to stop drinking, change
started already – he knowingly takes a deliberate
action.
Paradoxical Directive in Couple and Family Therapy
Application of Concept in Couple and
Family Therapy
Paradoxical directive is most useful in helping
clients move beyond impasses, dealing with resis-
tance, and highlights that clients are in control of
their symptoms.
Impasse: Families often feel stuck and hope-
less when they reach out for external help. They
have tried and exhausted all the logical solutions
to solve their problems. All the family members
are trapped in the same uncomfortable yet stable
behavioral pattern, an impasse. The first therapeu-
tic task is to help them break out of their habitual
patterns of behaving or thinking. This first move is
the hardest, as at this stage every family member is
blaming everyone else and waiting for everyone
else to make the first move. Prescription of symp-
toms is a good choice to get clients out of this
impasse. It gives permission to everyone in the
family to continue to do whatever they are already
doing, only with a very slight twist that is consid-
ered manageable by the family members. Yet the
slight twist gets them out of the habitual pattern
and creates a movement, thus the change process
starts. Once the change process starts, clients
begin to see the difference and start to trust the
therapist, the therapist can use less indirect and
more direct directives.
Resistance: Nonsensical it may seem to be,
some clients present a problem that they want to
solve and at the same time want to prove that the
problem is unsolvable (I am right to be in the
problem because it is unsolvable. You are wrong
to think it is solvable.). The therapist will go
nowhere if he/she tries to solve the problem log-
ically as an expert (“Yeah, that sounds good, but it
is not going to work.”). Paradoxical directive is an
excellent choice in dealing with such resistance.
Like a Judo master, the therapist does not confront
the nonsensical resistance with common sense but
channels the energy that clients exert in resistance
to achieving the desired change, turning the
resistance to an important vehicle of change.
A commonly used paradoxical directive is to
agree with the client that the problem can not be
solved and block or discourage clients from
2121
developing desired behavior. When there is no
need to resist, clients will use the energy to
prove that the therapist is wrong anyways by
doing what is discouraged. Teenagers on proba-
tion often see the therapist as “one of them.” Their
need to prove the therapist wrong and to defeat the
therapist is the energy that can be channeled to
achieve the desired outcomes if the therapist con-
vinces the teenagers that the desired outcome is
actually undesirable and unachievable.
Clients in control of symptomatic behavior:
clients often present themselves as helpless and
controlled by their symptoms (“I am paralyzed by
the worries.”). The therapist may direct client to
produce the symptom at certain time or location.
This directive itself suggests to clients that they
have control of their symptoms, at least at when
and where. If clients can produce the symptom at
the designated time or location, they are showing
that they are in full control of their symptoms.
Clinical Example
The wife of the previously mentioned man with
alcoholic problem wanted him to stop drinking,
too. But it was impossible not to rescue him when
he passed out on the street (“If I don’t drag him
into the house, my whole family will be a
laughing stock in the neighborhood.”), or when P
he did not show up for work (“If I don’t cover for
him, he would be fired in a heartbeat. Then what?
Our whole family will suffer!”). She wanted him
to be responsible for his own action, at the same
time set alarm clock every night and woke him up
every morning to go to work. A classical case that
she desperately wanted to solve the problem and
at the same time presented to the therapist that it
was an unsolvable problem.
The therapist’s first paradoxical directive was to
block the desired behavior that she wanted to see in
the client: “You are not ready for him to change. As
a matter of fact, you probably don’t want him to
change. His drinking makes you a hero. Your chil-
dren will forever remember you as the one who
saved the whole family. If he stops drinking, you
would be just like me, a regular suburban woman
2122
who lives a boring life, attends to mundane things,
like going to PTA meetings, listening to my friends
complaining about their children, dealing with the
latest social media stuff that my children are getting
into and I don’t have a clue . . . My children don’t
ever see me as a hero. I am just a boring mom. Just
between you and me, I have to volunteer in the
animal shelter to clean dog poop. At least someone
there may think I am great and useful.”
The therapist listed a host of the desired behav-
iors that she would like the client to engage in to
replace her enabling behavior, and made them
sound boring and undesirable in the same breath.
This paradoxical directive agreed with the client
that she was perfectly reasonable not want to
change, which eliminated her need to resist but
changed the nature of the reason: she was not
helplessly trapped in the problem but actively
benefiting from the problem. The client had to
decide what to do with the energy that she had
accumulated to resist any change. She would have
to prove that the therapist was wrong and that
these desirable behaviors were not boring and
undesirable by engaging in these behaviors.
With client ready to make a move, the therapist
used a second directive targeted a very specific
behavior: setting alarm to remind the husband of
his job responsibility. The detailed assessment of
this behavior revealed that the wife actually
set alarm clock for herself to wake up so that she
could wake her husband up, of course with resent-
ment towards his not being responsible to wake
himself up. Thus, her day would start with resent-
ment that she sometimes misplaced on their teenage
children. The husband blissfully enjoyed the human
alarm clock, even though he had to face her anger
later in the day, which he cited as one of his reasons
to drink. The wife wanted him to set his own alarm
clock and wake up on his own (a sign of taking
responsibility) but dared not risk the consequences
(losing his job) if he failed to be responsible. The
therapist’s directive to the wife was: “You can see
the resentment early in the morning really irritates
you and your kids, people who don’t deserve the
resentment. Why don’t you give it to whom it really
belongs, your husband, let it irate him? Let’s figure
Paradoxical Directive in Couple and Family Therapy
out a way to give him your resentment loud and
clear. Why not set three alarm clocks as loud as
possible, put one on his side of the bed, one by the
door, and one in the opposite side of the room? In
the morning you just lay back and watch him irri-
tated as he deserves. If he gets angry and wants to
fight, well, what else is new? Then get the fight out
of the way before you start your day.”
This directive kept all the behavior elements
(setting alarm clocks, irritating each other,
fight), but rearranged the sequence of them. It
not only allowed the wife to continue to do what
she dared not not to do, it actually increased the
intensity of her responsibility (three alarms,
much louder than necessary). This directive
gracefully took away her function of being
responsible for him by changing the purpose of
the behavior from a boring routine of waking
him up to delivering her resentment. This direc-
tive also introduced a little bit lighthearted play-
fulness into the morning ritual that was laden
with resentment, which made it less dreadful for
her to do something different.
The wife reported the following week that she
enjoyed watching him grumpily fighting with the
three alarm clocks for two mornings. On the third
day, he set one alarm clock by himself.
Cross-References
▶ Strategic Family Therapy
References
Haley, J. (1987). Problem-solving therapy (2nd ed.).
San Francisco: Jossey-Bass Publishers.
Nichols, M., & Schwartz, R. C. (1991). Family therapy:
Concepts and methods (2nd ed.). Boston: Allyn and
Bacon.
Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1967).
Pragmatics of human communication: A study of inter-
actional patterns, pathologies and paradoxes.
New York: W. W. Norton.
Watzlawick, P., Weakland, J., & Fish, R. (1974). Change:
Principles of problem formation and problem resolu-
tion. New York: W. W. Norton.
Paré, David
Paré, David
W. Madsen
Family-Centered Services Project, Watertown,
MA, USA
Introduction
David Paré is an academic and prominent family
therapist based at the University of Ottawa. With a
consistent focus on practice, he has authored or
edited extensive publications, including 4 books
and over 50 journal articles, book chapters, and
conference proceedings. In addition, he has been
invited to offer extensive conference and workshop
presentations from 1994 to the present. He has also
been very active behind the scenes contributing to
the development of the field through organizing and
coordinating various conferences and serving on the
editorial boards of numerous journals (including
Journal of Systemic Therapies and Canadian Jour-
nal of Counselling and Psychotherapy).
Career and Contributions
After completing an initial Master’s Degree in
Journalism in 1980, David went on to complete
an M.Ed. and subsequently a Ph.D. in Counselling
Psychology at the University of Alberta in 1997.
Since then he has been at the University of Ottawa
with a continual focus on expanding the field of
family therapy. His first sole-authored published
articles in Family Process made a case for moving
from a cybernetic view of families to a cultural
view that made much more room for a focus on
the role of language, meaning, power, and dia-
logue. He has been very influenced by collabora-
tive and narrative approaches but has consistently
not limited himself to any one model but is con-
stantly bringing in ideas and practices from across
the spectrum of constructionist and poststructural
ideas. He has worked to link these different
approaches into a broader whole.
2123
In his edited books, he has brought together
writers from around the world who practice in
different ways but share epistemological and
ethical commitments. In the process, he has
often built enhanced connections between con-
tributors in that way and contributed to the con-
tinual growth of a community of practice.
His 2013 book, The Practice of Collaborative
Counseling and Psychotherapy: Developing
Skills in Culturally Mindful Helping in Thousand
Oaks, CA: Sage Publications, was an effort to
expand counseling skills from the previous com-
mon humanist/developmental underpinning to a
base that makes sense of counseling as a cultural,
dialogical and political, co-constructive practice.
His most recent edited book, Audet, C., and Paré,
D.A. (Eds.) (2017), Social Justice and Counsel-
ing: Discourse in Practice in New York, NY:
Routledge Press, has focused on broadening our
field’s consideration of social justice in counsel-
ing, suggesting that social justice is not merely
about “advocating” for clients outside of the con-
versations (although this is important) but rather
recognizing that justice/injustice issues unfold
throughout therapeutic conversations. This is a
book that has the potential to radically transform
our field.
P
Cross-References
▶ Collaboration with Clients in Couple and Fam-
ily Therapy
▶ Collaborative and Dialogic Therapy with Cou-
ples and Families
▶ Cultural Identity in Couples and Families
▶ Dialogical Practice in Couple and Family
Therapy
▶ Gender in Couple and Family Therapy
▶ Just Family therapy
▶ Narrative Family Therapy
▶ Reflecting Team in Couple and Family Therapy
▶ Social Construction and Therapeutic Practices
▶ Training Social Workers in Couple and Family
Therapy
2124
References
Audet, C., & Paré, D. A. (Eds.). (2018). Counseling and
social justice: Discourse in practice. New York:
Routledge Press.
Paré, D. A. (2013). The practice of collaborative counsel-
ing and psychotherapy: Developing skills in culturally
mindful helping. Thousand Oaks: Sage Publications.
Paré, D. A. (2016). Creating a space for acknowledgment
and generativity in reflective group supervision. Family
Process, 55, 270–286. https://doi.org/10.1111/
famp.12214
Paré, D. A., & Larner, D. (2004). Collaborative practice in
psychology and therapy. Binghamton: Haworth press.
Strong, T., & Paré, D. A. (Eds.). (2004). Furthering talk:
Advances in the discursive therapies. New York:
Kluwer Academic/Plenum.
Parent Management Training
Theressa L. LaBarrie
The Family Institute at Northwestern University,
Chicago, IL, USA
Name of the Strategy or Intervention
Parent Management Training.
Synonyms
Behavioral parent training (BPT); Parent training
Introduction
Parent management training (PMT) is an
approach to treating child disruptive behaviors
by training caregivers to directly alter such behav-
iors. PMT was initially developed in the 1960s
by child psychologists who studied changing
children’s disruptive behaviors by intervening to
change caregiver behaviors (Forehand et al.
2013). It is now a key treatment approach found
to be effective in treating children with various
disruptive behaviors (Michelson et al. 2013). The
aims of PMT are to (1) improve parent manage-
ment skills and competence in dealing with
Parent Management Training
child behavior problems, (2) increase knowledge
on causes of defiant behavior, (3) decrease or
eliminate a child’s disruptive or inappropriate
behaviors, (4) increase child prosocial behavior
and compliance to commands and rules,
and (5) correct maladaptive parent-child interac-
tions, improving family unity (Barkley 2013;
Kazdin 1997).
In PMT, caregiver(s) work with a therapist who
educates them in the use of specific techniques to
alter parent-child interactions. PMT procedures
typically involve programming behavioral contin-
gencies into the contexts in which the disruptive
behavior is occurring, such as home or school.
Training is often provided in weekly individual
or group sessions for 10–16 weeks. After learning
a new skill (e.g., how to use time out effectively),
caregivers are asked to go home and practice the
skill for a week with their child, reviewing their
progress, problem-solving any issues, and then
learning a new skill in subsequent sessions
(Fabiano et al. 2009).
Theoretical Framework
PMT’s techniques are grounded in social
learning theory. Central to social learning theory
is the concept that action frequencies increase
or decrease in response to the consequences
that occur following the action (Kazdin 1997).
The following learning principles and theories
also guide the PMT program: classical condition-
ing, operant conditioning, cognitive-behavioral
theory, behavioral analysis, and behavior modifi-
cation. Operant conditioning procedures are a
focal point of PMT, where the antecedents and
consequences of children’s behaviors are manip-
ulated to increase desired behavior and decrease
undesirable behavior. An underlying assumption
of the PMT model is that a parenting skills deficit
is at least partly responsible for the development
and/or maintenance of the disruptive child behav-
ior. Research in parent-child interactions in fami-
lies with such children found that parental
responses are often unintentionally reinforcing
unwanted behavior (Barkley 2013; Kazdin
1997). PMT trains caregivers to become more
Parent Management Training
discerning of their child’s behaviors and more
mindful of their reactions to the behavior.
Positive reinforcement and punishment are fun-
damental elements of PMT. Positive reinforcement
refers to affirming consequences that cause desired
target behaviors to increase (e.g., providing atten-
tion, affection, reward or praise), while punishment
refers to appropriate methods of responding to
undesired behaviors (e.g., withdrawing attention,
affection, or privileges/rewards). These two types
of consequences or responses must be carried out
so that they are immediate, specific, and consistent.
Consistency in responding is necessary because
inconsistent or erratic responses to unwanted
behavior can increase in frequency of the unwanted
behavior. Rewarding desired actions and with-
drawing rewards or applying punishment for unde-
sirable behavior is fundamental to the success of
PMT. Consistent consequences in response to the
child’s behavior result in behavior change. This
framework and the underlying principles have
been reportedly successful in treating childhood
externalizing symptoms for over 45 years (e.g.,
O’Leary et al. 1969).
Rationale for the Intervention
PMT has been practiced with a broad range of
child populations and problems. The interven-
tions primarily targets preschool to school-age
children who display noncompliant, defiant,
oppositional, stubborn, hyperactive, aggressive,
and/or socially hostile behavior. Although PMT
focuses on specific targeted behaviors rather than
on child diagnoses, it has been used in the treatment
of attention-deficit/hyperactivity disorder, autism
spectrum disorder, conduct disorder, intermittent
explosive disorder (age-inappropriate tantrums),
and oppositional defiant disorder (Feldman and
Kazdin 1995; Kazdin 1997). Starting in the
1970s, behavior modification procedures were
successfully used for children described as “hyper-
active” (O’Leary and Pelham 1978). Even children
with juvenile-onset diabetes, exhibiting poor rou-
tine and medication adherence, have benefited from
a PMT approach, as long as noncompliant or defi-
ant behavior is a primary problem (Barkley 2013).
2125
The program is not appropriate for children who are
severely aggressive and assaultive with others.
The procedures used in PMT are well
supported by empirical research demonstrating
significant improvements in child behavior and
it has been successful in treating children with
various problem behaviors (Kazdin 1997;
Michelson et al. 2013). Research suggests that
64% or more of families with ADHD and/or oppo-
sitional children may expect to demonstrate clin-
ically significant change or recovery with PMT
(Anastopoulous et al. 1993). Meta-analytic stud-
ies of children with ADHD have found the effect
size to be large for PMT (Michelson et al. 2013).
Further, PMT has been found to improve child
behavior, result in changes in parental behavior,
and improve parental attitudes toward children.
It has also been shown to increase knowledge of
parenting skills, reduce parenting stress, and
improve sense of self-esteem and parenting com-
petence, better sibling behavior, and better marital
and family functioning (Barkley 2013). Out-
comes, such as improvement in child behavior,
caregiver behavior, and parental attitudes toward
their children, have been found to generalize and
to be maintained for several years after treatment
termination (e.g., Webster-Stratton et al. 1989).
Description of the Strategy or P
Intervention
The concepts underlying PMT include estab-
lishing incentive programs before punishment
and recognizing that family interactions are recip-
rocal. PMT programs typically teach skills in a
series of steps, which can be taught as a contained
unit with therapy terminating at the last session or
the program can be integrated into ongoing family
therapy. The sequencing of the steps is deliberate
and based on much research. The ordering of the
steps emphasizes the development of positive
behavioral management methods within families
(Barkley 2013).
The parent management training model is com-
prised of several core elements. The intervention
is usually conducted primarily with the caregiver
(s) without the child present, although children
2126
may be asked to participate in some sessions.
Initial sessions focus on providing caregivers
with training and instruction on the social learning
principles and foundational concepts of behavior
modification underlying PMT.
In the PMT approach, therapists make exten-
sive use of didactic instruction, modeling, role
playing, and structured homework exercises to
teach techniques and skills to deal more effec-
tively with challenging child behaviors and pro-
mote effective parenting. Caregivers are trained
in defining, monitoring, and tracking the child’s
behavior (e.g., fighting, temper tantrums). They
then learn how to apply appropriate methods of
positive reinforcement and punishment. The foun-
dation of PMT begins with deliberately training
caregivers in how to develop and establish a suc-
cessful positive reinforcement procedures or
incentive programs well in advance of training
on punishment procedures. To do this therapists
refocus caregivers’ attention away from conduct-
problem behavior toward prosocial goals by
learning to provide positive reinforcement
(Fabiano et al. 2009; Kazdin 1997).
Positive reinforcement, a key element of
PMT, is given to the child demonstrating positive
or appropriate behaviors (e.g., complying with
a command to complete a task or demonstrating
respectful interactions with others) via various
techniques such as giving the child praise,
increased positive caregiver attention or earning
points toward obtaining a reward or privilege
desired by the child via token or point systems.
Meanwhile, caregivers are also taught to set
proper limits, by using methods such as removing
attention, for inappropriate behaviors. After
a strong foundation in positive reinforcement,
caregivers are taught methods to use when some
of the child’s problem behaviors continue to be
maintained. These include extinction and mild
punishment procedures, such as ignoring, remov-
ing rewards, points or privileges (response cost)
and time out in place of physical punishment. The
removal of rewards typically entails time away
from the circumstances and situations in which
the child can receive attention or engage in some
activity that is desired. In PMT caregivers are also
trained in giving clear instructions or commands
Parent Management Training
and in problem solving. Following each PMT
session, caregivers are asked to practice the skills
at home (Barkley 2013; Fabiano et al. 2009;
Kazdin 1997).
Additional aspects of PMT include training
caregivers to applying new skills starting with
the least challenging problems that will have the
highest likelihood of change, thus setting the care-
giver and child up with early successful experi-
ences that act as positive reinforcement for the
family. After skills have been applied with less
challenging problems, issues of increasing sever-
ity can be tackled. Caregivers can also utilize
shaping procedures by rewarding the child’s suc-
cessive approximations to the desired behavior in
order to achieve a behavioral goal that eventually
becomes rewarded more and more distinctively to
achieve a more specific behavioral goal (Fabiano
et al. 2009).
Case Example
Mr. and Mrs. Wilson requested therapy for their
10-year-old son, Sean. Earlier in the year, Sean
was diagnosed with ADHD. At the time of the
service request, Sean’s parents reported being at
their wits end and completely overwhelmed with
his behavior. While Sean had been doing well at
school, at home, he was unable to complete chores
and frequently threw tantrums when he did not get
his way. Homework would take him a long time to
complete because he was unable to sit still or keep
quiet. Sean also did scary things like run out
across the street without looking and wandered
away in crowds.
In speaking with a therapist, the Wilson’s
learned that their involvement in the therapy pro-
cess would be integral in order to support them in
learning specific techniques to aid in altering
Sean’s behaviors. They agreed to participate in
parent management training. Through the train-
ing, Mr. and Mrs. Wilson learned various strate-
gies to aid in managing Sean’s behavior. This
included the use of positive reinforcement contin-
gencies and understanding how to implement
them in an immediate and consistent manner.
Practice of PMT techniques began by having the
Parent-Child Interaction Family Therapy
parents intentionally setting up opportunities to
observe and positively attend to their son, provid-
ing positive affirmations when they observed him
engaging in desirable behaviors, such as cleaning
up after himself or listening to his parents direc-
tions and following-through adequately. Sean’s
parents are now careful to provide labeled praise
when he does something well (e.g., “Great job!
I like how you are continuing to quietly focus on
completing that set of homework problems.”).
Sean also earns “good job points” that get
recorded on his behavior chart. The point system
has been set up so that after earning a certain
number of points Sean can choose a fun activity
he would like to do from a list of options. They
have also learned to utilize punishment via
response cost or the loss of points, when Sean
engages in impulsive or dangerous behavior.
This method quickly gets Sean’s attention as he
is very motivated to earn his points and it provides
an opportunity for his parents to clearly and con-
sistently explain why points were lost and how he
can avoid losing points in the future. While par-
enting Sean continues to have its challenges,
Mr. and Mrs. Wilson report that they are no longer
at their wits end. Rather they are experiencing
better parent-child interactions and overall feel
much more cohesive as a family.
References
Anastopoulous, A. D., Shelton, T. L., DuPaul, G. J., &
Guevremont, D. C. (1993). Parent training for
attention-deficit hyperactivity disorder: Its impact
on parent functioning. Journal of Abnormal Child
Psychology, 21, 581–596.
Barkley, R. A. (2013). Defiant child: A clinician’s manual
for assessment and parent training (3rd ed.).
New York: Guilford.
Fabiano, G. A., Pelham, W. E., Jr., Coles, E. K.,
Gnagy, E. M., Chronis-Tuscano, A., & O’Connor, B. C.
(2009). A meta-analysis of behavioral treatments
for attention-deficit/hyperactivity disorder. Clinical
Psychology Review, 29, 129–140.
Feldman, J., & Kazdin, A. E. (1995). Parent management
training for oppositional and conduct problem children.
The Clinical Psychologist, 48, 3–5.
Forehand, R., Jones, D. J., & Parent, J. (2013). Behavioral
parenting interventions for child disruptive behaviors
and anxiety: What’s different and what’s the same.
Clinical Psychology Review, 33, 133–145.
2127
Kazdin, A. E. (1997). Parent management training:
Evidence, outcome and issues. Journal of American
Academic Child and Adolescent Psychiatry,
36, 1349–1356.
Michelson, D., Davenport, C., Dretzke, J., Barlow, J., &
Day, C. (2013). Do evidence-based interventions work
when tested in the “real world?” A systematic review
and meta-analysis of parent management training for
the treatment of child disruptive behavior. Clinical
Child and Family Psychology Review, 16, 18–34.
O’Leary, S. G., & Pelham, W. E. (1978). Behavior therapy
and withdrawal of stimulant medication in hyperactive
children. Pediatrics, 61, 211–217.
O’Leary, K. D., Becker, W. C., Evans, M. B., &
Saudargas, R. A. (1969). A token reinforcement
program in a public school: A replication and system-
atic analysis. Journal of Applied Behavior Analysis,
2, 3–13.
Webster-Stratton, C., Hollinsworth, T., & Kolpacoff, M.
(1989). The long-term effectiveness and clinical signif-
icance of three cost-effective training programs for
families with conduct problem children. Journal of
Consulting and Clinical Psychology, 57, 550–553.
Parent-Child Interaction
Family Therapy
Jiwon Yoo and Minsun Lee
Seton Hall University, South Orange, NJ, USA
Name of Model P
Parent-Child Interaction Therapy
Introduction
Parent-Child Interaction Therapy (PCIT) is an
evidence-based treatment for families of chil-
dren with behavioral issues (e.g., aggression,
defiance, and temper tantrums) and disruptive
behavioral disorders (e.g., Oppositional Defiant
Disorder and Conduct Disorder). PCIT involves
working directly with children and their parents
to improve children’s behavioral problems,
families’ parenting skills, the parent-child inter-
action patterns, and the overall quality of the
parent-child relationship. The PCIT therapist
coaches parents in two broad skills: Child-
2128
Directed Interaction and Parent-Directed Inter-
action. The former involves helping the parents
to play with their child in supportive ways to
strengthen their bond with the child, whereas
the latter involves enhancing parents’ manage-
ment of the child’s disruptive behaviors. PCIT
often consists of in vivo training of parents, with
the therapist observing the parent-child interac-
tion via a one-way mirror while providing live
coaching to the parents. Each session concludes
with a mutually determined homework assign-
ment of skills practice.
PCIT uses a unique combination of play ther-
apy, behavior therapy, and parent training to
teach families more effective techniques to
improve the parent-child relationship. Incorpo-
rating components of play therapy, PCIT allows
the children to build therapeutic alliances with
their therapists by providing a safe space to
express emotions in a healthy way, which pro-
duces a calming effect in the children. The ther-
apeutic bond serves as an example of healthy
attachment in the parent-child relationship,
which is often lacking in the parent-child rela-
tionship for children with disruptive behavioral
issues (Funderburk and Eyberg 2010). PCIT
incorporates child behavior therapy by having
the parents directly work with the child in ther-
apy, using specific techniques that can facilitate
the child’s behavior change at home. Lastly,
PCIT provides parent training on play therapy
skills and behavioral discipline techniques to
use every day at home, leading to lasting change
by way of healthy parent-child interaction
patterns.
The efficacy and effectiveness of PCIT has
been demonstrated with diverse diagnostic and
cultural groups, within the USA and internation-
ally. Research has shown that the implementation
of PCIT has improved parent-child relationships,
developed positive parenting strategies (e.g.,
reflective listening skills and prosocial verbaliza-
tion), and reduced child disruptive behaviors (e.g.,
temper tantrum and aggression) (Eyberg et al.
1995; Eisenstadt et al. 1993). Based on this scien-
tific evidence, PCIT continues to spur national and
international interest in its dissemination and
application.
Parent-Child Interaction Family Therapy
Prominent Associated Figures
PCIT was originally developed in the 1970s by
Sheila Eyberg at the Oregon Health Sciences Uni-
versity with the goal of establishing an interven-
tion program that incorporates techniques from
both play therapy and behavioral therapy. The
live coaching technique of PCIT draws from the
work of Constance Hanf, a psychologist who
developed a program to resolve behavioral issues
and improve compliance for developmentally
delayed children. In Hanf’s program, the parents
were trained to apply differential attention to the
child’s positive and negative behaviors. The ther-
apist also observed parents interact with their
child through a one-way mirror and used an ear-
piece to teach parents new techniques to manage
the child’s behaviors. PCIT uses the same
approach when teaching the parents new parent-
ing techniques, with the therapist communicating
via an earpiece to provide direct guidance to the
parents as they work with their child in the therapy
room (Funderburk and Eyberg 2010).
Theoretical Framework
Attachment theory. Children’s emotional reac-
tions to their primary caregiver can vary based on
their sense of security with their caregiver
(Bowlby 2005). From infancy, when children are
exposed to consistent parental warmth and
responsiveness, children develop a secure
parent-child relationship, which can have a lasting
effect on their understanding and development of
other future relationships (e.g., romantic relation-
ships and friendships), as well as their socio-
emotional development within their relationships.
Research has shown that children with a secure
attachment are likely to believe that their parents
will be available, helpful, and responsive when
encountering adverse and challenging situations
(Bowlby 2005). With this assurance, children feel
confident to explore their situations independently
and are more likely to respond to their parents in a
positive way. By contrast, unresponsive or incon-
sistent parenting can lead children to feel uncer-
tain about their parents’ helpfulness and
Parent-Child Interaction Family Therapy
availability when facing stresses and challenges,
contributing to an insecure attachment (i.e.,
anxious-ambivalent attachment style and
anxious-avoidant attachment style) with their par-
ents. Although insecure attachment is not consid-
ered “pathological,” insecure attachment is
associated with a higher risk of socio-emotional
malfunctioning and increased externalizing prob-
lems for children (Fearon et al. 2010). Based on an
understanding of the impact of attachment, PCIT
aims to facilitate parents’ acquisition of skills that
can help them be nurturing and responsive to their
children, which in turn will promote children’s
desirable behaviors and decrease negative
behaviors.
Developmental theory of parenting. In addi-
tion to attachment theory, PCIT is grounded in
Diana Baumrind’s developmental theory of par-
enting to incorporate the most effective parenting
style for children. According to Baumrind’s the-
ory, the authoritative parenting style, with high
emotional responsiveness, firm limit-setting, and
high psychological autonomy granted to children,
leads to the healthiest outcomes for children’s
psychosocial development. Compared to other
parenting styles, such as the authoritarian style
that values obedience and the permissive style
that is indulgent and neglectful, the authoritative
parenting style has been associated with fewer
psychological and behavioral problems in chil-
dren, higher sense of independence in children,
and greater family interaction and cohesiveness.
Using the authoritative parenting style as a proto-
type, PCIT provides parents with the opportunity
to learn new parenting techniques that can help
them to modify their child’s problematic behav-
iors in a nonintrusive manner and consistently
reinforce rationality and limit-setting, which are
essential to authoritative parenting (Lamborn
et al. 1991).
Social learning theory. Teaching parenting
techniques is a critical component of PCIT. It is
based on social learning theory, which emphasizes
learning through observation in a social context.
PCIT views the dysfunctional interaction between
parent and child as a repetitive cycle of negative
behavioral patterns, which can be reconstructed
through active skills training as a way to achieve
2129
healthy authoritative parenting. In PCIT, parents
learn, with direct guidance from the therapist, to
incorporate clear limit-setting and foster secure
attachment. These dual outcomes, in turn,
enhance the quality of the parent-child relation-
ship, allowing the relationship to better withstand
stress.
Populations in Focus
PCIT is designed for families of children aged 2–7
with behavioral issues and parent-child relation-
ship problems (Funderburk and Eyberg 2010).
PCIT may be used by parents, foster parents,
other major caretakers, as well as people in the
child welfare system, who are experiencing chal-
lenges in their interaction with the children. Due
to PCIT’s extensive caregiver-child dyadic ses-
sions and homework assignments that must be
completed together, it is required that caregiver
and child have regular, ongoing contact while they
participate in treatment. PCIT has been found to
help parents with children who experience the
following behavioral and emotional issues: fre-
quent temper tantrums, defiance, aggression,
inconsolable crying, attention-seeking behaviors,
short attention span, and power struggle with par-
ents and caregivers. Beyond these issues, parents
experiencing any difficulties in their parenting P
routine (e.g., having limited support in parenting,
feeling overwhelmed by their child’s emotional
and/or behavioral issues, and having an opposing
temperament with their child) may also benefit
from PCIT. In addition, PCIT has been supported
and validated by research to serve physically abu-
sive parents with children aged 4–12 (Chaffin
et al. 2004).
Strategies and Techniques Used in
Model
A typical PCIT program includes two sequential
phases with an average of 15 weekly sessions.
The first phase, Child-Directed Interaction
(CDI) – also called the relationship enhancement
phase – allows the parents to follow their child’s
2130
lead in their play in order to improve their rela-
tionship quality and reinforce positive child
behavior and self-esteem. The therapist guides
the parents to learn play therapy techniques, such
as the PRIDE skills in their interaction with their
child. P in PRIDE stands for praise. Parents are
encouraged to praise the child for appropriate
behavior by specifically labeling what they like
about the child’s behavior (e.g., “Good job mak-
ing that piece fit.”). R in PRIDE indicates reflec-
tion, referring to the parent repeating and
expanding upon the child’s words to encourage
communication (e.g., when the child says, “I’m
making a super-tall tower,” the parent repeats the
child by saying, “Yes, it is super-tall.”). I in
PRIDE represents imitation, in which the parents
mimic their child’s behavior in their play to dem-
onstrate their approval of the child’s behavior
and their engagement in the playtime. D in
PRIDE indicates description, which involves
parents verbally describing what the child is
doing in their play in order to show attention to
the child’s activities (e.g., when the child is
playing with the Play-Doh, the parents can say,
“You are rolling out the Play-Doh.”). Lastly, E in
PRIDE stands for enjoyment, referring to that
parents’ communication of enthusiasm for the
child’s activities through facial expressions,
positive touch, and tone of voice, to increase
parental warmth in play. Parents also learn to
actively ignore minor misbehavior and refrain
from using commands, criticism, sarcasm, and
negative words, such as “don’t” and “no.” Mas-
tery criteria for the CDI phase are the following:
Parents should be able to use (1) 10 behavior
descriptions, (2) 10 reflections, (3) 10 labeled
praises, and (4) no more than 3 total questions,
commands, and negative talk during a 5-min
play period. Through these skill-building ses-
sions, parents learn to practice consistent and
predictable parenting techniques, which may
allow them to experience greater confidence
when dealing with their children’s behavioral
issues in the home. By observing the behavioral
change in the parents, the child’s sense of safety
and confidence increase, while anger and frus-
tration toward the parents decrease (Budd
et al. 2011).
Parent-Child Interaction Family Therapy
Once the parents master these relationship-
enhancing skills, they progress to the second
phase, Parent-Directed Interaction (PDI) – also
called the discipline and compliance phase. In
this phase, parents learn to lead their child’s activ-
ity by providing the child with direct, easy-to-
understand commands and introducing conse-
quences for the child’s behaviors. For example,
the therapist guides the parents to provide praise
for compliance and verbal warning or a timeout
procedure for noncompliance. Mastery criteria for
the PDI phase are the following: the parents
should be able to demonstrate at least (1) four
commands, three of which are direct, and (2) cor-
rectly follow through on at least three of the com-
mands made to the child during a 50-min play
period. For both the CDI and PDI phases, the
therapist spends one session in the beginning
introducing and demonstrating to the parents the
principles and skills needed in the parent-child
interaction. The therapist then uses direct skill-
based teaching, using a wireless earphone and
microphone. That is, the therapist guides the par-
ents in their interaction with their child from an
adjacent room behind the mirror in an effort to not
impose on the interaction. This live coaching
technique allows the parents to promptly correct
any parenting mistakes they make and helps them
recognize their positive use of skills. During both
phases, specific parenting behaviors are coded by
the therapist and charted on a graph in each ses-
sion. By doing so, the therapist can provide par-
ents with immediate feedback regarding their
process and mastery of parenting techniques.
The parents are also given a 5 to 10-minute-long
homework assignment after each session to main-
tain and enhance their skills between sessions
(Budd et al. 2011).
Although the average number of sessions for
PCIT is known to be 15, PCIT is mastery-based
and time-unlimited because the families continue
with PCIT until they accomplish their treatment
goals, and their new skills are at mastery level.
The average number of sessions reflects the aver-
age time spent to reach the family’s treatment
goals. The ultimate goal of PCIT is to accomplish
the treatment goals established at the beginning of
treatment.
Parent-Child Interaction Family Therapy
Research about the Model
Numerous studies have studied the efficacy and
effectiveness of PCIT. Funded by the National
Institute of Mental Health (NIMH), the first ran-
domized study of PCIT was conducted with a
sample of 19 families of children with Conduct
Disorder (Eyberg et al. 1995). This study
observed an improvement in mothers’ praise
usage, a decrease in parents’ negative talk (e.g.,
sarcasm and criticism), and an increase in the
child’s compliance. In addition, a study with
24 mother-child dyads demonstrated a significant
improvement in parents’ reflective listening,
physical proximity, and prosocial verbalization,
as well as a decrease in parents’ criticism and
sarcasm, and positive change in parents’ mental
health and parenting attitude (Eisenstadt et al.
1993). This study also showed an improvement
in children’s compliance and self-esteem.
Regarding the maintenance of treatment effects,
Hood and Eyberg (2003) conducted a follow-up
study on mothers who had previously participated
in PCIT for their young children with Oppositional
Defiant Disorder (ODD) and associated behavior
disorders. Significant changes in the children’s
behavior were maintained 3–6 years after treatment.
More than 150 research studies have been
conducted across the decades to assess the appli-
cability of PCIT for various diagnostic groups.
For example, in a study of 110 physically abusive
parents, only 19% of the PCIT-participated par-
ents reported incidents of physical abuse against
their children after 850 days, compared to 49% of
the parents who attended a community parenting
group (Chaffin et al. 2004). PCIT has also been
shown to be effective in treating disruptive behav-
ior issues with comorbid mental retardation
(Bagner and Eyberg 2007), autism spectrum dis-
order (ASD) (Solomon et al. 2008), and other
mental health issues such as separation anxiety,
depression, self-injurious behavior, Attention
Deficit Hyperactivity Disorder, and adjustment
issues after parents’ divorce (Pincus et al. 2005).
PCIT has also been shown to improve parent-
child interactions and greater language gains for
children with language impairments (Allen and
Marshall 2011).
2131
In addition, studies have demonstrated the bene-
fits of PCIT across a variety of ethnic groups. For
example, Leung and colleagues (Leung et al. 2008)
studied the effectiveness of PCIT among Chinese
families in Hong Kong and observed a decrease in
child behavior problems and parenting stress, as
well as an increase in positive parenting practices.
Various cultural issues in the use of PCIT with
Chinese families were discussed in the study, with
recommendations regarding how to negotiate inev-
itable cultural differences in the perception of some
of the parenting skills (e.g., use of praise, application
of directive play, ignoring negative behaviors, and
extended families view of new parenting tech-
niques). A few studies have used a culturally
adapted version of PCIT to provide a culturally
sensitive treatment to diverse ethnic families (e.g.,
BigFoot and Funderburk 2011).
Case Example
Maria, a 5-year-old Puerto Rican girl, and her
parents sought PCIT for Maria’s frequent temper
tantrums, emotional meltdowns, and aggressive
behaviors, such as hitting, kicking, and throwing
household objects. In school, Maria had frequent
anger outbursts and would hit other children or cry
out of frustration. Maria’s teacher also reported
that Maria would often refuse to comply with the P
teacher’s instructions. Maria was recently diag-
nosed with Oppositional-Defiant Disorder
(ODD), and her parents were seeking assistance
in coping with this disorder. During the course of
the treatment, Maria’s mother and father jointly
attended 6 sessions, and her mother attended
11 sessions alone with Maria, totaling 17 sessions.
The sessions included 7 CDI sessions, 8 PDI ses-
sions, and 2 additional sessions to review treat-
ment progress.
At initial assessment, Maria’s mother reported
a high level of parental stress and behavioral con-
cerns for Maria, in addition to her lack of confi-
dence in her parent-child interaction with Maria.
Maria’s mother also reported high conflict in the
parental relationship, with frequent arguments
happening in front of Maria. Both Maria’s mother
and father demonstrated a relatively low rate of
2132
PRIDE skills in the beginning of the CDI phase.
During the course of the CDI sessions, Maria’s
parents engaged in playtime with Maria using
blocks and a dollhouse. In addition, Maria’s com-
pliance and prosocial behaviors were consistently
encouraged using PRIDE skills, and negative
behaviors, such as crying and yelling, were
actively ignored. When Maria exhibited aggres-
sive behaviors, Maria’s parents stopped their play-
time and explained to Maria the reasons for
stopping the playtime. Consequently, Maria’s
aggressive behaviors were decreased as she real-
ized her misbehavior no longer received much
attention. Maria’s mother appeared to feel less
overwhelmed in her interaction with Maria as
she presented less negative behavior and she was
able to enjoy her playtime with Maria as sessions
progressed.
During the course of the PDI sessions, Maria’s
mother initially used criticism and would often
raise her voice while using direct commands.
She also struggled to use time-outs consistently,
and at times used verbal threats to try to increase
compliance. The PCIT therapist had additional
teaching sessions with Maria’s mother to practice
the appropriate skills through instruction, demon-
stration, and role-play. The PCIT therapist also
worked collaboratively with Maria’s parents’ cou-
ple therapist to help decrease parental arguments
in front of Maria and increase parental consensus
around the management of Maria’s behaviors. The
PCIT therapist also worked with Maria’s teacher
at school to teach PCIT skills to use with Maria in
the classroom.
At the conclusion of treatment, Maria’s overall
behavior and interactions with her parents
appeared in the normal range and Maria no longer
met the criteria for ODD. In addition, Maria’s
mother reported significantly lower levels of par-
enting stress and a decrease in Maria’s aggressive
and destructive behaviors at home. Maria also
decreased her negative behaviors at school, per
the teacher’s report.
Cross-References
▶ Play in Couple and Family Therapy
Parent-Child Interaction Family Therapy
References
Allen, J., & Marshall, C. R. (2011). Parent-child interaction
therapy (PCIT) in school-aged children with specific
language impairment. International Journal of Lan-
guage and Communication Disorders, 46(4), 397–410.
Bagner, D. M., & Eyberg, S. M. (2007). Parent–child
interaction therapy for disruptive behavior in children
with mental retardation: A randomized controlled trial.
Journal of Clinical Child and Adolescent Psychology,
36(3), 418–429.
BigFoot, D. S., & Funderburk, B. W. (2011). Honoring
children, making relatives: The cultural translation of
parent-child interaction therapy for American Indian
and Alaska Native families. Journal of Psychoactive
Drugs, 43(4), 309–318.
Bowlby, J. (2005). A secure base: Clinical applications of
attachment theory (Vol. 393). London: Taylor &
Francis.
Budd, K. S., Hella, B., Bae, H., Meyerson, D. A., &
Watkin, S. C. (2011). Delivering parent-child interac-
tion therapy in an urban community clinic. Cognitive
and Behavioral Practice, 18(4), 502–514.
Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A.,
Brestan, E. V., Balachova, T., et al. (2004). Parent-child
interaction therapy with physically abusive parents:
Efficacy for reducing future abuse reports. Journal of
Consulting and Clinical Psychology, 72(3), 500.
Eisenstadt, T. H., Eyberg, S. M., McNeil, C. B., Newcomb,
K., & Funderburk, B. (1993). Parent-Child Interaction
Therapy with behavior problem children: Relative
effectiveness of two stages and overall treatment out-
come. Journal of Clinical Child Psychology, 22,
42–51.
Eyberg, S. M., Boggs, S. R., & Algina, J. (1995). Parent-
child interaction therapy: a psychosocial model for the
treatment of young children with conduct problem behav-
ior and their families. Psychopharmacology Bulletin, 31,
83–91.
Fearon, R. P., Bakermans-Kranenburg, M. J., van
Ijzendoorn, M. H., Lapsley, A. M., & Roisman, G. I.
(2010). The significance of insecure attachment and
disorganization in the development of children‘s exter-
nalizing behaviour: A meta-analytic study. Child
Development, 81, 435–456.
Funderburk, B. W., & Eyberg, S. (2010). History of PCIT.
In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim
(Eds.), History of psychotherapy: Continuity and
change (2nd ed., pp. 415–419). Washington, DC: APA.
Hood, K. K., & Eyberg, S. M. (2003). Outcomes of parent-
child interaction therapy: Mothers’ reports of mainte-
nance three to six years after treatment. Journal of
Clinical Child and Adolescent Psychology, 32(3),
419–429.
Lamborn, S. D., Mounts, N. S., Steinberg, L., &
Dornbusch, S. M. (1991). Patterns of competence and
adjustment among adolescents from authoritative,
authoritarian, indulgent, and neglectful families. Child
Development, 62, 1049–1065.
Parentified Child in Family Systems
Leung, C., Tsang, S., Heung, K., & Yiu, I. (2008). Effec-
tiveness of parent-child interaction therapy (PCIT)
among Chinese families. Research on Social Work
Practice, 19, 304–313.
Pincus, D. B., Choate, M. L., Eyberg, S. M., & Barlow,
D. H. (2005). Treatment of young children with sepa-
ration anxiety disorder using Parent-Child Interaction
Therapy. Cognitive and Behavioral Practice, 12(2),
126–135.
Solomon, M., Ono, M., Timmer, S., & Goodlin-Jones,
B. (2008). The effectiveness of parent–child interaction
therapy for families of children on the autism spectrum.
Journal of Autism and Developmental Disorders,
38(9), 1767–1776.
Parentified Child in Family
Systems
Kristy L. Soloski, Brie Turns, Cydney Schleiden
and Porter Macey
Texas Tech University, Lubbock, TX, USA
Synonyms
Parental Child; Parentification
Introduction
Parentification* in the family system is defined as
a functional and/or emotional role reversal
wherein the child sacrifices his or her own needs
in order to accommodate and care for emotional or
logistical needs of a parent (Chase 1999). An
important aspect of the parent-child relationship
is how both parties learn to respond to one
another’s needs. On one side of the spectrum,
responding to a parent’s needs can help a child
develop compassion and reciprocity with others
(Chase 1999); on the opposite end, if a parent
depends too much on the child, forcing them to
assume many of the parent’s responsibilities, the
parentified child* may learn that his or her needs
are less important than others (Chase 1999).
When children take over parental responsibilities,
they will often leave the childhood status func-
tioning more as an adult.
2133
Prominent Associated Figures
Parentification* has been described from different
theoretical approaches, including cybernetics,
structural family therapy, and contextual family
therapy, and by prominent figures including Greg-
ory Bateson, Salvador Minuchin, Ivan
Boszormenyi-Nagy, Barbara Krasner, and John
Bowlby. These family system researchers have
somewhat different perspectives on the definition
of parentification* (Jurkovic et al. 1991) and
focus upon different elements of parentification*
(e.g., behaviors or emotions; Hooper 2007).
Cybernetics. Before the formal terms
parentified child* and parentification* were first
used in clinical literature, the characteristics and
dynamics they represent had been recognized by
many researchers (Jurkovic 1997). For example,
Bateson began studying patterns of paradoxical
communication in families living with schizo-
phrenic children. The concept of being caught in
a “double bind” is a situation in which no matter
what a person does, she/he “can’t win” (Bateson
et al. 1956). Parentification* can thus be a double
bind. When the parent depends on the child for
their emotional and/or physical needs, the child is
faced with the decision of being the caregiver for
the parent or distancing themselves from those
who are charged to care for them. This double
bind causes tension and stress for the child and P
is one of the reasons parentification* can be
harmful.
Structural Family Therapy. In structural
family therapy, Minuchin (1974) describes the
parental child* as one who has the responsibility
and authority to care for other children in the
family. Boundaries between the parents and the
parental child* are often diffuse, while boundaries
between the parent subsystem and the other chil-
dren are rigid. This parental child* has a level of
autonomy and responsibility that is beyond his or
her years. This structure is functional for many
families and may be especially prevalent in large
families, families with working parents, or in
single-parent families. It can become problematic
to have a parental child* structure if the delegated
authority was not explicitly discussed or negoti-
ated. It can also be problematic when the child
2134
becomes the primary authority figure over his or
her siblings, and the parental unit is largely
unavailable to serve in that role. The demands of
this role may become overwhelming to the paren-
tal child* or they may exceed his or her develop-
mental level.
Contextual Family Therapy. In contextual
therapy (Boszormenyi-Nagy and Krasner
1986), parentification* of a child is defined not
solely through the role that the child takes on but
also through the act of being available to fulfill
the parent’s needs. This may mean that the child
takes on more responsibility than is appropriate
for his or her age or that the child is emotionally
available to care for the parent’s needs. For
example, a possessive and overprotective parent
may place the child in a role to fulfill a need for
reduced anxiety, but in doing so interrupts the
child’s ability to develop his or her own person-
ality and thus becomes permanently available to
the parent. Parentification* becomes problem-
atic when the child gives more than he or she
receives in return, becoming destructively
parentified*, a form of destructive entitlement.
Relational factors differentiate whether the
parentification* is harmful. For example, if the
child is acknowledged for being helpful and
available, they are given back resources and
energy rather than only being drained by the
role. When the child’s resources and trust
reserves become depleted by the parent,
the fair balancing of the relationship ledger
becomes unbalanced, and parentification* moves
from an appropriate adaptation to destructive enti-
tlement. The child’s ability to individuate, engage
with their peers, or assumeappropriate adult roles
is stunted by the parent’s need for their availabil-
ity. Destructive parentification* can drain a child’s
resources early on impacting their ability to pro-
vide to the next generation as a parent or to pro-
vide to a romantic relationship in the future.
Description
There are two common types of parentification*
identified throughout the literature. Emotional
Parentified Child in Family Systems
parentification* involves a child filling an emo-
tional or psychological void in the family for
either the parent or siblings (Hooper 2007).
A child in this role may become the parent’s friend
or social support system, or the child may become
his or her sibling’s parent. Instrumental
parentification* is defined as a child is in charge
of completing parental tasks, such as cooking,
cleaning, shopping, and caring for siblings
(Hooper 2007). Jurkovic et al. (1999) discuss
parentification* as a continuum of responsibility
according to the duration and extensiveness of
caretaking. Destructive parentification* is defined
as a child who over-functions in a parental role.
The opposite end of the spectrum is “infantiliza-
tion,” a child who under-functions in a parental
role but is fulfilling the parent’s emotional needs
of being a dependent child (Jurkovic et al. 1999).
The two categories, “healthy non-parentified” and
“adaptive parentified,” complete the continuum.
Adaptive parentification* consists of caretaking
responsibilities that may increase or intensify
because of crisis or acute stress, but these contri-
butions are recognized by the parents and are only
expected for a limited time (Jurkovic et al. 1999).
Theorists have varied in their descriptions
surrounding parentification. Bowlby (1973)
explains the parentification* phenomenon as
the inverse relationship between parent and
child. Boszormenyi-Nagy and Spark (1973)
wrote about a subjective distortion in the rela-
tionship where one acts as though the child is
the parent. Minuchin (1974) pointed out that
parentification* can be natural “in large fami-
lies, in single-parent families, or in families in
which both parents work” (p. 97). When
parentification* is temporary, it is associated
with responsibility, autonomy, and competence
in families where the children are offered sup-
port and recognized for their accomplishments
(Burnett et al. 2006). Parentification* can be
associated with problematic outcomes for the
child and caregiver. For example, parents or
caregivers relying on children excessively for
extended amounts of time can be associated
with depression (Barnett and Parker 1998) and
personality styles that are narcissistic and self-
defeating (Jones and Wells 1996).
Parentified Child in Family Systems
Relevance to Couple and Family Therapy
The type (i.e., emotional or instrumental
parentification*), duration, and excessiveness
of the parentification* influence the effects
parentification* can have on the child and
family members. Couple and family therapists
will likely work with families presenting with
parentification* and should be aware of its pos-
sible implications. It is important to identify fac-
tors contributing to the role the parentified child
will take and how this role will influence his or
her relationships in the future. These factors can
include gender, SES, availability of another care-
giver, others outside of the parental subsystem
that require care, and the nature by which the
child became parentified (Barnett and Parker
1998). Some of the most common reasons a
child becomes parentified include divorce, sub-
stance abuse, death, and mental or physical dis-
ability of the primary caregiver(s) (Barnett and
Parker 1998). Older daughters might be expected
to assist with childcare and household chores,
and older male children could be involved with
farming, or the family business, or working part
time to boost the family income. Family thera-
pists need to distinguish between the family
needing their children’s help to keep afloat as
opposed to relying on them excessively even
when alternatives are present.
The couple and family therapist should also be
aware of the negative outcomes as a result of
parentification*. For example, the parentified
child’s development of self may be compromised,
potentially leading to the development of features
of personality disorders such as narcissistic
and self-defeating (i.e., masochistic) characteris-
tics (Jones and Wells 1996). Destructive
parentification*, in particular, has been associated
with feelings of grief from the loss of parental
figures, guilt, shame, and peer problems (e.g.,
Jurkovic 1997). Parentified children report having
childhoods that include parents not being physi-
cally present for their psychological needs. Other
children find it difficult to be happy and enjoy life
because the family members they are caring for
are not emotionally, physically, or financially
well. Extreme parentification* has also led to the
2135
child turning to peers to avoid the pressures at
home, which can lead to gang affiliation and alco-
hol and drug use (Jurkovic 1997). Gender and
race/ethnicity may play a role in parentification,
both in terms of who is more parentified and the
effects of parentification. For example, Black
Americans may have higher levels of
parentification (Hooper et al. 2014), which may
also be more strongly related to psychopathology
than it is for White Americans (Hooper
et al. 2011). Males may be more parentified than
are their female counterparts (Hooper et al. 2014),
and female parentified children are at an increased
risk for teenage pregnancy as compared to
unparentified females (Minuchin et al. 1967).
Couple and family therapists should be aware
that the risk of parentification* is elevated in cer-
tain populations. Low socioeconomic status and
minority status children are considered most at
risk (Barnett and Parker 1998). This often occurs
when a caregiver’s work keeps them away from
home and the child takes on the parental duties of
that family member. Parentification* is also com-
mon in immigrant families. New immigrant par-
ents may rely on their children for help with
language issues and assistance in navigating edu-
cational, medical, and legal systems. Although
there are negative emotions that can be associated
with this role, many children who are parentified
due to immigration develop positive traits. Spe- P
cifically they are found to have commitment to
their family and resiliency (Cheng 2012).
Finally, couple and family therapists should be
aware that although parentification* occurs in
numerous types of families, parentification* can
be functional. For example, destructive
parentification* or infantilization is more func-
tional in highly stressed families, such as families
raising a child with special needs (Siegle and
Silverstein 1994). Older and younger siblings of
children with special needs participate in more
caretaking roles in comparison to siblings of typ-
ically developing children (e.g., Siegle and
Silverstein 1994). Some have expressed concern
that siblings who adopt a parentlike role toward
the child with the disability may receive less sup-
port and attention from his or her parents (e.g.,
Siegle and Silverstein 1994). Siegle and
2136
Silverstein (1994) view parentification* as a cop-
ing mechanism for siblings of children with
autism. They believe that in order to maintain
closeness and approval from the parents, siblings
will take on responsibilities for their sibling with
autism. Researchers investigating the conse-
quences of parentification* have found a variety
of results. Some report tension between the
parentified* child and the mother and decreased
quality interactions between the mother and typi-
cally developing child, while others report the
parentified* child can develop a greater empathy
toward others (Siegle and Silverstein 1994).
Clinical Example of Application
of Theory in Couples and Families
The Dukes family includes an alcoholic mother,
Sara, a father named Sunny, a 14-year-old son
named Michael, and an 8-year-old-sibling named
Kate, whom Michael cares for. Sara, now sober,
has undergone intensive outpatient treatment for
her alcohol use and is now in family therapy to
resolve family patterns related to alcohol use and
resulting from it. Sara began drinking when she
and Sunny, lost their child during the third trimes-
ter. In his father’s emotional absence, since the
loss of the baby, Michael became the emotional
support for his mother as well as would adhere to
her needs when she would pass out from drinking.
Kate relies on Michael for caregiving including
getting to school, getting ready for bed, and all
emotional support.
Structural Family Therapy. Couple and fam-
ily therapy employing a structural approach
would work to realign the family by clarifying
boundaries between the parental subsystem and
the parental child* and allowing more access to
the parental system for the other children in the
family (Minuchin 1974). The parental child*
maintains some authority over the other siblings,
but is relegated back to the sibling subgroup with
a position of leadership. Restructuring the system
can be done by working with different family
subsystems.
Working with the Dukes, the therapist could
work with Sara and Sunny (the parental subsystem)
Parentified Child in Family Systems
addressing the issue that exacerbated Sunny’s emo-
tional distance as well as Sara’s alcohol abuse. This
would allow the family to restructure the boundaries
in a healthier manner. Once Sunny and Sara were
able to establish themselves at the top of the hierar-
chy, Michael would again be able to access the
parental subsystem in times of need rather than
being part of it. Instead of relying on Michael for
all her needs, Michael would only need to care for
Kate in age appropriate ways, such as babysitting
while the parents occasionally go out or walking
with her to the store.
Contextual Family Therapy. Contextual ther-
apy would work to deparentify a child with the
family by having parents provide due crediting to
the child as a means of balancing their entitlement
(Boszormenyi-Nagy and Krasner 1986). The inter-
ventions are first aimed at identifying and altering
the exploitative behaviors. When the parent
acknowledges the child’s experience and the value
of their behavior to the family, the parent becomes
more trustworthy to the child and the parent earns
constructive entitlement. With the Dukes family, the
therapist worked with the parents to have both mom
and dad acknowledge the difficulty of what Michael
had to go through for the family and help the parents
take ownership of not doing more for Michael (i.e.,
not caring for him in the way he needed). In contex-
tual therapy, parents would provide genuine
acknowledgment of the contributions of the child
to the family. Michael’s father, Sunny, would thank
Michael for caring for his mother especially when
she wasn’t able to care for him and commended his
courageousness. Michael’s mother, Sara, would
thank him for taking her place and caring for Kate
when she was not as good of a mother as she should
have been and told him she appreciated his kind-
ness. Both Sara and Sunny would spend time telling
Michael that he deserved to have more time to spend
as a child and apologized for him not receiving that
time. By doing this, trustworthiness between the
child and parents should be restored. Next, treatment
would help the parentifying adults become more
independent, which allows the child to engage
again in childlike behavior. This was done through
engaging the parents and providing therapeutic par-
tiality wherein the parents could discuss their suffer-
ing related to the miscarriage of their baby and the
Parenting in Families
pain experienced because of the alcohol use. In
cases where the parentified child is grown and the
parents are not able to be incorporated in treatment,
contextual therapy would work with the client to
understand and acknowledge the unfairness in what
was asked from him or her, and what failed to be
provided to him or her, as a child.
Cross-References
▶ Contextual Family Therapy
▶ Ledgers in Couple and Family Therapy
▶ Structural Family Therapy
References
Barnett, B., & Parker, G. (1998). The parentified child:
Early competence or childhood deprivation. Child Psy-
chology and Psychiatry Review, 3(4).
Bateson, G., Jackson, D. D., Haley, J., & Weakland,
J. (1956). Toward a theory of schizophrenia. Behav-
ioral Science, 1(4), 251–254.
Boszormenyi-Nagy, I. K., & Krasner, B. R. (1986).
Between give and take: A clinical guide to contextual
therapy. New York: Brunner/Maze.
Boszormenyi-Nagy, I. K., & Spark, B. R. (1973). Invisible
loyalties: Reciprocity in intergenerational family ther-
apy. New York: Brunner/Mazel.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation.
New York: Basic Books.
Burnett, G., Jones, R. A., Bliwise, N. G., & Ross, L. T.
(2006). Family unpredictability, parental alcoholism,
and the development of parentification. The American
Journal of Family Therapy, 34(3), 181–189. https://doi.
org/10.1080/01926180600550437.
Chase, N. D. (1999). Parentification: An overview of the-
ory, research, and societal issues. In N. D. Chase (Ed.),
Burdened children: Theory, research, and treatment of
parentification (pp. 3–33). Thousand Oaks: Sage.
Cheng, Y. Y. (2012). Re-conceptualizing parentified
children from immigrant families. Doctoral disserta-
tion, Alliant International University, 2012. Pro-
Quest Dissertation Publishing, 1–182. (UMI
No. 3478052).
Hooper, L. M. (2007). The application of attachment the-
ory and family systems theory to the phenomena of
parentification. The Family Journal: Counseling and
Therapy for Couples and Families, 15(3), 217–223.
Hooper, L. M., DeCoster, J., White, N., & Voltz, M. L.
(2011). Characterizing the magnitude of the relation
between self-reported childhood parentification and
adult psychopathology: A meta-analysis. Journal of
Clinical Psychology, 67(10), 1028–1043.
2137
Hooper, L. M., Tomek, S., Bond, J. M., & Reif, M. S.
(2014). Race/ethnicity, gender, parentification, and
psychological functioning comparisons among a
nationwide university sample. The Family Journal:
Counseling and Therapy for Couples and Families,
23(1), 33–48.
Jones, R. A., & Wells, M. (1996). An empirical study of
parentification and personality. American Journal of
Family Therapy, 24, 145–152.
Jurkovic, G. J. (1997). The plight of the parentified child.
New York: Brunner Mazel Inc.
Jurkovic, G. J., Jessee, E. H., & Goglia, L. R. (1991).
Treatment of parental children and their families: Con-
ceptual and technical issues. The American Journal of
Family Therapy, 19(4), 302–314.
Jurkovic, G. J., Morell, R., & Thirkield, A. (1999).
Assessing childhood parentification: Guidelines for
researchers and clinicians. In N. D. Chase (Ed.), Bur-
dened children: Theory, research, and treatment of
parentification (pp. 92–113). Thousand Oaks: Sage.
Minuchin, S. (1974). Families & family therapy. Cam-
bridge, MA: Harvard University Press.
Minuchin, S., Montalco, B., Guerney, B., Rosman, B., &
Schumer, F. (1967). Families of the slums. New York:
Basic Books.
Siegle, B., & Silverstein, S. (1994). What about me?
Growing up with developmentally disabled sibling.
New York: Plenum Press.
Parenting in Families
Martha E. Edwards
P
Ackerman Institute for the Family, New York,
NY, USA
Name of Concept
Parenting in Families
Synonyms
Caregiving
Introduction
A parent’s job is to prepare children to live suc-
cessfully in the world. This entails ensuring their
children’s physical survival as well as their
2138
cognitive, social, emotional, and moral develop-
ment so that they are prepared to take their place in
adult society. The specific capacities that parents
encourage in their children will vary depending on
the society into which children are being social-
ized, what constitutes success there, and what
parents think children need to feel, believe, and
do to function successfully.
In societies that value individual achievement,
often associated with western, industrialized
countries, parents tend to privilege the develop-
ment of independence, self-confidence, and skills.
In societies that value relatedness, often associ-
ated with eastern or rural countries, parents tend to
encourage the development of respect, proper
demeanor, and self-control (Harwood et al.
2001). While these differences in goals reliably
distinguish one society from another, there is also
a great deal of diversity in goals within societies
and within cultural groups.
In the United States, for example, African
American parents and other parents of color are
acutely aware of the dangers their children face –
dangers to which white parents are often oblivi-
ous. Children and adults of color are subjected to a
level of aggression (both “micro aggressions” and
the threat of bodily harm and death) many more
times than white adults and children. Because of
these dangers in the environment, it is not unusual
for parents of color to use more restrictive and
punitive parenting practices with their children,
often in a paramount effort to ensure their safety.
Cross-cultural research provides a reminder of
the vast differences in both parenting goals and
practices. The patterns revealed by this research
are helpful in informing family therapists to the
possible goals and beliefs that shape parenting
practices and to guide their inquiry in the particu-
lar culture of each family they see.
Parenting Processes in Families
The practices that parents use to achieve their
socialization goals for their children fall under
three broad categories (Edwards 2002). The first
process entails connecting with the child emotion-
ally, providing a deep sense of security, trust, and
Parenting in Families
embeddedness in relationship with others
(Parenting Processes Category 1: Developing the
Emotional Relationship). Parents then create the
conditions and engage in interactions that facili-
tate children’s learning sensory-motor, cognitive,
social-emotional, and linguistic skills to navigate
the world (Parenting Processes Category 2: Pro-
moting Exploration and Learning) and to live
cooperatively with others (Parenting Processes
Category 3: Guiding Toward Interdependence).
These are summarized in Fig. 1.
Developing the Emotional Relationship
Children come into this world prepared to be in
relationship with their caregivers and both their
physical and emotional survival depends on the
quality of this bond (Lieberman 2013). Infants
rely on their parents to provide safety and security.
The child signals distress or fear, and the sensitive
caregiver ideally responds in a way that comforts
the distress and restores the sense of safety. Over
many repetitions, the child develops trust in the
relationships with caregivers and comes to know
the world as safe, and the relationship is labeled as
a “secure attachment” (Bowlby 1982). Securely
attached infants develop an internal working
model of relationships whereby they are worthy
and competent to get their needs met by trustwor-
thy caregivers (Bretherton 2005).
In contrast, when parents are not responsive,
i.e., when they are inconsistent or neglectful, inse-
cure attachment can result. Insecurely attached
children must adapt to the caregiver and develop
strategies to try to insure their caregivers’ prox-
imity. The strategies, however, entail excluding
aspects of their experience that the caregiver can-
not tolerate in an often desperate attempt to main-
tain some connection and thus protection and
comfort. These attempts come at a significant
cost to children’s well-being in that they must
constrict their experience and suppress their unac-
ceptable thoughts and feelings.
Two broad categories of insecure attachment
have been identified. The first is what Bowlby
(1982) and Ainsworth et al. (1978) labeled
“ambivalent attachment,” whereby the child of
the inconsistent parent must constantly monitor
the parent’s emotional state and physical
Parenting in Families 2139

Developing the Emotional

Relationship

 Attunement
 Reflective Function
 Enjoyment
 Communication Repair

Selected child capacities

Focused attention
Delay of gratification
Frustration tolerance
Ability to self soothe
Expressive Communication
Receptive Comprehension
Relatedness
Sympathy and empathy
Use of thoughts & feelings to solve
problems & attain goals
Capacity to decenter
Ability to hold complexity in thinking

Promoting Exploration & Learning Guiding Toward Interdependence

 Provide safe and stimulating  Establish expectations for

environment positive behavior (routines,
 Engage in meaningful modeling, encouraging,
conversation teaching)
 Scaffolding – help just  Use reflective dialogues
enough  Address misbehavior –
 Tolerate tension in the setting limits and
struggle consequences
P

PROXIMAL AND DISTAL CONTEXT

Parenting in Families, Fig. 1 The parenting processes model

closeness. As a result, these children have diffi-
culty functioning independently and often use
heightened emotionality (whimpering, whining,
crying) in an attempt to get and keep the parent’s
attention and ministrations. What is often
displayed is a mixture of grief and anxiety, and
what is often underneath and defensively
excluded, because it may threaten the attachment
relationship, is anger. This sets the stage for
heightened emotionality and difficulties with
affect regulation in the future.
Bowlby and Ainsworth labeled the second cat-
egory of insecure attachment as “avoidant attach-
ment.” Here, the child responds to the neglectful
parent by minimizing emotional experience and
expression so as to maintain the attachment rela-
tionship. On the surface, the child appears not to
need the parent. But during the separations and
2140
reunions used to formally assess attachment while
monitoring physiological activation, these chil-
dren’s seemingly calm outward demeanor masks
great internal agitation (Cassidy 1994). At a very
early age, these children disconnect from their
true feelings (fear, distress) and take on a way of
being that seems to signal “I don’t need you; I’m
just fine without you; you don’t need to do any-
thing for me.” But they lose both the capacity for a
more authentic connection and as well as access to
a wide range of emotions that help them adapt to
situations and achieve goals.
These two categories of insecure attachment
are organized strategies to cope with less than
ideal caregiving. Main (1995) identified a fourth
category of attachment – neither secure or
insecure – that she called “disorganized.” In
this situation, the parent who is abusive (and,
thus, frightening) or the parent who is abused
(and, thus, frightened) presents a terrible
dilemma for the child, leading to intense anxiety
and overwhelming affect to which he has no
strategy for abatement. While the child might
yearn to move toward the parent in moments of
his own distress or fear, the parent represents
either the source of fear, or, in her own fear
state, is unable to provide comfort. As a result,
these children have no organized strategy for
dealing with this dilemma. They may combine
strategies, e.g., first moving toward and then
moving away, or spin in circles. Psychologically,
they may use dissociation and splitting to gain
some distance from this untenable situation,
leading to long-term risk for mental health
difficulties.
These descriptions of attachment classifica-
tions are generalizations based on large numbers
of parent-child dyads. Individuals may have some
features of multiple types of attachment classifi-
cations, which get triggered by different relation-
ships in their lives. Nevertheless, these
classifications are useful to understand the short-
term and long-term impact of parent-child inter-
actions. Over many repetitions of these early pat-
terns of interacting, children develop internal
working models of self and other in relationship
that shapes their expectations for and behavior in
future interactions.
Parenting in Families
The phenomenology of sensitive and respon-
sive parent-child interactions appears to include
both an intuitive, often unconscious component,
called attunement, as well as an intentional, more
conscious component, called reflective function.
In attunement (Stern 1985), parents intuitively
mirror their children’s emotional states, for exam-
ple, responding to the child’s wide smile (facial
cue) with a vocalization that is raised in pitch, or
matching their body language. Parents may not
even be aware of how attuned they are to their
children. But the children implicitly know that
their parents “get” what they are feeling, and this
contributes to the sense of being known and the
capacity to know oneself.
Parents with a more highly developed capacity
for reflective function consciously conceptualize
both self and other as intentional beings who
think, imagine, desire, and intend (Fonagy et al.
1991). This capacity enables them to see their
child’s behavior in a more nuanced and layered
way. Rather than seeing the child as “bad” or
“driving me crazy,” for example, the parent digs
deeper to understand the root of the child’s behav-
ior, thus guiding a more effective response. The
experience of being perceived as “having a mind
of one’s own” is internalized by the child who
then learns to accept, reflect upon, and be guided
by his or her own inner states.
While Bowlby and his colleagues focused on
the function of the attachment system to regulate
the child’s distress and safety, parents’ attuning to
and responding in kind to their children’s plea-
sure, joy, and exuberance are also important for
development. Not only are they positive experi-
ences, in and of themselves; these interactions
also facilitate children’s physiological capacities
for these positive, but sometimes overwhelming,
emotions (Siegel 1999). Through these positive
social experiences, children learn that relation-
ships are associated both with protection from
negative experiences and relief from distress as
well as pleasure, zest, and excitement. Their emo-
tional range is broadened, and they learn that joy
is multiplied when shared with others.
In the moment-to-moment dance between par-
ent and child, there are many opportunities for
missteps. In microanalyses of parent-infant
Parenting in Families
interaction, Tronick (1989) found that parents and
children were coordinated only 30% of the time.
Sensitive and responsive parents recognize these
miscoordinated interactions and promptly repair
them so that the child can move from distress back
to a more positive affective state. Through this
pattern of connection-disruption-repair, repeated
from early childhood throughout adolescence,
children learn to tolerate distress and realize that
difficulties in relationships are temporary and can
be overcome.
The capacity to be emotionally connected with
others is critical for children’s and adult’s physical
and mental health throughout the life span (Thoits
2011). It also provides the foundation for chil-
dren’s exploration and learning about the world.
Promoting Exploration and Learning
In addition to the attachment system that regulates
closeness and safety, Bowlby (1982) conceptual-
ized an exploratory system that propels the child
outward to explore and learn about the world.
These two systems are reciprocal in that when
children’s attachment needs are not active, the
exploratory system can be activated. From this
secure base, they can explore and learn about the
world, knowing they have the support from care-
givers if needed. Attachment provides support for
the child’s burgeoning skills in at least three
important ways. First, when the attachment is
secure, children have learned that they can have
a reasonable effect on their caretakers and that
their needs can be met, all of which help the
child develop a sense of agency in the world.
Second, children monitor the parents’ reactions,
a process called social referencing (Bretherton
1982), and use them to gauge the safety of the
current environment. Third, the trust and security
the child feels in the relationship with parents set
the stage for the child to use other adults as men-
tors who are helpful and provide support for
learning.
Parents support this exploration and learning
by providing or making sure their children have
access to a safe and stimulating environment,
replete with objects (not necessarily toys) to
manipulate and learn about, print material to sup-
port literacy, and language that puts their
2141
experience into words to be shared with others.
Children whose parents engage them in meaning-
ful conversation early on develop greater vocab-
ularies in the preschool years and have greater
reading capacities in elementary school (Hart
and Risley 1995).
Parents must walk a fine line between helping
too much and helping too little, as both can be
detrimental to children’s development. Parents’
capacities to carefully observe and perceive if
their children need help are key. Also important
is their ability to break a task into steps that are
more manageable for their children, a process
called scaffolding (Bruner 1983).
For parents, supporting their children’s explo-
ration and learning requires them to tolerate their
own tension generated by the struggle sometimes
required to learn and master new skills. Struggling
is a process inherent in worthwhile endeavors. If
parents cannot tolerate watching their children
struggle, they may lend assistance prematurely,
which is sometimes experienced as both intrusive
as well as discouraging to children, and can inhibit
striving and mastery (Gottman et al. 1997).
Children whose parents promote their explora-
tion and learning not only learn specific sensory-
motor, cognitive, linguistic, and social-emotional
skills but also develop a confidence in their ability
to learn additional skills, called self-efficacy
(Bandura 1997). They expand their capacities to P
tolerate both frustration and uncertainty and to
develop their courage to continue to try in the
face of potential or actual failure, resulting in an
increased sense of self-respect. This stands in
stark contrast to children who feel they either
must out-perform everyone around them or are
so afraid of failing that they do not try and make
excuses (to themselves and others) for their lack
of activity and accomplishments. Furthermore,
the capacity to explore and learn about the
world, along with the secure and robust emotional
relationships with parents and others, help chil-
dren to accept themselves and others and prepare
them to live interdependently.
Guiding Toward Interdependence
The term “interdependence” refers to the capacity
to see one’s embeddedness in ever-widening
2142
circles of family, friends, and community and to
share with others the responsibility for developing
and maintaining these relationships and living
cooperatively for mutual benefit. Guiding chil-
dren toward interdependence entails helping
them overcome their natural egocentricity and
begin to see themselves as part of a community
and to live cooperatively with others. This entails
the capacity to think about and feel with others
and the desire and ability to contribute to their
welfare. Parents use three types of strategies to
guide their children toward this interdependence.
The first set of strategies involves facilitating their
children’s positive behaviors through the use of
routines, modeling, encouragement, directives,
and teaching.
Facilitating Children’s Positive Behaviors
Redl and Wineman (1952) used the term “rou-
tines that relax” because after the routine is
developed, it becomes the scaffolding for the
child’s positive behaviors. Parents don’t have to
continually direct their children’s behavior nor
negotiate with them about what will happen. The
routine simply stands, and both parent and child
can relax in the knowledge of what will happen
as a result and can put their energies to more
productive endeavors.
Modeling is another key strategy for facilitat-
ing positive behavior in children, giving children
concrete images of what is done by the significant
caregivers in their lives. Modeling results in the
internalization of social rules for behavior that are
carried into other situations. In particular, children
who observe how their parents handle emotion are
learning what emotions are and are not acceptable
and how one expresses and regulates these
emotions (Izard 1991).
Parents’ encouragement of their children’s
positive behavior is also a powerful tool. Encour-
agement emphasizes what the child can do (rather
than not do) and therefore develops a child’s sense
of accomplishment in doing what is required by a
situation. Encouragement also helps parents to
avoid the trap of often beginning with “no” and
engendering unnecessary power struggles.
Through both its focus on positive behaviors and
its impact on reducing negative interactions,
Parenting in Families
encouragement strengthens the parent-child rela-
tionship. Directives are part of the encouragement
strategy, as sometimes it is necessary for parents
to simply tell their children what to do.
Finally, teaching children appropriate and safe
ways to behave both prior to and in the midst of
challenging situations is sometimes overlooked
by many parents as a way of facilitating positive
behavior. They often expect that their children
already know what to do and react negatively
when their children do not behave in these
expected ways. Parents initially assume responsi-
bility for doing much of what their children will
eventually learn to do themselves until they teach
their children how to, for example, clean up, cook,
dress, and travel. Similarly, teaching and practice
are necessary for the development of positive
social and emotional skills.
Reflective Dialogues
A second set of parenting strategies is encapsu-
lated in reflective dialogues between parents
and children (Cohen et al. 2006; Gottman
2001; Greene and Ablon 2006). There are
three essential components of these dialogues.
The first is helping children put together the
story of their experience, developing narratives
that help them make sense of what happens in
their world. One version is the everyday review
of their daily lives in which parents and children
engage, helping children understand the con-
nections between one event and another,
between their experience and their feelings
about it, between their actions and another’s
reaction or response. These dialogues result in
an enhancement of children’s reflective function
and a deeper understanding of self and other.
When children have experienced trauma, these
reflective dialogues are particularly important.
The experience of trauma can often result in a
mixed-up sense of what occurred and misattri-
butions (“It was my fault”; “I should have been
able to prevent it”) that negatively affect chil-
dren’s views of themselves. Reflective dia-
logues can provide a vehicle for the healing of
trauma and restoration of the normal develop-
mental trajectory by creating a coherent narra-
tive of the trauma and revising distorted
Parenting in Families
conclusions children draw from these difficult
experiences.
The second component of reflective dialogues
is the awareness, acceptance, and encouragement
of the appropriate expression of emotions. This
requires that parents value emotions and can tol-
erate intense feeling and make room for multiple,
and possibly conflicting, emotions. Parents attune
to the nuances of their children’s emotional states
and help them identify and label what they are
feeling. Naming emotions helps children learn
that others not only understand these feelings but
also experience them. The process of naming feel-
ings also helps to contain them and use them
productively.
The third component of reflective dialogues is
discussion of what to do or problem-solving. It is
not enough to merely empathize with children’s
feelings, it is important to help them figure out
what to do in the situation that triggered the emo-
tions. This entails both an invitation to problem-
solve and parents’ encouragement of their chil-
dren’s creativity and responsibility taking in
developing solutions to the problem. While it
might be tempting for parents to step in and give
their children the answer, this is another opportu-
nity for children to learn to struggle with worthy
problems and for parents to tolerate the tension in
their children’s initial efforts to solve their own
problems.
Setting Limits and Providing Consequences
A third set of strategies that guide children toward
interdependence is setting limits and providing
consequences for inappropriate behavior.
Through limits and consequences, children learn
how their behavior affects others and what is
acceptable and not acceptable. If the parent-child
relationship is a good one, the child has an incen-
tive for maintaining it by learning to channel his or
her behavior in more prosocial directions.
In addition, the physiological effects of appro-
priate limits are central to the development of
affect regulation and prosocial behavior (Schore
1994). Limits often trigger painful, but necessary,
shame states in children. When attachment is
secure, limits are appropriate, and parents can
reconnect effectively after the limit-setting
2143
episode, then limits facilitate maturation of brain
regions directly involved in affect regulation and
behavioral inhibition.
Parenting Outcomes
Through secure attachment and robust emotional
relationships and parents’ capacities to encou-
rage children’s exploration, learning, and
interdependence, children develop essential capa-
cities for success in society (see Fig. 1). These
include the self-regulatory ability to focus their
attention, delay gratification, tolerate frustration,
and soothe themselves. They also develop the social
capacities for expressive and receptive communica-
tion and empathy and sympathy. Finally, they
develop the cognitive capacities for using their
thoughts and feelings to solve problems and attain
goals as well as to see the world in its complexity
rather than in “black and white” terms.
Determinants of Parenting Processes
Parents’ capacities to enact these processes are
shaped by factors from both the parent and the
child as well as the context of the parent-child
relationship. These factors include genetics/neu-
robiology (e.g., both parent and child tempera- P
ment), parents’ experiences of being parented
and other significant childhood experiences, and
both proximal environments (e.g., co-parenting
and marital relationship, sibling configuration
and relationships) and distal environments (e.g.,
extended family, friends, work, neighborhood,
and institutional systems). These environments
can provide support but they can also be sources
of conflict, domination, oppression, and/or danger
that both shape and potentially hamper parents
from achieving their parenting goals.
Application of Concept in Couple and
Family Therapy
These parenting processes involve seemingly
contradictory dynamics – connecting and letting
2144
go, fulfilling desires and setting limits, and
assisting and allowing for independent struggle.
It can be challenging for parents to be clear about
what they are doing with their children in any
particular interaction and to be flexible in shifting
back and forth between these different positions.
There are a number of areas where therapists
can be helpful to parents, guiding them toward
practices that will fulfill the goals that they have
for their children. First, therapists can engage
parents in discussions of the goals they have for
their children, asking the following questions.
What are the qualities and characteristics they
think are important for their children’s success?
What makes these important to a parent? How
much do co-parents agree on these qualities and
characteristics and the rationale for their impor-
tance for child rearing? What are the practices that
parents use to influence their children, and do
they, in fact, lead to the desired qualities and
characteristics?
Second, therapists can help parents take a pro-
active rather than reactive stance with their chil-
dren. Many times, parents react to their children
rather than thinking ahead to what they want their
children to learn and how they are going to teach
their children these important life lessons. If par-
ents think it is important, for example, to stand up
for themselves, to delay gratification, or focus
their attention, what experiences do children
need to develop these capacities? By reflecting
on these questions, parents can more proactively
and effectively follow their intentions by provid-
ing children with specific experiences that will
lead to the capacities they want to nurture in
their children.
Third, therapists may sometimes need to hold
the belief and vision that children can learn these
important lessons when parents might not yet
have the confidence that their children can do
so. So often parents report some version of “She
doesn’t listen to me,” or “He will never learn.”
And until parents have the experience of riding
out the turbulence that sometimes comes with
their children learning new ways of behaving,
they may simply give up on the notion that their
children can learn how to regulate their affect and
behavior, how to think of other people, or how to
Parenting in Families
become more self-sufficient. So the therapist
becomes the holder of this hope and confidence in
children’s capacities to learn until parents have
enough experiences that they, too, can be confident
that children can live up to the expectations set.
Fourth, therapists can encourage the consis-
tency and persistence that parents need in order
for children to learn these important lessons. It is
sometime the case that parents hope and/or expect
their children to be able to behave appropriately
after only a few instances of using new routines,
communicating new expectations, or setting new
limits. It often takes many, many repetitions of
these experiences for children to be sure that their
parents actually mean what they say. As a result,
parents may need the support from the therapist to
maintain the new patterns and tolerate their chil-
dren’s protests or skepticism, especially if they
have been preceded by many instances of indul-
gence, neglect, or abuse. Furthermore, therapists
can help parents to anticipate that, when
attempting to become more consistent and clear
in their parenting, children’s negative behavior
will often get worse before it improves. It is as if
the child is testing the parent and asking “if I push
her button hard enough, will the old parenting
behaviors return?” The support of the therapist
during this critical time of change can make the
difference between parents kindly but firmly
“holding the reins” or capitulating to a child’s
demanding behavior in exasperation.
Fifth, therapists can be helpful to parents by
helping them understand their own affective trig-
gers and build their reflection function and
capacities for affect and behavior regulation.
These moments of dysregulation can have
many origins. Parents’ own internal working
models of relationships may not be conducive
to doing what parents need to do. Experiencing
children’s anger, frustration, sadness, and the
myriad of other emotions that children express
may be particularly painful, scary, or difficult for
parents to tolerate. They may not have the reflec-
tive capacities to see underneath their children’s
behavior to understand their feelings, beliefs,
intentions, and desires in a way that helps chil-
dren deal with what actually fuels their behavior.
Their lack of understanding of their children’s
Parenting in Families
difficult behaviors may lead to a downward spiral
of punishment and acting out.
Finally, therapists must examine their own par-
enting goals, beliefs, and practices to understand
where they come from and why they are important
and take care not to impose them on families.
A respectful, curious, and collaborative stance is
essential, especially when therapist and family
come from different cultural groups or occupy
different social locations that make it more diffi-
cult for the therapist to comprehend a family’s
experiences and points of view.
Clinical Example
Maria and Daniel are married cis-gendered par-
ents of three children, highly concerned about
their middle child, Cory, who is 5 years old.
They describe Cory as bullying the whole family.
He is aggressive, especially toward his 4-year-old
brother, Brian, and not as much to his 8-year-old
sister, Caroline. Cory carries on long temper tan-
trums, talks of killing himself and others, and at
one point grabbed a knife and threatened his
mother with it.
In session, Cory presents as thoughtful, artic-
ulate, and highly desirous of connection to his
family. But Maria is worn out. As an adult immi-
grant from Colombia, she has no support from
extended family. Daniel undermines her parent-
ing authority and engages his sons in a coalition
against her, sometimes making fun of her Span-
ish accent. Brian was born just a year after Cory,
and Cory’s reaction was to hit, bite, and throw
things at his infant brother. Maria feared for
Brian’s safety and felt she had to protect him at
all costs. As a result, Maria is angry at Cory and
often avoids contact with him. She usually gives
in to his tantrums, not feeling strong enough to
hold her ground and contain Cory’s anger and
aggression.
In order for the situation to improve, it is essential
that Cory reconnect with his mother; but she feels it
is more of a burden than a pleasure. She needs to feel
more support from Daniel, and it may also be help-
ful to build her support system outside the family.
With this foundation, it will be more feasible for
2145
Maria to make time for Cory, reading with him and
having him help her with routine activities like
preparing meals, going grocery shopping, and
cleaning. Cory has been a willing and helpful par-
ticipant in these activities in the few times that he
and Maria have engaged in them, and it builds on a
child’s natural desire to be helpful and competent. It
will also give Maria time to talk with Cory about his
experience in the family.
When Cory gets upset, he often says things
like, “You hate me. No one loves me.” Maria
and Daniel try to talk him out of these feelings,
which often escalates the negative cycle as he
desperately tries to get them to understand how
he feels. Instead, Maria and Daniel can learn how
to slow things down and take in what he is saying
with empathy and understanding. Neither Maria
nor Daniel experienced this kind of approach to
emotions and reflective dialogues in their families
of origin, and it may be important to explore their
own experiences of being parented and how that is
same, similar, or different to how they would like
to be with their own children. As Cory feels that
his parents understand his experience and what he
is feeling and thinking, he can begin to be more
receptive to their point of view, and they can work
on improving their patterns of interaction.
P
References
Ainsworth, M. D. S., Blehar, M. D., Waters, E., & Wall,
S. (1978). Patterns of attachment: A psychological
study of the strange situation. Hillsdale: Lawrence
Erlbaum.
Bandura, A. (1997). Self-efficacy: The exercise of control.
New York: Freeman.
Bowlby, J. (1982). Attachment and loss: Vol. 1. attachment.
New York: Basic Books.
Bretherton, E. (1982). Social referencing, intentional com-
munication, and the interfacing of minds in infancy. In
S. Feinman (Ed.), Social referencing and the social
construction of reality in infancy (pp. 57–77).
New York: Plenum Press.
Bretherton, I. (2005). In pursuit of the internal working
model construct and its relevance to attachment rela-
tionships. In K. E. Grossman, K. Grossman, &
E. Waters (Eds.), Attachment from infancy to adult-
hood: The major longitudinal studies (pp. 13–47).
New York: Guilford Press.
Bruner, J. (1983). Child’s talk. New York: Norton.
2146 Parenting Skills Training in Couple and Family Therapy

Cassidy, J. (1994). Emotion regulation: Influence of attach-

ment relationships. Monographs of the Society for
Research in Child Development, 69, 228–249.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006).
Treating trauma and traumatic grief in children and
adolescents. New York: Guilford Press.
Edwards, M. (2002). Attachment, mastery, and
interdependence: A model of parenting processes.
Family Process, 41, 389–404.
Fonagy, P., Steele, H., Moran, G., Steele, M., & Higgitt,
A. (1991). The capacity for understanding mental
states: The reflective self in parent and child and its
significance for security of attachment. Infant Mental
Health Journal, 13, 200–217.
Gottman, J. M. (2001). Meta emotion, children’s emotional
intelligence, and buffering children from marital con-
flict. In C. D. Ryff & B. H. Singer (Eds.), Emotion,
social relationships, and health. Oxford: Oxford Uni-
versity Press.
Gottman, J. M., Katz, L. F., & Hooven, C. (1997). Meta-
communication: How families communicate emotion-
ally. Mahwah: Lawrence Erlbaum.
Greene, R. W., & Ablon, J. S. (2006). Treating explosive
kids: The collaborative problem-solving approach.
New York: Guilford Press.
Hart, B., & Risley, T. R. (1995). Meaningful differences in
the everyday experience of young American children.
Baltimore: Paul H Brookes.
Harwood, R. L., Handwerker, W. P., Schoelmerich, A., &
Leyendecker, B. (2001). Ethnic category labels, paren-
tal beliefs, and the contextualized individual: An explo-
ration of the individualism-sociocentrism debate.
Parenting: Science and Practice, 1(3), 217–236.
Izard, C. E. (1991). The psychology of emotions. New
York: Plenum Press.
Lieberman, M. D. (2013). Social: Why are brains are wired
to connect. Oxford: Oxford University Press.
Main, M. (1995). Recent studies in attachment: Overview,
with selected implications for clinical work. In
S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment
theory: Social, developmental, and clinical perspec-
tives (pp. 407–474). Hillsdale: Analytic Press.
Redl, F., & Wineman, D. (1952). Controls from within:
Techniques for the treatment of the aggressive child.
Glencoe: Free Press.
Schore, A. N. (1994). Affect regulation and the origin of
the self: The neurobiology of emotional development.
Hillsdale: Lawrence Erlbaum.
Siegel, D. J. (1999). The developing mind: Toward a neu-
robiology of interpersonal experience. New York:
Guilford Press.
Stern, D. (1985). The interpersonal world of the infant:
A view from psychoanalysis and developmental psy-
chology. New York: Basic Books.
Thoits, P. A. (2011). Mechanisms linking social ties and
support to physical and mental health. Journal of
Health and Social Behavior, 52, 141–161.
Tronick, E. Z. (1989). Emotions and emotional communica-
tion in infants. American Psychologist, 44(2), 112–119.
Parenting Skills Training in
Couple and Family Therapy
Lena M. Lopez Bradley and Jenae P. Torres
Loma Linda University, Loma Linda, CA, USA
Synonyms
Evidence-based parenting programs; Parent edu-
cation; Parent education programs; Parent effec-
tiveness training; Parent management training;
Parenting
Introduction
Parenting requires a vast array of skills to guide a
child through the developmental stages of life.
Countless parent-child interactional sequences
shape and inform a child’s perception of self,
others, and the world. Parents can face a multitude
of challenges as they attempt to establish the rules,
roles, customs, beliefs, and values that shape the
context of family life. When parents and children
encounter obstacles, it can be helpful to seek out
outside intervention and resources, such as par-
enting skills training, to assist in providing addi-
tional knowledge, skill building, and support. In
cases of child abuse and/or neglect, parents may
be required to attend parenting skills training or a
specified evidence-based parenting program to
ensure that parents or caregivers can provide
their children with the safety and stability required
by law (Child Welfare Information Gateway
2013).
Due to the vast array of training techniques and
programs available, the focus of this discussion
provides a broad overview of the development,
rationale, and common characteristics of
evidence-based parenting programs in general,
rather than focusing on any one particular pro-
gram. Utilizing an evidence-based parenting pro-
gram (EBPP) is becoming a standard practice for
many organizations seeking to provide quality,
cost-effective, and efficacious services to the
Parenting Skills Training in Couple and Family Therapy
families they serve. EBPPs are attractive due to
the ability to produce positive outcomes for fam-
ilies and assist in obtaining funding for services as
well (Small and Mather 2009). Decades of
research indicates that the participation in an
evidence-based parenting program can have last-
ing positive impact on reducing disruptive or risky
behavior in children and increasing the overall
relational well-being for parents and children
(Shaffer et al. 2001).
Definitions
The development and application of parenting
skills programs have shifted significantly over
time. Though parenting programs vary in regard
to targeted populations, length of service, delivery
methodology, format, and setting, there are sev-
eral core characteristics that assist in defining
evidence-based parenting programs overall. Fun-
damental to all parenting programs is providing
education to parents that promote the health,
safety, and overall well-being of children and
families. Programs aim to teach and collaborate
with parents so that they can actively acquire
parenting skills that reduce undesired or disrup-
tive behaviors in children (Centers for Disease
Control and Prevention 2009). Skill building for
parents can focus on learning about the needs of
children during specific developmental stages,
practicing effective communication, learning
alternative means of discipline, boundary or rule
setting, and promoting the positive interactions
between parents and children to support the
parent-child relationship (Child Welfare Informa-
tion Gateway 2013).
Programs generally consist of teaching and
practicing standardized interventions or tech-
niques that can be implemented across time, in a
variety of settings, and across cultures. Common
goals aim to increase cooperation and responsive-
ness in children, teach parents effective non-
violent parent practices, and eliminate violence
toward children (Haslam et al. 2016). To meet
the specific needs of an identified population
(e.g., young children 0–5, adolescents, and/or
2147
specified disorders such as ADHD, autism), it is
vital that one becomes informed of the various
EBPPs that are available and the appropriateness
of fit for the family seeking services.
Theoretical Framework
During the early to mid-1900s, governmental
focus on child welfare regarding issues such as
proper care, practices that led to abuse and/or
neglect, and delinquent behavior supported prac-
titioners’ and researchers’ efforts to create parent-
ing programs that could assist families in creating
safety and stability and reduce delinquency and
risky behavior in children (Ponzetti 2015). The
field of mental health has long acknowledged the
significant impact parenting practices have in the
development of abuse, neglect, mental and emo-
tional disorders, and other risky behaviors. Thus,
treatment models and structured parenting pro-
grams focused on parent education and alternative
means of discipline practices.
Initially, parenting programs placed emphasis
on the practitioner as an expert providing educa-
tion and skill building through didactic methods.
Just as the field of marriage and family challenged
the view of the clinician as the expert, parenting
programs have also followed suit. While pro- P
grams continue to provide psychoeducation com-
ponents, there is now an emphasis on a
collaborative therapeutic alliance with parents to
be co-creators of change (Hukkelberg and Ogden
2013). In the formation of parent training pro-
grams, two distinct approaches began to emerge,
an approach that primarily focused on increasing
the ability of a parent to elicit desirable behavioral
responses from children and one that emphasized
the promotion of the parent-child relational bond.
Current meta-analysis research suggests that
models that incorporate several aspects of both
approaches produce more effective outcomes of
enhanced parent-child interaction (Kaminski et al.
2008; Carr 2009).
Programs that focused primarily the behavioral
component aimed to increase parental capabilities
by providing psychoeducation and behavioral
2148
techniques (Shaffer et al. 2001). Behavioral parent
skills training focused on changing parent and
child behaviors through techniques derived from
concepts of social learning theory. Clinicians edu-
cated parents about basic principles of reinforce-
ment and trained parents to apply them in daily
interactions with their children (Karpiak and
Dishon 2016). Parents were instructed on how to
implement positive and negative reinforcement
strategies to shape their child’s behaviors. Positive
reinforcement was used to increase desired behav-
iors. For example, if a child performs a protocol
task, a parent could give him or her affirmation in
the form of verbal praise. By focusing on and
reinforcing positive behaviors from the child, the
parent informs the child of the expected behav-
ioral responses in a nurturing manner that can
promote positive interaction and produce desired
behavioral responses in the future (Karpiak and
Dishon 2016). The intended goal is for the child to
eventually perform expected behaviors without
reinforcement. Clinicians also trained parents to
accurately use negative reinforcement to decrease
undesired behaviors. When a child performs a
negative behavior, the parent was directed to
remove a desired item or privilege from the
child. This aimed to reduce negative behaviors
like tantrums. The desired outcome of behavioral
parent training was to provide parents with the
skills to maximize positive and minimize negative
behaviors in the child. Though outcomes of these
programs demonstrated positive behavior modifi-
cation for some, critics argued that more severe
behavioral problems and the complexity of
parent-child dynamics require models to consider
contextual and relational factors that impact out-
comes (Shaffer et al. 2001).
As a result, programs began to incorporate
more interventions that target relational dynamics.
Relational parent training intended to change the
parent-child relationship because it has been
found that parent and child behaviors are mutually
reinforcing (Smith et al. 2013). A parent and child
can become caught in a negative and reinforcing
cycle consisting of non-compliance from the child
and increasing demands from the parent. The
interaction pattern escalates until it reaches a
deadlock (Smith et al. 2013). Relational parent
Parenting Skills Training in Couple and Family Therapy
training aimed to interrupt the coercive and
destructive cycle by teaching parents about the
emotions underlying a child’s behaviors (Shaffer
et al. 2001). Practitioners taught parents commu-
nication skills, like active listening, to increase
their ability to relate to their child (Kaminski
et al. 2008). Parents learned how to build a solid
relationship with their children and how to sup-
port children with difficult behaviors.
As knowledge has increased, practitioners now
understand the benefit of combining behavioral
and relational methods to make parent training
programs more effective (Kaminski et al. 2008).
Unifying behavioral and relational parent training
techniques allows practitioners to target a child’s
negative behaviors from multiple perspectives.
Relationship building and emotional communica-
tion skills complement the behavioral training
component. Although the skills can be different,
they are supplemental. For instance, a child may
be more responsive to behavioral strategies, if the
child feels emotionally validated by his or her
parent.
Rationale for the Strategy or
Intervention
Parents and children are dealing with complex
issues arising from ever changing methods of
parenting, the recent surge in technology, an
increase in psychological disorders in children,
and high expectations placed on parents to raise
high-achieving children (Mahoney 2012;
O’Keeffe and Clarke-Pearson 2011). Parents
often seek resources and support in attempting to
raise happy and healthy children, yet they can feel
overwhelmed by the plethora of books, blogs, and
advice from well-intentioned peers and family
members. It can be difficult for parents and chil-
dren to know how to respond to each other given
the demands they experience on a daily basis.
Parents are struggling to obtain knowledge about
what effective parenting looks like. Parents may
attempt to utilize interventions such as time-out or
taking away privileges, but without proper tech-
nique, consistency, and follow-through, parents
may be unsuccessful.
Parenting Skills Training in Couple and Family Therapy
Limited knowledge about effective child-
rearing approaches, combined with other
stressors, like finances and family conflict, can
lead parents to fall back on less desirable parent-
ing techniques such as yelling, threatening, and
spanking. Utilizing corporal punishment is not
only damaging to the child, the parent-child rela-
tionship, and producing desired outcomes, but it
also makes parents vulnerable to Child Protective
Services intervention. In fact, in cases where par-
ents utilize abusive methods, they are often
required to fulfill a parenting education program
as part of a structured case plan to regain custody
of their children (Child Welfare Gateway 2013).
In addition, parents and children may not be
adequately equipped to manage the rapid pace of
technological advancement of the twenty-first
century. Many children have access to Internet
content via mobile phones, tablets, and com-
puters, which may or may not be monitored by
adult supervision (O’Keeffe and Clarke-Pearson
2011). Now, more than ever, children are being
exposed to harmful information and content (e.g.,
pornography, cyberbullying, predators) that can
negatively impact cognitive and emotional devel-
opment. It can be difficult for parents to keep up
with the level of supervision required to keep
children safe on the Internet and know how to
respond when exposure leads to harmful out-
comes. The accessibility of the Internet and the
pressure to allow children to have access to social
media can place undue stress on parents to set and
maintain limits for children. Parents need help in
navigating this ever changing landscape of digital
exposure so that they can learn how to have con-
versations with their children to address safety
concerns. Furthermore, O’Keeffe and Clarke-
Pearson (2011) pointed out that excessive social
media use has the potential to decrease a child’s
ability to self-regulate. Children are vulnerable to
developing mental and emotional conditions, and
parents need education and support to combat
these risks.
Despite an increased knowledge and research
about mental health, children continue to face a
growing number of mental, emotional, and social
issues. There has been an increase in mental
health diagnoses in children, especially
2149
neurodevelopmental disorders and conduct disor-
ders (Center for Disease Control and Prevention
2016), and experts continue to debate causality.
Some researchers attribute the rise in childhood
issues to the high demands placed on a child by
adults (Mahoney and Vest 2012). There is a current
push for children to be high achieving in academics
and in extracurricular activities. Adults often pro-
mote the ideal child as being someone who is well-
rounded in multiple areas. This can lead to over-
scheduling of activities, which has been shown to
increase stress and anxiety in children already sus-
ceptible to psychopathology (Mahoney and Vest
2012). Parental success seems to be determined by
the success of a child. Parents can spend large
amounts of time, money, and other resources to
maintain a child in extracurricular activities in the
hope of boosting the child’s opportunities for suc-
cess. Parents and children can both experience exter-
nal and internal pressure to be successful, to “have it
all,” and to have the appropriate responses even
through the most difficult of times.
It is evident that parents and children are coping
with a multitude of stressors. Therefore, it is imper-
ative that researchers continue to develop parent
training programs that extend beyond the parent-
child relationship to increase support for families
and incorporate multilevel systemic interventions
(Carr 2009). Currently, several evidence-based par-
ent programs offer a combination of behavioral and P
relational components, along with school-based
interventions, community collaboration, and thera-
peutic family work (Kaminski et al. 2008). Capital-
izing on the parenting component creates change
within one system of a child’s life; however incor-
porating the other pieces of the child’s larger context
can further increase positive results (Carr 2009).
Children continue to spend a substantial time with
their parents, but they are also embedded within
other subsystems. Children encounter extended
family members, coaches, scout leaders, religious
clergy, and so many more people regularly. Supports
need to be in place for a child to thrive in
places beyond the therapy room and home. Parent
participation in evidence-based parenting programs
may go far beyond providing education but also
in connecting families with multiple pillars of
support.
2150
Description of the Strategy or
Intervention
A substantial amount of evidence-based parenting
programs exist, and the number continues to grow
as outcome data and new research emerge. Pro-
grams are developed and modified to respond to
the various needs parents and children face
throughout the life span. Though programs differ
in terms of number of sessions, target age
populations, delivery methods, and settings, pro-
grams must meet specific criteria to be considered
empirical and efficacious (Assmussen 2012).
First, programs undergo rigorous testing and
ongoing evaluation to demonstrate how effective
outcomes are to targeted populations. Participants
of programs are evaluated via survey question-
naires and/or assessment at the onset of the pro-
gram, during specified intervals, and at
termination (Haslam et al. 2016). Organizations
are also informed of the need to be a part of
ongoing training, monitoring, and evaluation of
outcome measures. Research demonstrates that
effective parent training programs contain specific
characteristics such as utilizing strengths-based
approaches, family skills building, parent partner-
ships, trained and qualified staff, clear goals, and
continuous evaluation (Child Welfare Information
Gateway 2013). In addition, practitioners, in par-
ticular, need to be mindful of the added training,
costs, and ongoing evaluation necessary to prac-
tice any particular parenting program.
To ensure program fidelity, evidence-based
parenting programs follow standardized curricu-
lum structures that detail specific interventions
and practices that assist parents in the day-to-day
interactions with their children. Common inter-
ventions or techniques can include implementing
time-outs for both parents and children, boundary
or limit setting, increased shared family time,
family meetings, increased coping skills, personal
strengths building, setting natural and logical con-
sequences for undesirable behavior, learning
effective communication skills, providing praise
and encouragement, monitoring emotional
responses for both parents and children, and
increasing interactions that promote parent-child
bonding, where a primary aim is to increase
Parenting Skills Training in Couple and Family Therapy
parent’s confidence and ability to raise their chil-
dren in a loving supportive environment (Haslam
et al. 2016). Parents are encouraged to ask ques-
tions, receive constructive feedback, and practice
the interventions they have learned.
Just as curriculums are tailored to specific
targeted populations, so are the varying forms of
participant structure and delivery settings. Pro-
grams can be structured to work with parents
one on one individually, in a group setting with
other parents of similar criteria, and/or a blended
structure where some sessions are held as a group
and interactions with practitioners on an individ-
ual basis also occur. At the onset, participants are
informed of their requirements for participation,
the structure of the meetings or sessions, and
where the meetings or sessions will be held. Par-
ent programs can be held in an agency setting,
community setting, and/or in-home setting.
In-home settings, for example, may make it easier
to accommodate to family schedules, practice
interventions in the moment, build practitioner-
parent collaboration, and assist in the completion
of the program, where efforts are made to recruit,
maintain engagement, and provide services that
make it practical and desirable for parents to
attend (Axford et al. 2012).
When deciding an evidence-based parenting
program to participate in, parents and practi-
tioners need to take into account the required
number of sessions, location, and participant
structure to ensure that the program meets the
needs of the family and the parents have an
increased ability to complete the parent program.
Future directions of parenting programs must con-
tinue to evolve and take into consideration chal-
lenges such as accessibility of service to families,
ongoing training and evaluation demands for
practitioners, costs associated with implementa-
tion, and overall dissemination of programs to
targeted populations (Shaffer et al. 2001).
Case Example
Melissa (29) and George (31) have two children
April (9 years old) and Andrew (5 years old).
Melissa and George both work full time and
Parenting Skills Training in Couple and Family Therapy
believe that the demands and stress of their jobs
have impacted the time they have for each other
and for their children. Recently, they have been
experiencing severe behavioral and academic
problems with their daughter, April. During a
parent-teacher conference, April’s teacher dis-
cusses how April’s inattention and aggression
have increased. The teacher reports that April
struggles with paying attention, following instruc-
tions, and completing assigned tasks and she has
also started bullying peers in the class. The teacher
reports that April is smart but that she is concerned
that if left unattended, April’s academic perfor-
mance and her social interactions with her peers
will continue to suffer. During the meeting,
Melissa and George acknowledge that they too
have experienced difficulties at home. They strug-
gle with getting April to complete her homework
and to follow directions. They report that she
either ignores commands or argues back resulting
in yelling matches, tears, and frustration. The
teacher recommends an evaluation and possible
therapeutic support services to assist the family in
responding to April’s behavioral challenges. The
teacher provides Melissa and George with referral
information for the school evaluation and sug-
gests contacting the 2-1-1 information hotline to
get information about local support services, such
as family therapy and/or parenting classes, within
the community.
Upon the recommendation of April’s teacher,
Melissa reaches out to her local community-based
counseling center for services. She finds a
counseling center that provides family counseling
and a parenting skills program called Triple
P Positive Parenting (Turner et al. 2010). Melissa
and George meet with a marriage and family
therapist who is certified in the Triple P program,
and they discuss ways in which the program may
be beneficial to the family. The therapist also
addresses any concerns and questions Melissa
and George may have regarding their participation
in the program. George expresses concern that he
and Melissa will be judged by others as “bad
parents,” but he also recognizes that April’s
behavior is escalating quickly and that they may
also have similar experiences as their son,
Andrew, gets older. The therapist listens to
2151
George’s concerns and offers validation to both
he and Melissa for making efforts to learn alter-
native ways that they may be able to respond to
their children in a loving and nurturing manner.
Melissa acknowledges to the therapist that she
has found it difficult to know how to respond to
April’s acting-out behavior. She admits that she
often gives in to April’s demands and is reluctant
to use corporal punishment because she was
spanked often as a child. George reports that he
intervenes with punishment for April when Melissa
asks for help but that he defers the majority of
parenting responsibilities to Melissa. Both parents
report that they are often tired and give in to the
demands of their children because they feel guilty
for having to work long hours. Melissa is tearful and
George is noticeably upset regarding the situation.
The therapist conducts an assessment of the family’s
needs and their ability to actively participate in the
Triple P program. Melissa and George are given
details of the program and make a commitment to
attend the 8-week course.
At the onset of the program, all parents in the
group are given a workbook that outlines the
topics that will be covered. They are informed
that the program will include ongoing assessment,
group meetings, and planned telephone calls with
the therapist to tailor the program to each of the
families’ needs. During the weekly sessions,
Melissa and George learn that positive parenting P
involves finding opportunities to give praise for
desired behavior, setting clear rules and expecta-
tions, and consistently giving clear calm instruc-
tions to their children. At home, Melissa and
George make note of how they are trying to
respond differently when April has an outburst.
George reports that he is making more attempts to
intervene when April is crying because she is
frustrated with homework. Instead of getting frus-
trated himself, he remembers to look for April’s
strengths and give her praise for her efforts. He is
hopeful that his confidence and his relationship
with April will get stronger as he learns more in
the program. Melissa notes that she is trying to
yell less and explain her expectations of April’s
behavior more clearly. Melissa too is trying to
praise April’s effort rather than expecting
perfection.
2152
All parents in the group are encouraged to find
as many opportunities to practice the skills
learned throughout the course. They are asked to
share their experiences with the group and to
provide details of successes and continued areas
of growth. The therapist emphasizes that behav-
ioral changes take time and consistent effort to see
desired outcomes. She also discusses ways each
parent can monitor his or her own emotional
responses when problems in the family arise.
Issues such as conflict, disobedience, miscommu-
nication, and emotional outbursts are normalized
as common occurrences in parent-child interac-
tions, but parents are taught that these situations
create opportunities to teach children appropriate
responses.
Parents finish the Triple P program knowing
that learning and implementing new skills take
time, consistency, and trial and error. Melissa
and George report to the therapist and to the
group that they are making more efforts to notice
positive qualities and interactions with their chil-
dren but also in each other. Melissa acknowledges
that though time to spend together continues to be
limited, she and George are trying to work more as
a team to respond to the kids in a different way and
to appreciate the time they do have together.
George admits that he was skeptical that the pro-
gram would make a significant difference but he
can see how conflict in the family has been
reduced and is happy to report that April’s behav-
ior is improving at school and at home.
Cross-References
▶ Attention Deficit Hyperactivity Disorder
(ADHD) in Couple and Family Therapy
▶ Authoritarian Parenting
▶ Authoritative Parenting
▶ Children in Couple and Family Therapy
▶ Co-parenting in Couple and Family Therapy
▶ Family Rules
▶ Family Structure
▶ Fathers in Families
▶ Infants in Couple and Family Therapy
▶ Learning Theory in Couple and Family
Therapy
Parenting Skills Training in Couple and Family Therapy
▶ Mothers in Families
▶ Parentified Child in Family Systems
▶ Psychoeducation in Couple and Family
Therapy
▶ Single Parent Families
▶ Young Parenthood Program
References
Assmussen, K. (2012). The evidence-based parenting
practitioner’s handbook. New York: Routledge.
Axford, N., Lehtonen, M., Kaoukji, D., Tobin, K., & Berry,
V. (2012). Engaging parents in parenting programs:
Lessons from research and practice. Children and
Youth Services Review, 34(10), 2061–2071.
Carr, A. (2009). The effectiveness of family therapy and
systemic interventions for child-focused problems.
Journal of Family Therapy, 31(1), 3–45. https://doi.
org/10.1111/j.1467-6427.2008.00451.x
Center for Disease Control and Prevention. (2016). Chil-
dren’s mental health. Retrieved August 24, 2017, from
https://www.cdc.gov/childrensmentalhealth/features/kf-c
hildrens-mental-health-report.html
Child Welfare Information Gateway. (2013). Parent edu-
cation to strengthen families and reduce the risk of
maltreatment. Washington, DC: U.S. Department of
Health and Human Services, Children’s Bureau.
Haslam, D., Mejia, A., Sanders, M. R., & de Vries, P. J.
(2016). Parenting programs. In J. M. Rey (Ed.),
IACAPAP e-textbook of child and adolescent mental
health. Geneva: International Association for Child
and Adolescent Psychiatry and Allied Professions.
Hukkelberg, S. S., & Ogden, T. (2013). Working alliance
and treatment fidelity as predictors of externalizing
problem behaviors in parent management training.
Journal of Consulting and Clinical Psychology, 81(6),
1010. https://doi.org/10.1037/a0033825
Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L.
(2008). A meta-analytic review of components associ-
ated with parent training program effectiveness. Jour-
nal of Abnormal Child Psychology, 36(4), 567–589.
https://doi.org/10.1007/s10802-007-9201-9
Karpiak, C. P., & Dishon, T. J. (2016). Parent training. In J. C.
Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.),
APA handbook of clinical psychology: Vol. 4. Psychopa-
thology and health (pp. 491–503). Washington, DC:
American Psychological Association.
Mahoney, J. L., & Vest, A. E. (2012). The over-scheduling
hypothesis revisited: Intensity of organized activity par-
ticipation during adolescence and young adult outcomes.
Journal of Research on Adolescence, 22(3), 409–418.
https://doi.org/10.1111/j.1532-7795.2012.00808.x
O’Keeffe, G. S., & Clarke-Pearson, K. (2011). The impact
of social media on children, adolescents, and families.
Pediatrics, 127(4), 800–804. https://doi.org/10.1542/
peds.2011-0054
Parenting Wisely Enrichment Program
Ponzetti, J. J. (2015). Evidence-based parenting education:
A global perspective. New York: Routledge.
Centers for Disease Control and Prevention. (2009). Parent
training programs: insight for practitioners. Atlanta,
GA: Centers for Disease Control and Prevention.
Shaffer, A., Kotchick, B.A., Dorsey, S., Forehand, R.
(2001). The past, present, and future of behavioral
parent training: Interventions for child and adolescent
problem behavior. The Behavior Analyst Today, 2,
pp. 91–105.
Small, S. A., & Mather, R. S. (2009). What works, Wiscon-
sin evidence based parenting program directory. Mad-
ison: University of Wisconsin Madison/Extension.
Smith, J. D., Dishion, T. J., Moore, K. J., Shaw, D. S., &
Wilson, M. N. (2013). Effects of video feedback on early
coercive parent–child interactions: The intervening role
of caregivers’ relational schemas. Journal of Clinical
Child & Adolescent Psychology, 42(3), 405–417.
https://doi.org/10.1080/15374416.2013.777917
Turner, K. M. T., Markie-Dadds, C., & Sanders, M. R.
(2010). Facilitator’s manual for group Triple P
(III ed.). Milton: Triple P International Pty. Ltd.
Parenting Wisely Enrichment
Program
Donald A. Gordon and Bob Pushak
Family Works, Ohio University, Athens, OH,
USA
Name of Intervention
Parenting Wisely (PW)
Synonyms
Parenting Wisely (Teen) Online; Parenting Wisely
(Young Child) Online; Parenting Wisely Teen
Group Program DVD; Parenting Wisely Young
Child Group Program DVD
Introduction
Parenting Wisely is an online, interactive,
computer-based, parent skill education program
for families of children ages 3–18. The interactive
format requires parents to stay alert and engaged.
2153
The program is versatile and can be used by par-
ents individually, or practitioners can use the pro-
gram with parents, or it can be used in group
parent training.
The program has been shown to increase
healthy child development and reduce behavior
problems including both parent and teen verbal
and physical aggression, and aggression
between spouses (Rolland-Stanar et al. 2001).
The program has been shown to decrease delin-
quency (Gordon et al. 1999), teen depression
(Feil et al. 2011), and both teen and parent
substance abuse via increases in the use of prob-
lem solving skills, enhanced family relation-
ships, and increases in the support family
members give to each other (Waldron et al.
2014). The program increases knowledge and
use of effective parenting skills. Parents report a
greater sense of competence and satisfaction in
their role as parents (Cefai et al. 2010). The
program increases parental monitoring and
involvement with school work. Research
shows the program reduces risk factors linked
to teen pregnancy, suicide, and school dropout.
Parents report high program satisfaction. Par-
ents indicate the teaching format of the program
is easy to follow. The problem scenarios are
realistic, relevant to their families, and the par-
enting skills are reasonable solutions to those
problems (Segal et al. 2003). P
The program has been implemented in the
United States, Australia, Canada, Singapore,
France, Ireland, New Zealand, Portugal, and
the United Kingdom. English, Spanish, and
Portuguese versions of the program are available
and a French version is being developed. The
families depicted include African-American,
Hispanic-Latino, and Caucasian families. The
program has been shown to be effective with
culturally diverse populations. PW has been des-
ignated as an effective program by Communities
That Care and an Exemplary Level 2 program
by Strengthening American Families. Parenting
Wisely has been included in the National Regis-
try of Evidence-based Programs and Practices
and the California Clearinghouse based on the
quality of research support and ease of successful
dissemination.
2154
Prominent Associated Figures
Don Gordon is the progenitor of the Parenting
Wisely program and the Children in Between,
a second online parent education program,
which teaches parenting skills to divorced parents.
Gordon is the Professor Emeritus of Psychology
at Ohio University. Bob Pushak is a retired child
mental health therapist and the developer of cur-
ricula for using Parenting Wisely to do parent
education classes.
Theoretical Framework
Parenting Wisely is based on learning theory,
cognitive psychology, family systems theory,
mindfulness, and neurobiology. The parent train-
ing is based on the work of Connie Hanf from the
University of Oregon Medical School and on
work related to the coercion theory of Gerald
Patterson from the Oregon Social Learning Center
(Patterson and Yoerger 2002). Skills related to
learning theory include praise, prompting, role
modeling, point systems, clear expectations, fam-
ily rules, planned ignoring, functional behavioral
analysis, behavioral contracting, and social rein-
forcement through things like hugs, kisses, and
other forms of positive physical contact.
Family systems theory content is based on Don
Gordon’s research conducted treating juvenile
delinquents using Functional Family Therapy,
a program developed by James Alexander
(Alexander and Parsons 1982; Gordon 2003).
The program teaches communication skills such
as speaking respectfully, active listening,
I-statements, and problem solving. Cognitive con-
tent is portrayed by actor voice overs to depict
how family member’s thoughts and assumption
about malicious intent contributes to family con-
flict. The voice overs portray how positive
reframes change the meaning of behaviors which
helps all family members to see each other in a
more compassionate, empathic light and to see all
family members as victims when conflict occurs.
These reframes along with positive self-talk help
parents to remain calm when responding to
conflict.
Parenting Wisely Enrichment Program
Strategies and Techniques Used in the
Model
The program provides strategies that go beyond
the immediate family unit and target the school
system, peer relationships, and substance abuse
problems. The program covers monitoring and
improving behavior at school and strategies for
developing a collaborative parent school partner-
ship. The program covers common mistakes par-
ents make when their child’s friend is a negative
influence and provides effective ways to monitor
and influence peer relationships.
The video content of the teen version of PW
was updated and became available online in
2012. New content on mindful parenting and
neurobiology was added which has been popu-
lar with parents. Mindful parenting has been
shown to increase emotional regulation and
greater parental role satisfaction. Neurobiology
content has been primarily added in footnotes to
the written text which can be skipped if a parent
is not interested. This portrays how positive or
undesirable parenting behaviors impacts par-
ents and children on a neurobiological level
and how this effects healthy development in
children.
Rational for the Program
Behavior problems in children are one of the
strongest predictors of negative childhood out-
comes including delinquency, substance abuse,
school problems, school dropout, teen pregnancy,
mental health problems, suicide, relationship
problems, employment difficulties, and maladap-
tive parenting of second generation children.
There is a need for brief, effective, and cost-
efficient interventions that reduce behavior prob-
lems in children that do not require intensive
practitioner training or expensive ongoing quality
assurance mechanisms. These interventions need
to be accessible, especially in remote locations,
and reduce problems with stigmatization and
parental intervention resistance. Parenting Wisely
is an evidence-based program that meets these
criteria.
Parenting Wisely Enrichment Program
Description of Parenting Wisely
Information is presented visually, auditorily, and
in printed text to increase absorption of informa-
tion in multiple ways. The text is written at a grade
6 reading level. The computer can read all text out
loud so literacy is not a barrier. Parents can pro-
ceed at their own speed and complete the program
in two to three sessions. A common obstacle to
parent education is the stigma of attending a par-
ent education class and parental defensiveness
and resistance due to parents feeling judged and
criticized by a parent educator. Online PW can be
completed in complete anonymity without the
presence of an educator so that learning is not
impeded by stigma or defensiveness.
Parents view video scenes depicting common
family conflicts followed by options depicting
harsh/coercive parenting, permissive parenting,
or more effective parenting skills. Parents chose
a response and watch a video depicting the
consequences of that choice. Each solution is
followed by an interactive question and answer
critique followed by a quiz to reinforce learning.
Viewing the different responses helps parents to
realize that problem of child behavior can be
significantly increased or diminished depending
on how the parent responds to that behavior.
When effective skills are portrayed, the parent’s
attention is directed to these skills by an onscreen
narrator and by text at the bottom of the screen.
The effective solutions still portray occasional
parental mistakes which communicates that par-
ents do not have to perform skills perfectly in
order to achieve improvements in child behavior.
After viewing all response options, parents com-
plete a multiple choice quiz to tests learning.
Parents are then able to proceed to another prob-
lem scenario.
Parents can click on highlighted skills such as
“praise” to access a glossary where a voice along
with written text defines that skill and lists the
advantages of that skill. Clicking on a “play exam-
ples” button activates a voice providing examples
of that skill. Parents receive a workbook that
includes critiques to each solution, review ques-
tions, and examples of behavior charts. The work-
book also lists advantages of each skill, steps
2155
for skill performance, and practice exercises.
The online program automatically tracks how
much of the program is completed, parent pro-
gress on review questions, and multiple choice
tests. The online program prompts parents to com-
plete unfinished portions of the program and skill
practice exercises through emails or text messages
sent to the parent’s cell phone.
The adolescent version of the programs
covers ten problem scenarios that are common
in many families but occur even more frequently
in high-risk families. These include: getting
children to do housework; helping children
with school problems; curfew problems; step-
parent step-child conflict; monitoring school,
homework and friends; loud music and incom-
plete chores; speaking respectfully and sharing
computer time; sibling conflict and aggression;
getting children ready for school on time; and
finding drugs in a teen’s bedroom. The young
child program problem scenarios include: chil-
dren acting up in public; helping children with
poor marks and school troubles; when children
interrupt conversations and phone calls; helping
children solve conflict with their friends; help-
ing children get to bed on time; helping children
get ready for school; and controlling sibling
arguing.
P
Populations in Focus
Parenting Wisely is ideal for families who are
unlikely to access, or likely to be resistant to,
traditional parent training interventions (Gordon
et al. 1999). Single parent and stepfamily concerns
are addressed because these families have a greater
risk for child behavior problems. Parents and chil-
dren can use the program together, especially the
online format, which they can do it at home. The
program can be used on a continuum for either
prevention or treatment. The program is used by
all personnel who work with children, parents, and
families such as schools, public health nurses, child
protection agencies, substance abuse agencies,
family therapy agencies, court and probation ser-
vices, foster parent agencies, mental health, hospi-
tals, churches, prisons, and the police.
2156
Agencies can use a DVD version of PW for
a traditional group program in ten sessions (2 h
each). A therapist led intervention, however,
reintroduces the possibility of problems with
perceived judgment and parental resistance men-
tioned above. Not all parents will be open to
participate in a group program or they may
prematurely drop out. For this reason, it is
recommended parents complete online PW prior
to attending a group.
Research About the Model
In the original group program research about
45% of parents who completed self-
administered PW were willing to return and
successfully complete the group program
(Pushak and Pretty 2008). Those parents who
declined group intervention or dropped out of
the group program had already received a very
brief and powerful intervention, and for some of
these families no further intervention was
needed. The average Total Problem scores on
Eyberg Child Behavior Inventory (Eyberg and
Ross 1978) decreased by 29% for the individual
use of Parenting Wisely and by 43% for the
group program. The effect size for individual
use of the program was 0.64 which is similar
to other evaluations of individual use of the
program (Cefai et al. 2010; Cotter et al. in
Press; Feil et al. 2011; Gordon et al. 1999;
Kacir and Gordon 1999; Segal et al. 2003).
The effect size for group program was 1.1
(Pushak and Pretty 2008). Those parents who
did complete the group program also had better
long-term results. A 100 page group program
manual covers strategies for engaging parents,
reducing problems with resistance, information
on conducting roleplays, and group manage-
ment skills. Although the group manual
includes integrity measures for each session,
because content is primarily computer based
and the group program does not require the
same degree of practitioner training or
Parenting Wisely Enrichment Program
expensive quality assurance mechanism com-
pared to other evidence-based interventions.
The group provides an opportunity for parents
to refine skill practice and have an in-depth
exposure to the content of the program.
Practitioners who would like additional infor-
mation or support in implementing PW can
contact Family Works at http://familyworksinc.
com/. Abstracts and full articles on PW research
can be found at www.familyworksinc.com/
research. The Substance Abuse and Mental Health
Services website provides independent review of
the research on PW at: http://www.nrepp.samhsa.
gov/ViewIntervention.aspx?id=35.
Case Example
A therapist received an urgent call from Alexa a
mother who he worked with 5 years earlier regard-
ing her daughter Summer who had clinically signif-
icant behavior problems at home and school. Alexa
had previously completed both online and the
young child PW group program and made strong
gains with her daughter. Alexa had just received a
call from school. Summer was suspended for an
undetermined period because she had kicked a boy
in the head. The school reported the boy likely had a
crush on Summer, but she found his behavior
towards her obnoxious. Summer had asked a school
counsellor for help, but when the boy’s behavior
continued Summer kicked him. The children who
witnessed the incident were shocked by the severity
of Summer’s aggressive behavior.
Alexa was angry that the school had not done
more when Summer first asked for help and she
was worried about how this incident might affect
Summer socially since she only had a few
friends. Alexa dreaded getting into a big fight
when she tried to address what had happened
with Summer and so contacted the therapist
for help.
The therapist encouraged Alexa on the phone
to use several skills from PW such as: positive
self-talk to help herself to stay calm; to begin the
Parenting Wisely Enrichment Program
conversation by praising Summer for asking a
counsellor for help; to use I statements to
express concern for how Summer’s aggression
might damage her relationships with her friends
who had never seen her be so violent before and
how disappointed Alexa was that Summer had
resorted to violence. The therapist would not
have attempted this kind of over the phone
coaching with someone who had not completed
the PW group program and was not already
acquainted with these skills. The big fight did
not happen. After mom finished speaking, Sum-
mer simply hung her head.
The therapist met with Alexa the next day.
She and the therapist watched a PW problem
scenario where a boy got into trouble for fight-
ing at school and the mother had legitimate
reasons for being angry about how the school
failed to respond proactively to the problem.
Alexa and the therapist were able to discuss
common mistakes parents make in this situation
without Alexa becoming defensive since it was
the parent in the video who was making the
mistakes. The therapist and Alexa used some
of the positive strategies depicted by PW to
plan how Alexa could maintain a collaborative
approach with the school and reduce the likeli-
hood of a long expulsion or Summer being
placed in an alternate school where she would
be exposed to peers who would be a negative
influence. Alexa attended the next available teen
PW group program where she re-established
and refined her use of effective parenting skills.
The therapist continued to help her with the
challenge of keeping Summer connected to
friends who were a positive influence and
established effective ways of monitoring friends
who were not always a positive influence.
Cross-References
▶ Alexander, James
▶ Behavioral Parent Training in Couple and
Family Therapy
▶ Functional Family Therapy
2157
▶ Learning Theory in Couple and Family Therapy
▶ Parent Management Training
▶ Patterson, Gerald
References
Alexander, J. F., & Parsons, B. V. (1982). Functional
family therapy. Monterey: Brooks/Cole.
Cefai, J., Smith, D., & Pushak, R. (2010). The PW parent
training program: An evaluation with an Australian sam-
ple. Journal of Child & Family Behavior Therapy, 32,
17–33.
Cotter, K.L., Rose, R.A., Bacallao, M., & Smokowski, P.R.
(in press). Parenting Wisely Six Month Later: How
implementation delivery impacts program effects at
follow up. Journal of Primary Prevention.
Duncan, L., Coatsworth, J., & Greenberg, M. (2009). A model
of mindful parenting: Implications for parent–child rela-
tionships and prevention research. Clinical Child and
Family Psychology Review, 12(3), 255–270.
Eyberg, S., & Ross, A. (1978). Assessment of child
behavior problems: The validation of a new inventory.
Journal of Clinical Psychology, 16, 113–116.
Feil, E., Gordon, D. A., Waldron, H., Jones, L. B., &
Widdop, C. (2011). Development and pilot testing of
an internet-based parenting education program for
teens and pre-teens: Parenting Wisely. The Family
Psychologist, 27(22), 22–26.
Gordon, D. A. (2003). Intervening with families of trou-
bled youth: Functional family therapy and parenting
wisely. In J. McGuire (Ed.), Offender rehabilitation
and treatment (pp. 193–220). Chichester: Wiley.
Gordon, D. A., Kacir, C., & Pushak, R. E. (1999). Effec-
tiveness of an interactive parent-training program for
changing adolescent behavior for court-referred par- P
ents. Unpublished manuscript. Ohio University, OH.
Kacir, C., & Gordon, D. A. (1999). Parenting Adolescents
Wisely: The effectiveness of an interactive videodisk
parent training program in Appalachia. Child & Family
Behavior Therapy, 21(4), 1–22.
Patterson, G. R., & Yoerger, K. (2002). A developmental
model for early- and late-onset antisocial behavior.
In J. B. Reid, J. Snyder, & G. R. Patterson (Eds.),
Antisocial behavior in children and adolescents:
A developmental analysis and model for intervention
(pp. 147–172). Washington, DC: American
Psychological Association.
Pushak, R., & Pretty, J. (2008). Individual and group use of
a CD-ROM for training parents of children with dis-
ruptive disorders. Unpublished manuscript. Child and
Youth Mental Health, Penticton, BC.
Rolland-Stanar, C., Gordon, D.A., & Carlston, D. (2001).
Family violence prevention via school-based CD-ROM
parent training. Unpublished manuscript. Ohio University,
OH.
2158
Segal, D., Chen, P. Y., Gordon, D. A., Kacir, C. Y., &
Gylys, J. (2003). Development and evaluation of a
parenting intervention program: Integration of scien-
tific and practical approaches. International Journal of
Human-Computer Interaction, 15, 453–468.
Waldron, H., Hops, H., & Ozechowski, T. (2014). Report
to National Institute on Drug Abuse on grant for treat-
ment of adolescent substance abuse in juvenile courts.
Oregon Reseach Institute, Eugene, OR.
Parra-Cardona, Ruben
Richard Wampler
Michigan State University, Haslett, MI, USA
Introduction
The thrust of Dr. J. Ruben Parra-Cardona’s edu-
cation, research, teaching, and life is greater
social justice. His experiences in his family
and education in a Mexican Jesuit college
moved him to work with street children in
Juarez until political upheavals encouraged
him to seek a master’s in couple and family
therapy at Syracuse University. In the years
since completing his master’s and later his doc-
torate at Texas Tech University (TTU), he has
focused on (a) cultural adaptation, (b) substance
abuse, and (c) domestic violence, especially
research and services for Latino/a communities
in the USA and Latin America.
Although his prior life experiences and edu-
cation had prepared him, his formal focus on
cultural adaptation began in his doctoral pro-
gram at TTU with the challenge of providing
in-home services for low-income minority fam-
ilies of juvenile probationers, largely Latino/a.
Later, he was an in-home therapist serving
Latino/a families in the Parent Empowerment
Project, working beside a community-based
parent educator. The professional relationship
he established with his doctoral advisor,
Dr. Richard Wampler, was particularly influen-
tial as he embraced the challenge of integrating
Parra-Cardona, Ruben
scientific rigor with social justice. Still later, he
used what he had learned in these in-home pro-
grams to develop and run multi-session father-
ing groups for teen fathers on probation. These
groups led to his 2004 dissertation on fathering
and his first publications. Working closely with
Dr. Karen Wampler, attachment expert, was also
a highly relevant phase of his training as his
current program of research is strongly
influenced by attachment theory.
Career
Moving to Michigan State University (MSU),
he found opportunities to explore the experi-
ences of Mexican immigrant and Mexican
American parents, develop a culturally-relevant
framework for clinical work with Latino fami-
lies at risk of elder abuse and neglect, and use a
cultural framework and understanding to treat
men of Mexican ancestry who were court-
ordered to groups because of domestic violence.
Over the years, he received funding from TTU,
MSU, and NIH for his research. He broadened
his research collaborations to include substance
abuse prevention research with Latino adoles-
cents and adults, and critically, evidence-based
parenting interventions (Parent Management
Training-Oregon, PMTO).
His training in PMTO and collaboration with
Marion Forgatch has been a key phase of his
professional development as a prevention
researcher, particularly as it refers to disseminat-
ing PMTO with underserved Latino communi-
ties. Thus, his first cultural adaptation
randomized trial was funded by NIMH and
consisted of a randomized control study focused
on the cultural adaptation of PMTO for low-
income Latin American immigrants in Detroit.
Participants had a child under the age of 10 and
lived in southwest Detroit. Drawing on his expe-
riences in Texas and Michigan, he designed his
research to (a) recruit these families successfully
(e.g., Spanish-speaking community recruiters
and staff), (b) allow them to attend consistently
Parra-Cardona, Ruben
(e.g., providing meals for parents and children),
and (c) easily understand the material (e.g., pro-
viding and soliciting multiple examples from
participants). The culturally-enhanced version
of the program included special topics on parent-
ing issues specific to the parents’ experiences in
Mexico regarding sex roles and parenting. In
addition, this version of the program had a strong
focus on helping parents cope with contextual
challenges such as racial discrimination. Both
versions of the program achieved a very high
retention rate, including 80% + of fathers).
Both quantitative and qualitative (e.g., parent
reports) outcome measures supported the value
of each program at the end and 6 months later.
Importantly, the culturally-enhanced version of
the PMTO intervention was found to have an
even greater impact on reports of child internal-
izing and externalizing behaviors. Subsequently,
he was funded by the National Institute on Drug
Abuse (NIDA) to replicate the culturally-adapted
PMTO in Detroit with Latin American immi-
grant parents of adolescents at risk of drug abuse.
Collaboration is a hallmark of Dr. Parra-
Cardona’s research and writing, and his earlier
research and the Detroit projects involved partners
from the community and around the country. His
commitment to social justice led him to an impor-
tant collaboration with colleagues in Mexico to
investigate the impact of a culturally-adapted
PMTO program for low-income mothers referred
for child neglect with US Agency for International
Development funding (Monterrey, MX; Centro de
Investigación Familiar [CIFAC]). He developed a
productive relationship with domestic violence
prevention and intervention specialists as well
(Chihuahua, MX; Instituto Regional de Estudios
de la Familia).
Contributions to the Field
Dr. Parra-Cardona’s national and international
research in parent education, child and elder
abuse, and domestic violence prevention has
led over 30 publications in refereed journals
2159
and 7 chapters included in professional books
(as of 2016), as well as 60 refereed presentations
at professional conferences and some 30 invited
addresses. In addition, he authored manuals for
PMTO groups for Latino parents of children and
adolescents and a manual for the teen fathers
group. He serves or has served as cultural and
research consultant/advisor to the National
Domestic Violence Hotline, National Hispanic
Research Center, Child Trends, Abt Associates,
US Health and Human Services Administration
for Children and Families (ACF), Oxford
University’s “Sinovuyo Caring Families Pro-
gramme,” Casa de Esperanza, the White House
Domestic Policy Council and ACF’s text4baby
initiative, National Resource Center on Domes-
tic Violence, the American Association for Mar-
riage and Family Therapy’s Minority
Fellowship Program, the Healthy Marriage and
Fatherhood Initiatives, as well as to other
NIH–funded research projects.
Dr. Parra-Cardona has also served as Associ-
ate Director of the MSU Research Consortium
on Gender-based Violence (RCGV). Working
along with Cris Sullivan, RCG Director, helped
to considerably inform his prevention research
according to a gender-based violence perspec-
tive. To enhance his ability to conduct research
on prevention and intervention for parents and
for gender-based violence, he has recently com- P
pleted an additional certificate degree in epide-
miology at the MSU College of Human
Medicine. He has successfully supervised doc-
toral dissertations at MSU, in addition to serv-
ing as a dissertation committee member and on
master’s committees. A member of the Family
Process Institute and CIFAC boards of directors
and the editorial boards of Family Process, the
Journal of Marital and Family Therapy, and
Family Relations, he serves as an ad hoc
reviewer for a number of journals, as well as a
member of departmental and university
committees.
In spite of his many and exhausting profes-
sional commitments, he remains a devoted spouse
and father of two beautiful daughters.
2160
Cross-References
▶ Addressing Racial Trauma in Therapy with
Ethnic-Minority Clients
▶ Boyd-Franklin, Nancy
▶ Cultural Competency in Couple and Family
Therapy
▶ Cultural Identity in Couples and Families
▶ Cultural Values in Couples and Families
▶ Ethnic Minorities in Couple and Family
Therapy
▶ Ethnicity in Couples and Families
▶ Extended Family
▶ Falicov, Celia
▶ Hardy, Kenneth V.
▶ Intercultural Couples and Families in Couple
and Family Therapy
▶ Patterson, Gerald
References
Parra-Cardona, J. R., Wampler, R. S., & Sharp, E. (2006).
“Wanting to be a good father”: Experiences of adolescent
fathers of Mexican descent in a teen fathers program.
Journal of Marital and Family Therapy, 32, 215–232.
Parra-Cardona, J. R., Domenech Rodríguez, M., Forgatch,
M. S., Sullivan, C., Bybee, D., Tams, L., Holtrop, K.,
Escobar-Chew, A. R., Bernal, G., & Dates, B. (2012).
Culturally adapting an evidence-based parenting
intervention for Latino immigrants: The need to integrate
fidelity and cultural relevance. Family Process, 51, 56–72.
https://doi.org/10.1111/j.1545-5300.2012.01386.x.
Parra-Cardona, J. R., Escobar-Chew, A. R., Holtrop, K.,
Carpenter, G., Guzmán, R., Hernández, D., Zamudio,
E., & González Ramírez, D. (2013). En el grupo tomas
conciencia (in group you become aware): Latino immi-
grants’ satisfaction with a culturally informed intervention
for men who batter. Violence Against Women, 19(1),
107–132. https://doi.org/10.1177/1077801212475338.
Parra-Cardona, J. R., Aguilar, E., Wieling, E., Domenech
Rodríguez, M., & Fitzgerald, H. (2015). Closing the gap
between two countries: Feasibility of dissemination of an
evidence-based parenting intervention in México. Jour-
nal of Marital and Family Therapy, 41, 465–481. https://
doi.org/10.1111/jmft.12098.
Parra-Cardona, J. R., Lopez Zerón, G., Domenech
Rodríguez, M., Escobar-Chew, A. R., Whitehead,
M., Sullivan, C., & Bernal, G. (2016). A balancing
act: Integrating evidence-based knowledge and
cultural relevance in a program of prevention par-
enting research with Latino/a immigrants. Family
Process, 55, 321–337. https://doi.org/10.1111/
famp.12190.
Partners for Change Outcome Management System, The
Partners for Change Outcome
Management System, The
Barry Duncan1 and Jacqueline Sparks2
1
The Heart and Soul of Change Project, Jensen
Beach, FL, USA
2
Department of Human Development and Family
Studies, University of Rhode Island, Kingston,
RI, USA
Introduction
Despite overall couple and family therapy effi-
cacy, many clients do not benefit from treatment,
dropouts are a problem, and therapists vary sig-
nificantly in success rates, are poor judges of
negative outcomes, and grossly overestimate
their effectiveness (Duncan 2014). Progress Feed-
back (sometimes called “client feedback”) offers
one solution. It refers to the continuous monitor-
ing of client perceptions of benefit throughout
therapy and a real-time comparison with an
expected treatment response to gauge client pro-
gress and signal when change is not occurring as
predicted. With this alert, clinicians and clients
have an opportunity to shift focus, revisit goals,
or alter interventions before deterioration or
dropout.
One of the two progress feedback interventions
included in Substance Abuse and Mental Health
Administration’s (SAMHSA) National Registry
of Evidence-based Programs and Practices is the
Partners for Change Outcome Management Sys-
tem (Duncan 2012). Only the Partners for Change
Outcome Management System (PCOMS) has
demonstrated significant improvement in out-
comes with couples and families. Emerging from
clinical practice and designed with the front-line
clinician in mind, PCOMS employs two, four
item, reliable and valid scales, one focusing on
outcome (the Outcome Rating Scale; Miller et al.
2003) and the other assessing the therapeutic alli-
ance (the Session Rating Scale; Duncan et al.
2003). PCOMS directly involves clinicians and
clients, including youth, in an ongoing process
of measuring and discussing both progress and
Partners for Change Outcome Management System, The
the alliance – the first system to do so. PCOMS
assesses the client’s response to service and feeds
that information back to both the therapist and
client to enhance the possibility of success via
identification of clients at risk for a negative out-
come. Widespread implementation of PCOMS
has enabled the development of algorithms for
expected treatment response based on extensive
databases as well as an electronic system for data
collection, analyses, and real-time feedback.
Studies report that clients receiving PCOMS
have 3.5 times higher odds of experiencing reli-
able change and less than half the chance of dete-
rioration, making a strong case for clinician use of
progress feedback in general and PCOMS specif-
ically. PCOMS evolved from a clinical, relational,
and value-driven starting place in its developer’s
practice (Duncan 2014) to an empirically vali-
dated methodology for improving outcomes and
a viable quality improvement strategy.
Theoretical Framework
PCOMS is an evidenced based practice, but it is
not what typically comes to mind – it is not a
specific treatment model or intervention for a spe-
cific client diagnosis or problem. Rather, PCOMS
is a-theoretical and not diagnostically based.
PCOMS has demonstrated significant improve-
ments for both clients and therapists regardless
of the theoretical orientations of therapists or the
diagnoses of the clients. More importantly,
PCOMS is evidence based at the individual
client-therapist level, promoting a partnership
that monitors whether this approach provided by
this therapist is benefiting this client or family. In
other words, it is evidence-based practice one
client at a time.
Rationale for the Strategy or
Intervention
The purpose of PCOMS is to partner with clients
to identify those who are not responding and
address the lack of progress to keep clients
engaged while new directions are collaboratively
2161
sought. There are six rationales for PCOMS. First,
PCOMS is supported by five randomized clinical
trials (RCT) conducted by the Heart and Soul of
Change Project that demonstrate that client pro-
gress and alliance feedback significantly improves
outcomes across modalities and therapies
(Duncan and Reese 2015). These RCTs led to
the SAMHSA designation of PCOMS as an
evidence-based practice, distinguishing it from
other couple and family progress feedback sys-
tems. Second, PCOMS has demonstrated that it is
a viable quality improvement strategy in real
world settings and may be more cost effective
and feasible than transporting evidence-based
treatments for specific disorders (Reese et al.
2014). Agencies implementing PCOMS have
enjoyed outcomes comparable to those achieved
in RCTs. Third, PCOMS addresses the problems
of the field by reducing dropouts, cancelations, no
shows, length of stay, and therapist variability
while providing objective information about cli-
nician and agency effectiveness (Duncan and
Reese 2015).
Fourth, PCOMS incorporates two known pre-
dictors of ultimate treatment outcome, early
change (Baldwin et al. 2009), and the therapeutic
alliance (Horvath et al. 2011). Studies reveal that
the majority of clients experience the majority of
change in the first eight visits. Couples and fam-
ilies who report little or no progress early on will P
likely show no improvement over the entire
course of therapy. A second robust predictor of
change solidly demonstrated by a large body of
studies is the therapeutic alliance. Clients who
highly rate their partnership with their therapists
are more apt to remain in therapy and benefit from
it. Monitoring progress and the alliance provides a
tangible way to identify nonresponding clients
and relationship problems before clients drop out
or achieve a negative outcome. Fifth, PCOMS
directly applies the research about what matters
in therapeutic change, the common factors
(Duncan et al. 2010). Collaborative monitoring
of outcome engages the most potent source of
change, clients, heightening hope for improve-
ment, and tailors services to client preferences
thereby maximizing the alliance and participation
(Duncan 2014).
2162
Finally, a sixth rationale speaks to consumer
rights and the foundations of couple and family
therapy practice. Despite well-intentioned efforts,
the infrastructure of couple and family therapy
(paperwork, procedures, and professional lan-
guage) can reify noncontextualized descriptions
of client problems and silence their views,
goals, and preferences. Routinely requesting,
documenting, and responding to client feedback
has the potential to transform power relations by
privileging client beliefs and goals over poten-
tially culturally biased and insensitive practices.
Valuing clients as credible sources of their own
experiences of progress and relationship allows
consumers to teach clinicians how to be the most
effective with them and reverse the hierarchy of
expert-delivered services. PCOMS provides a
readymade structure for collaboration with con-
sumers and promotes a more egalitarian therapeu-
tic process.
Outside the therapy dyad, client-generated data
help overcome inequities built into everyday ser-
vice delivery by redefining whose voice counts.
Without the data, client views do not stand a
chance to be part of the real record – that is, critical
information that guides decisions or evaluates
eventual outcomes at larger programmatic or
organizational levels. The data, as concrete repre-
sentations of client perspectives, offer a direct way
to describe benefit at clinician and agency levels
as well as keep client voice primary to how ser-
vices are delivered and funded.
Description of the Strategy or
Intervention
PCOMS is a light-touch, checking-in process that
usually takes about 5 min but never over ten for
administering, scoring, and integrating into the
therapy. PCOMS gently guides models and tech-
niques toward the client’s perspective, with a
focus on outcome. Besides the brevity of its mea-
sures, PCOMS also differs from most systems in
that client involvement is routine and expected;
client scores on the progress and alliance instru-
ments are openly shared and discussed at each
administration. Client views of progress serve as
Partners for Change Outcome Management System, The
a basis for beginning therapeutic conversations,
and their assessments of the alliance mark an
endpoint to the same. With this transparency, the
measures provide a mutually understood refer-
ence point for reasons for seeking service, pro-
gress, and engagement.
PCOMS and the session start with the Out-
come Rating Scale for adolescents and adults
and the Child Outcome Rating Scale (CORS:
Duncan et al. 2006) for children ages 6–12,
which provide client-reported ratings of progress.
As Fig. 1 reveals, rather than a symptom
checklist on a Likert Scale, the ORS and CORS
are visual analog scales consisting of four 10 cen-
timeter lines, corresponding to four domains
(individual, interpersonal, social, and overall),
allowing for the client’s idiosyncratic rendering
of his or her life circumstance. Clients place a
mark on each line to represent their perception of
their functioning in each domain if using a paper
and pencil version or touch or click an iPad or
other device if using the web based application of
PCOMS. In the case of a family entering services
because of a problem related to a child or adoles-
cent, the parent or caregiver scores only the CORS
(for a child) or ORS (for an adolescent) based on
his or her perception of how the child or adoles-
cent is doing. Asking the parent or caregiver to
score his or her own ORS sends the message that
the therapist is interested in their functioning,
even though that is not the reason for service.
This could risk the alliance as parents or care-
givers may believe that the therapist is not aligned
with their view of the problem but, instead, has a
covert belief that the parent or caregiver them-
selves are the problem. The primary point is to
ensure that the therapist accepts the reason for
seeking help and communicates that as clearly as
possible through both verbal and nonverbal
means to clients.
Parental and caregiver scores of a youth pre-
sented as the reason for service provide crucial
perspectives of how therapy is going. Parent/care-
giver change scores are significantly correlated
with children’s and adolescent’s scores. In other
words, when youth record change, caregivers typ-
ically report similar amounts and directions of
change and vice versa. In some circumstances, it
Partners for Change Outcome Management System, The
Partners for Change Outcome Management System,
The, Fig. 1 The Outcome Rating Scale (ORS), Session
Rating Scale (SRS), Child ORS, and Child SRS (Copyright
is also useful to get others who are significantly
involved with a child, or so-called collateral
raters, to score their views using the CORS/
ORS. For example, a teacher instrumental in refer-
ring a child for counseling or a probation officer
assigned by a court to monitor a youth charged
2163
2000, 2002, 2003, and 2003 by B. L. Duncan and
S.D. Miller. For examination only. Download free working
copies in 24 languages at https://heartandsoulofchange.com)
with a delinquency offense are good candidates to
bring into the process. People who play pivotal
roles in the child’s life can become witnesses to
and advocates for positive change. Periodic meet-
ings with these individuals, the youth, and family
can facilitate support for the child or adolescent’s
2164 Partners for Change Outcome Management System, The

efforts and collaboratively contribute to goal set-
ting and strategies for problem resolution.
Therapists use a centimeter ruler to sum the
client’s total score, or the web version automati-
cally totals and graphs the score, with a maximum
score of 40 (see Fig. 2). Lower scores reflect more
distress. The paper and pencil PCOMS family of
instruments are free for individual use at heartand
soulofchange.com which also contains free
resources regarding implementing PCOMS at cli-
nician and agency levels. The web version is a
commercial product available at betterout
comesnow.com
Given that at its heart, PCOMS is a collabora-
tive intervention, it is important that couples and
families understand two points at the start: (1) the
ORS and CORS will be used to track outcome in
every session and (2) the ORS and the CORS

Partners for Change Outcome Management System, The, Fig. 2 The web-based Child Outcome Rating Scale
(CORS) (top) and graph with CORS scores and expected treatment response (ETR) (bottom)
Partners for Change Outcome Management System, The
provide a way to make sure that the client’s voice
about progress is not only heard but remains cen-
tral. Introducing the ORS to families requires
tailoring the talk to the age, understanding capa-
bility, and level of attention of multiple family or
couple members. In the first meeting, the
ORS/CORS pinpoints where the client sees him
or herself, allowing for an ongoing comparison in
later sessions.
The task after the score is totaled is to make
sense of it with the final authority – the client.
Everyone needs to understand what their score
means and have a shared understanding of how
the scores reflect their reason for seeking therapy.
It helps to put the forms (or laptop or other device)
out on an open surface (e.g., coffee table) where
everyone can see. This is a powerful gesture com-
municating that the work is collaborative, the
therapist will not be the private keeper of special
information, and everyone’s point of view will be
known and valued. It is not unusual for children to
flock around a set of scores with a natural curiosity
for who scored what. Couples are often similarly
curious about their partners’ scores and will read-
ily make comments about similarities or differ-
ences with their own. The PCOMS outcome
scales allow everything to be literally on the
table right from the beginning – the agreements
and disagreements that everyone knows about,
except the therapist, until now. The ORS/CORS
bring an understanding of the couple and family’s
experience to the opening minutes of a session.
The “clinical cutoff” facilitates a shared under-
standing of the ORS/SRS and is often a step
toward connecting the scores to the reason for
seeking or receiving services. Twenty-five (out
of 40) is the cutoff for adults, meaning that, on
average, persons seeking clinical services will fall
below that, and those not typically seeking
counseling will score above. Although adoles-
cents use the ORS, their cutoff is slightly higher,
28. Children’s cutoff on the CORS is also 28 as
well as when parents/caregivers are scoring the
CORS for children and the ORS for an adolescent.
The therapist lets each person know, in everyday
language that is understandable to them, whether
they are above or below the cutoff. For those
showing below cutoff scores, the therapist assures
2165
them that they made a good decision to come
in. For those scoring above the cutoff, clinicians
simply validate their score by saying that it looks
like things are going pretty well, which leads to
the next logical question – what are the reasons for
meeting at this time?
Clients usually score the scale that reflects the
reason for service lower than the rest. Of note,
when a child or adolescent scores above the cut-
off, they will often still provide a clue to what is
troubling them by placing one mark lower than
others. Finally, the domain scores offer a glimpse
of what is going well in a person’s life. It is
worthwhile to briefly mention this when
reviewing the ORS/CORS scores, or, at least,
make a mental note to inquire more about these
areas at some point later in the interview.
The next vehicle for connecting the ORS and
CORS to the reasons for service relates to the
specific domains. The ORS/CORS is individually
tailored by design, requiring the practitioner to
ensure that the measure represents both the cli-
ent’s experience and the reasons for service. Sim-
ply seeing which domain or domains are scored
lower allows the therapist to hone in on the most
distressed dimension. The therapist can comment
on this area and to ask if the score on that domain
represents the reason for seeking counseling or
being referred for counseling. Or the therapist
can allow the conversation to reveal the reason P
for service and then make the connection to the
lowest domain. Once that is established, there is a
shared understanding regarding which domain is
the focal point for tracking change. For example,
typically couples will come in with the interper-
sonal domain scoring lower than others. It is not
hard to confirm that this is what they want to
address through counseling. It also reveals who
is more distressed about the relationship and who
likely set up the appointment – and perhaps who
was dragged in by their partner. At the moment
clients connect the marks on the ORS/CORS with
the situations that prompt their seeking help, the
ORS becomes a meaningful measure of progress
and a potent clinical tool. And that moment facil-
itates the next question: “What do you think it
will take to move your mark just one cm to the
right; what needs to happen out there and in
2166
here?” The ORS sets the stage and focuses the
work at hand.
Couples and families either agree about their
views of the level and areas (domains) of distress
or they do not. When they agree, therapists can
comment on it as a strength, highlight the com-
monality, and use it as a stepping stone to establish
mutual goals. Different scores are to be expected
and simply represent the reality and complexity of
working therapeutically with more than two in the
room. For starters, different scores are concrete
and visible, allowing therapists to inquire early on
about everyone’s unique perceptions and beliefs.
The sooner this is done, the quicker goals for each
person can be identified and efforts made to link
these into a common strategy and mutually
desired endpoint. Alternatively, discrepant scores
may persist, and therapists can successfully vali-
date those differences and still work toward a
positive outcome.
Disagreements between clients in their scores
on the ORS/CORS simply speak to the dynamics
frequently present in couple and family therapy.
The instrument just puts those differences front
and center in the first minutes of the session. The
ORS/CORS gives an instant read on things like
who is in the most distress about relationship
and/or youth problems and who perhaps was
coerced into therapy. Not surprisingly, in couple
work the one wanting to work on or save the
relationship is often the one demonstrating more
distress on the ORS. Similarly, the youth, who is
essentially mandated to therapy, will often score
higher on the outcome measure (in less distress)
than the parent or caregiver’s rating of the youth.
Also not surprising is that the one who is dragged
to therapy is often over the cutoff. The discussion
of distress via ORS scores shines a light on these
important issues allowing their open discussion
and subsequent planning for how therapy can
meet each individual’s needs.
The Session Rating Scale (SRS; Duncan et al.
2003) or Child Session Rating Scale (CSRS; see
Fig. 1), also four item visual analog scales, cover
the classic elements of the alliance (Bordin 1979)
and are given toward the end of a session. Similar
to the ORS/CORS, each line on the SRS/CSRS is
10 cm and can be scored manually or
Partners for Change Outcome Management System, The
electronically. Use of the SRS/CSRC encourages
all client feedback, positive and negative, creating
a safe space for clients to voice their honest opin-
ions about their connection to their therapist and
to therapy. Introducing the SRS/CSRS works best
as a natural extension of the therapist’s style. For
clients to feel comfortable giving alliance feed-
back, it has to be clear that there is no “bad news”
on the alliance measure and that the therapist truly
wants to know how he or she can improve the
client experience of the therapy – and is not
looking for compliments or is fearful about receiv-
ing feedback.
Clients tend to score all alliance measures very
high and the SRS/CSRS is no exception. For clients
scoring above the cutoff of 36, the therapist need
only thank the client, inquire about what the client
found particularly helpful, and invite the client to
please inform the therapist if anything can improve
the therapy. For clients scoring below 36, the con-
versation is similar but also attempts to explore what
can be done to improve the therapy. The SRS/CSRS
provides a structure to address the alliance, allows
an opportunity to fix any problems, and demon-
strates that the therapist does more than give lip
service to forming good relationships.
After the first session, PCOMS simply asks:
Are things better or not? The longer therapy con-
tinues without measurable change, the greater the
likelihood of drop out and/or a poor outcome. The
ORS/CORS scores are used to engage the couple
or family in a discussion about progress, and more
importantly, what should be done differently if
there is not any. While there may be agreement
regarding the two possible change scenarios, it
may be that there are different views. For exam-
ple, as depicted below, a spouse may be seeing
things improve because his partner has returned to
live in the home, but her view of the situation
indicates deterioration. This is of course the
challenge – to create a therapeutic context where
everyone, different views and all, benefits. The
best way to judge success is when both persons
in a couple benefit or when both the youth and
caregiver demonstrate gains in therapy.
Regardless of the congruence or discrepancy
between client scores, the task of the therapist
from session to session is to identify client
Partners for Change Outcome Management System, The
perceptions of progress and the alliance and
respond appropriately. When ORS/CORS scores
increase, a crucial step to empower the change is
to help clients see any gains as a consequence of
their own efforts. It is interesting to see how a
simple jump of even a few points on the ORS can
spur conversation about how small changes can
be carried forward to address the problems at
hand. Reliable and clinically significant change
provides helpful metrics to gauge noted gains.
Reliable change is a change of 6 points or more
on the ORS/CORS and is likely not due to chance
or measurement error. Clinically significant
change is a change of 6 points or more on the
ORS/CORS and crossing the clinical cutoff
(25 for adults; 28 for youth and caretakers). The
client starts in the “clinical” range and transcends
the cutoff to the nonclinical range. When clients
reach a plateau or what may be the maximum
benefit they will derive from service, planning
for continued recovery outside of therapy starts.
A more important discussion occurs when
ORS/CORS scores are not increasing. The longer
therapy continues without measurable change, the
greater the likelihood of dropout and/or poor out-
come. PCOMS is intended to stimulate all inter-
ested parties to reflect on the implications of
continuing a process that is yielding little or no
benefit. Although addressed in each meeting in
which it is apparent no change is occurring, later
sessions gain increasing significance and warrant
additional action – what Duncan and Sparks
(2002) have called checkpoint conversations and
last chance discussions.
Checkpoint conversations are conducted at the
third to sixth session and last-chance discussions
are initiated in the sixth to ninth meeting. The
trajectories observed in outpatient settings suggest
that most clients who benefit usually show it in
3–6 sessions (Duncan 2014); and if change is not
noted by then, then the client is at a risk for a
negative outcome. The same goes for sessions 6–9
except that the urgency is increased, hence the
term “last chance.” An available web-based sys-
tem provides a more sophisticated identification
of clients at risk by comparing the client’s pro-
gress to the expected treatment response of clients
with the same intake score.
2167
The progression of the conversation with cou-
ples and families who are not benefiting goes from
talking about whether something different should
be done, to identifying what can be done differ-
ently, to doing something different. Doing some-
thing different can include, for example, inviting
others from the client’s support system, using a
team, developing a different conceptualization of
the problem, trying another approach or model, or
referring to another therapist or venue of service
such as a religious advisor or self-help group –
whatever seems to be of value to the client.
PCOMS spotlights the lack of change,
making it impossible to ignore, and often ignites
both therapist and the couple or family into
action – to consider other treatment options and
evaluate whether another provider may offer a
different set of options and perhaps a better
match with client preferences, culture, and frame
of reference.
The feasibility of two four-item scales has
resulted in over a million administrations of the
PCOMS measures in electronic data bases.
PCOMS is used in every state, by the eight largest
public behavioral health organizations in their
respective states, and in over 20 countries includ-
ing province-wide implementation in Saskatche-
wan and national implementation in couple
agencies in Norway. Over 200,000 consumers
per year use PCOMS as part of their service. P
Five RCTs demonstrate a significant advantage
of PCOMS over treatment that does not include
progress feedback. Clients using PCOMS
achieved more pre–post treatment gains, higher
percentages of reliable and clinically significant
change, faster rates of change, and were less likely
to drop out.
Routinely measuring outcome and the alliance
with every couple and family ensures that neither
issue is left to chance. This allows both transpar-
ency and true partnership with clients, keeping
their perspectives the centerpiece. In addition, it
serves as an early warning device that identifies
clients who are not benefiting so that the client and
the therapist can chart a different course. This, in
turn encourages the family clinician to step out-
side of business as usual, do new things, and
therefore continue to grow as a therapist.
2168
Case Example
Roberto was distraught that his wife, Nancy, had
moved out, leaving him to care for their two
daughters. At the first session, Roberto’s ORS
score was 17.5 and Nancy’s 12.7, with the inter-
personal scale coming in the lowest at 5.4 and 2.2,
respectively, confirming that these were two dis-
tressed individuals with a marriage on the brink.
When the therapist invited each to tell the story
behind the numbers and explain their marks on the
interpersonal scale, Roberto described his loneli-
ness and said he just wanted his wife to come back
home. Nancy pointed to her mark on the ORS and
recounted his late nights at work and indifference
to her needs. SRS scores reflected a rocky start.
When the therapist asked about what was needed
to move the SRS in a more positive direction,
Roberto said he wanted the therapist to focus
more on Nancy moving back home. Nancy said
she wanted the therapist to help them talk together
so that Roberto would hear her.
At the next session, Roberto’s ORS indicated
nearly a four-point jump, as he felt more hopeful
that Nancy would return given that she attended
therapy; by session three, his ORS surpassed the
cutoff, because Nancy, perhaps succumbing to
Roberto’s pleas, moved back. With a note of
relief, Roberto described their home life as more
or less “back to normal.” His SRS scores for
sessions two and three increased, indicating a
strengthening therapeutic alliance. Meanwhile,
despite a similar rise in SRS scores for Nancy,
her third session ORS score was a paltry 13.
Clearly, something was gravely amiss in her life
and therapy was failing to help.
In session four, Nancy’s ORS plummeted to a
dismal 9.2 while Roberto’s ORS at session four
continued to increase to 27.8. The therapist
showed the couple a graph of their two change
trajectories, reflecting in sharp relief the dramatic
difference. The two ORS paths provided a com-
pelling rationale to inquire about Nancy’s decline
corresponding with her return home. With encour-
agement, Nancy opened up about her dreams to
pursue a meaningful career and to have time away
from household responsibilities. Though these
Partners for Change Outcome Management System, The
were not new themes, there was an urgency and
clarity absent from previous sessions. The thera-
pist supported Nancy’s dreams and encouraged
Roberto to respond to his wife in a way that
showed that he took her seriously. At the same
time, Roberto was asked to talk about his needs to
manage the demands of his job, the primary finan-
cial support for the household, and his limited
ability to share equally in home tasks. This time
the conversation was real, significantly different
than their usual stalemated communication.
Nancy’s ORS scores significantly increased over
the next three sessions as the couple continued to
make necessary adjustments in their relationship.
This therapy may have reached this point with-
out PCOMS but the chances of dropout were high,
particularly after the first session without prompt
alliance feedback and the fourth session without
concrete evidence of their disparate views. Differ-
ent scores on the ORS in couple or family work
may be interpreted as cause for concern when, in
truth, they are cause to rejoice; therapists and their
clients are given the opportunity to unambigu-
ously face the reality of their different views and
then to gauge and celebrate convergences when
they occur. In the case of Roberto and Nancy,
session four proved a turning point for strategies
to meet their conflictual needs.
Cross-References
▶ Alliance Scales in Couple and Family Therapy
▶ Progress Research in Couple and Family
Therapy
▶ SCORE
▶ Systemic Therapy Inventory of Change
References
Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Niel-
sen, S. (2009). Rates of change in naturalistic psycho-
therapy: Contrasting dose-effect and good-enough
level models of change. Journal of Consulting and
Clinical Psychology, 77, 203–211.
Bordin, E. (1979). The generalizability of the psychoana-
lytic concept of the working alliance. Psychotherapy,
16, 252–260. https://doi.org/10.1037/h0085885.
Patterson, Gerald
Duncan, B. (2012). The partners for change outcome man-
agement system (PCOMS): The heart and soul of
change project. Canadian Psychology, 53, 93–104.
https://doi.org/10.1037/a0027762.
Duncan, B. (2014). On becoming a better therapist:
Evidence based practice one client at a time
(2nd ed.). Washington, DC: American Psychological
Association.
Duncan, B. L., & Reese, R. J. (2015). The partners for
change outcome management system (PCOMS):
Revisiting the client’s frame of reference. Psychother-
apy, 52, 391–401.
Duncan, B., & Sparks, J. (2002). Heroic clients, heroic
agencies: Partners for change. Jensen Beach FL:
Author.
Duncan, B., Miller, S., Sparks, J., Claud, D., Reynolds, L.,
Brown, J., & Johnson, L. (2003). The session rating scale:
Preliminary psychometric properties of a “working” alli-
ance measure. Journal of Brief Therapy, 3, 3–12.
Duncan, B., Sparks, J., Miller, S., Bohanske, R., & Claud,
D. (2006). Giving youth a voice: A preliminary study of
the reliability and validity of a brief outcome measure
for children. Journal of Brief Therapy, 5(1), 5–22.
Duncan, B., Miller, S., Wampold, B., & Hubble, M. (Eds.).
(2010). The heart and soul of change: Delivering what
works (2nd ed.). Washington, DC: American Psycho-
logical Association.
Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds,
D. (2011). Alliance in individual psychotherapy.
Psychotherapy, 48, 9–16. https://doi.org/10.1037/
a0022186.
Miller, S., Duncan, B., Brown, J., Sparks, J., & Claud,
D. (2003). The outcome rating scale: A preliminary
study of the reliability, validity, and feasibility of a brief
visual analog measure. Journal of Brief Therapy, 2,
91–100.
Reese, R. J., Duncan, B., Bohanske, R., Owen, J., &
Minami, T. (2014). Benchmarking outcomes in a
public behavioral health setting: Feedback as a qual-
ity improvement strategy. Journal of Consulting and
Clinical Psychology. https://doi.org/10.1037/
a0036915.
Patterson, Gerald
Shalini Lata Middleton
Alliant International University, Sacramento,
CA, USA
Name
Gerald R. Patterson, Ph.D. (1926–2016)
2169
Introduction
Gerald Patterson was a research scientist who
significantly contributed to our understanding of
coercive and antisocial behaviors in children. His
work made him a pioneer in psychology, specifi-
cally in a theory of aggression, parent-training
forms of intervention, and multiple-method mea-
surement with emphasis on direct observation of
family interaction. His books on parenting are still
widely used by both parents and mental health
professionals today.
Career
Gerald Patterson attended Northland College in
Ashland, Wisconsin, from 1946 to 1947 and
Gustavus Adolphus College in St. Peters, Min-
nesota, from 1947 to 1948. He got both his
Bachelor of Science and Master of Arts in Psy-
chology from the University of Oregon,
Eugene, in 1951. He later received his Ph.D. in
Psychology in 1956 at the University of Minne-
sota, Minneapolis.
Dr. Patterson started his career as an Instructor
in Medical Psychology at the Psychiatric Institute
of the University of Nebraska Medical School in
1955. In 1957, he spent 9 years as Professor in the
Department of Psychology at his alma mater. Dur- P
ing this time, he served 1 year as President of the
Oregon Child Guidance Association 1960,
followed by another year as Director of Clinical
Training at the University of Oregon, Eugene, and
2 years on the State Board of Psychological
Examiners, Oregon. He became Research Profes-
sor at the same alma mater for 11 years in the
School of Education starting in 1967. During
this time, he served a year as President of the
Association for the Advancement of Behavior
Therapy and a Research Scientist for the Oregon
Research Institute. After this position, from 1977
and on, he was a Research Scientist at the Oregon
Social Learning Center.
Dr. Patterson received various honors
throughout the years for the contributions he
has made to the field, including an award for
2170
Distinguished Scientific Contributions to
Developmental Psychology by the Society for
Research in Child Development (1997), an
Honorary Doctor’s Degree in Psychology from
the University of Bergen, Norway (2000), the
Presidential Award by the Society of Prevention
Research (2003), and the Parenting and Fami-
lies SIG’s Trailblazer Award at the Annual Con-
vention of the American Association of
Behavior Therapists (2004).
Contributions to Profession
Gerald Patterson is best known in the psycho-
logical community for his revolutionary
research-based models on children’s antisocial
behavior and delinquency, his coercion theory,
and his methods for observing family interac-
tions directly. He co-founded Oregon Social
Learning Center (OSLC) in Eugene, Oregon.
His work at OSCL helped expand the empirical
and theoretical groundwork for coercion the-
ory, which later facilitated the development of
the Oregon Model of Parent Management
Training (PMTO). He used randomized PTMO
intervention trial data to illustrate the causal
mechanisms that underlie aggression, which
further solidified the tenants of his coercion
theory.
Dr. Patterson has authored more than
200 peer-reviewed journal articles and several
books, including Families, Parents and Adoles-
cents Living Together, Living with Children,
Coercive Family Process, and Antisocial Boys.
His very first book, Living with Children, has
sold more than a half-million copies since being
published in 1969. In Families, he helped par-
ents realize the crucial role they play in their
children’s lives. His multiple-part book on Fam-
ilies and Parents and Adolescents Living
Together provided parents with everything
from the skills on how to get through their
children’s teenage years to how to talk about
issues and solve problems. He continued to con-
tribute to the field of psychology and to the
better understanding and functioning of the
family unit until his passing in 2016.
Patterson, Jo Ellen
References
Patterson, G. R. (1971). Families: Application of social
learning to family life. Champaign: Research Press
(Also in Family Process, 1976, 15, 2, 265–273).
Patterson, G. R. (1982). Coercive family process. Eugene:
Castalia Publishing.
Patterson, G. R., & Forgatch, M. S. (1987). Parents and
adolescents: I. Living together. Eugene: Castalia Pub-
lishing Company.
Patterson, G. R., Reid, J. B., & 1940- & Dishion, Thomas
J & Oregon Social Learning Center. (1992). Antisocial
boys. Eugene: Castalia.
Patterson, Jo Ellen
Todd M. Edwards1 and Richard Bischoff2
1
Marital and Family Therapy Program, University
of San Diego, San Diego, CA, USA
2
University of Nebraska, Omaha, NE, USA
Introduction
Jo Ellen Patterson, PhD, is a Professor of Marital
and Family Therapy (MFT) at the University of
San Diego (USD) and a Voluntary Clinical Asso-
ciate Professor in the Departments of Family
Medicine and Public Health and Psychiatry at
the University of California, San Diego
(UCSD). Her major scholarly and clinical
contributions have been in the areas of family
therapy training, a biopsychosocial systems
approach to family therapy, global mental health,
and the integration of mental health into primary
care. She serves on the editorial boards of the
Journal of Marital and Family Therapy, the
American Journal of Family Therapy, and Fam-
ilies, Systems, & Health.
Career
Dr. Patterson received her bachelor’s degree in
Special Education from Baylor University, her
master’s degree in Counseling from Wake Forest
University, and her doctoral degree in Family and
Child Studies from the University of North
Patterson, Jo Ellen
Carolina, Greensboro. She obtained a Rotary
Scholarship to Cambridge University for a year
to study history and culture. A few years later, she
moved to Zaire and did field work in rural com-
munities for the Agency for International Devel-
opment (AID). She later lived in Cairo for 2 years,
where she served as a consultant for the interna-
tional school and taught at the American Univer-
sity in Cairo (AUC). She began her faculty
position at USD in 1988. Dr. Patterson has been
awarded three Fulbright Awards – to Norway in
1995, New Zealand in 2003, and Hong Kong
in 2008.
Contributions to Profession
Dr. Patterson came to the field of marriage and
family therapy through a route that would be
considered unconventional today. Her education
in multiple disciplines exposed her to systems
theory, which fit with her way of thinking about
human problems and intervening with couples
and families for lasting impact. Never content
with traditional disciplinary boundaries, systems
theory helped her to see not only the interrelated-
ness among family members but the interrelated-
ness in what professionals from multiple
professions could achieve when collaborating to
address individual and family problems.
At the time she was beginning her doctoral
work, George Engel published his seminal work
in which he proposed a biopsychosocial model for
understanding the connection between human
biological and behavioral functioning. This inno-
vative perspective challenged how both medical
and mental health professionals viewed patients,
disease, and functioning, and how intervention
would occur. The biopsychosocial model pro-
vided a language and conceptual framework for
how Dr. Patterson sees the world and opened
pathways for increasing impact through multi-
disciplinary collaboration.
Early in her career, she began to explore oppor-
tunities to increase her impact on families by
collaborating with medical providers in a way
that would address biopsychosocial functioning.
Dr. Patterson is a networker. She used these
2171
networking skills to develop a professional rela-
tionship with Dr. Joseph Scherger, who, in the
early 1990s, was director of the Family Medicine
Residency Program at Sharp HealthCare in San
Diego and a national leader in the field of Family
Medicine. Discussions with Dr. Scherger led to
opportunities for Dr. Patterson to move her mental
health practice into the Family Medicine Resi-
dency Program so that she could put into practice
collaborative healthcare principles based on the
biopsychosocial model. Thus, she was one of
several pioneers in the specialization of medical
family therapy.
Dr. Patterson soon recognized the impor-
tance of training and supervision in medical
family therapy. Through her collaboration with
Dr. Rusty Kallenberg in the Division of Family
Medicine at UCSD, she began training MFT
Masters students in outpatient primary care
clinics. Through this clinic, MFT students train
alongside medical residents in the family med-
icine residency, collaborating with one another
in the care of patients coping with a variety of
mental health and medical problems. She later
expanded her medical family therapy training to
pediatrics and reproductive medicine.
Dr. Patterson understands that mental health
providers need to be able to understand the
worldview, practice environment, and practice
standards of the medical profession in order to P
be able to be good collaborators. Much of her
scholarship is in the area of helping mental
health therapists understand psychopharmacol-
ogy and other medical treatment strategies and
protocols. One of her particular skills is in trans-
lating medical language so that family therapists
understand it.
Dr. Patterson recognizes emerging trends in
healthcare and introduces them to the field of
family therapy. In addition to the integration of
mental health into primary care, she has written
about the neuroscience revolution and discussed
its impact on relationships and family therapy.
More recently, her interests have expanded into
the area of global mental health, which focuses
on increasing access to high-quality mental
health services in low- and middle-income
countries.
2172
Cross-References
▶ Biopsychosocial Model in Couple and Family
Therapy
▶ Medical Family Therapy
▶ Medical Model in Couple and Family Therapy
▶ Psychopharmacology in Couple and Family
Therapy
References
Patterson, J., & Magulac, M. (1994). Pharmacology for
family therapists. Journal of Marital and Family Ther-
apy, 20, 151–171.
Patterson, J., Albala, A., McCahill, M., & Edwards, T. M.
(2006). The therapist’s guide to psychopharmacology:
Working with patients, families and physicians to opti-
mize care. New York: Guilford.
Patterson, J., Williams, L., Edwards, T. M., Chamow, L., &
Grauf-Grounds, C. (2009). Essential skills in family
therapy: From the first interview to termination
(2nd ed.). New York: Guilford.
Patterson J., & Vakili, S. (2014). Relationships, environ-
ment, and the brain: How emerging research is chang-
ing what we know about the impact of families on
human development. Family Process, 53, 22–32.
Williams, L. M., Patterson, J., & Edwards, T. M. (2014).
Clinician’s guide to research methods in family ther-
apy: Foundations of evidence-based practice.
New York: Guilford.
Paul, Norman
Alexis Hershfield
Alliant International University, Los Angeles,
CA, USA
Norman Leo Paul, M.D., (born July 5, 1926,
Buffalo, NY, USA – died October 14, 2011,
Concord, MA) was an American psychiatrist
and family therapist. An early pioneer in the
field of family therapy – Paul believed that an
individual’s total family unit should be used as a
tool to treat mental illness. He is credited for
recognizing the importance of family of origin
and extended family members when treating
psychopathology.
Paul, Norman
Norman L. Paul earned his Doctor of Medicine
degree at the University of Buffalo in 1948. He
received postdoctoral training at the University of
Cincinnati. Following his service as a captain in
the US Air Force, Medical Corps, Paul returned to
the United States to complete his medical training
as a resident at the Massachusetts Mental Health
Center in Boston, MA. Paul was then appointed as
research fellow in psychiatry at Harvard Univer-
sity and obtained additional training as an assis-
tant physician at Massachusetts Mental Heath
Center. He completed his fellowship in child psy-
chiatry at the James Jackson Putnam Children’s
Hospital in Boston, MA. Paul served as the chief
psychiatrist at Day Hospital from 1960–1964, as
assistant clinical professor at Tufts University
from 1964–1970, and as research assistant profes-
sor at Boston University from 1970–1971. In
1971, he was appointed as the director of conjoint
family therapy and coordinator of group psycho-
therapy at Boston State Hospital. Later, he would
be appointed as a lecturer and professor of psy-
chiatry at Harvard Medical School and professor
of neurology at the Boston University School of
Medicine. He was a founding member of the
American Family Therapy Association and the
Group for Advancement of Psychiatry. Paul was
also a member of the editorial board of Family
Process and Archives of the Foundation of
Thanatology.
Paul, an American psychiatrist and early
innovator in family therapy, is responsible for
acknowledging the role that the family of origin
and extended family play on individual psycho-
pathology and dysfunctional relationships. In his
innovative book, A Marital Puzzle, cowritten
with his wife, Betty, Paul introduced the concept
transgenerational analysis. Transgenerational
analysis seeks to connect present intrapersonal
and interpersonal abnormal behavior with past
family history. Paul believed that customs, mem-
ories, communication patterns, and relational
dysfunction of the past are transmitted within a
family from generation to generation. He under-
stood transgenerational transmission to be an
unconscious process that informed a person’s
intrapersonal and interpersonal emotional and
interactional patterns. Paul argued that
Peer Contagion/Deviancy
acknowledging transgenerational patterns would
lead to the reduction of relational problems and
individual mental illness. He contended that
insight gained from familial transgenerational
history would nurture feelings of empathy and
strengthen ties between family members. Paul
saw lost relatives, family of origin, and extended
family members as vital parts of the therapeutic
process. Additionally, Paul was responsible for
developing the use of multifamily group therapy,
in which multiple families participate in group
therapy. The aim is for the families to help one
another problem-solve and to realize the nor-
malcy and universality of their familial dysfunc-
tion. Paul is also a pioneer in the therapeutic use
of audio and videotape playback. Paul was
credited for using these techniques to enable
self-confrontation, deepen client awareness,
and address emotional issues and behavioral
discrepancies. He also developed a method
known as cross-confrontation in which he
exchanged videotapes, letters, poems, and
audio recordings between two separate families
during therapy sessions. His belief was that this
process would evoke emotional processes and
educate his clients on the universality of human
suffering.
Paul wrote extensively on the maladaptive role
that incomplete mourned loss from one generation
played on marital interactions and family systems
of subsequent generations. His technique, known
as operational mourning, aimed to help family
members with the long-term negative effects of
buried grief. It was utilized to treat psychopathol-
ogy and promote positive family and marital
relations. Paul was also committed to the
improvement of interpersonal functioning of
schizophrenic patients and was interested in the
role that family communication patterns had on
their psychological functioning. In addition to his
robust academic and clinical career, Paul pro-
duced a number of successful radio and television
series that centered on his work as a family ther-
apist, for which he received critical acclaim. He
was awarded the Peabody Broadcasting Award
from the Academy of Television Arts and Science
and nominated for an Emmy Award by the Acad-
emy of Television Arts and Science for his
2173
television program Trouble in the Family and a
Certificate of Merit from the Massachusetts Coun-
cil on Family Life for the radio series A Chance to
Grow.
Cross-References
▶ Communication in Couples and Families
▶ Family Secrets
▶ Intergenerational Couple and Family Therapy
▶ Multifamily Group Therapy
▶ Sexual Dysfunctions in Couple and Family
Therapy
References
Norman, L., Paul, N., & Paul, B. (1982). Death and
changes in sexual behavior. In Walsh (Ed.), Normal
family processes (pp. 229–250). New York: Guildford.
Paul, N. L. (1976). Cross-confrontation. In P. J. Guerin
(Ed.), Family therapy (pp. 520–529). New York: Gard-
ner Press.
Paul, N. (1981, October). The unconscious transmission of
hidden images and the schizophrenic process. Paper
presented at the 7th international symposium on the
psychotherapy of schizophrenia, University of Heidel-
berg, West Germany.
Paul, N. L., & Beernink, K. D. (1967). The use of empathy
in the resolution of grief. Perspectives in Biology and
Medicine, 11(1), 153–169. P
Paul, N. L., & Grosser, G. (1965). Operational mourning
and its role in conjoint family Therapy. Community
Mental Health Journal, 1(4), 339–345.
Paul, N., & Paul, B. (1975). A marital puzzle. New York:
W. Norton.
Peer Contagion/Deviancy
Damir S. Utržan and Timothy F. Piehler
University of Minnesota, Twin Cities,
Minneapolis, MN, USA
Synonyms
Deviancy training; Deviant peers; Peer influence;
Problem behavior
2174
Introduction
Peer contagion (Dishion and Tipsord 2011) refers
to the transmission of deviant behaviors between
youth (i.e., children and adolescents). Behaviors
are considered deviant if they violate social norms
and expectations. This includes, but is not limited
to, substance use, delinquency, and violence.
Compared to other risk factors, deviant peer affil-
iation is often the strongest predictor of conduct
problems in youth (Deković 1999). Deviant peer
affiliation also undermines normative develop-
mental trajectories and places youth at risk for
antisocial behaviors in adulthood (Piehler 2016).
An understanding of peer contagion is necessary
to clinical decision-making that promotes positive
youth development.
Theoretical Context
The social augmentation hypothesis suggests that
youth enter into relationships with deviant peers
because it is adaptive in their immediate environ-
ment (Dishion et al. 2008). Youth with poor social
skills, or otherwise inappropriate behaviors in
their interactions with peers, tend to be socially
marginalized. These youth do not experience
many positive social interactions, which leads
them to seek out peers willing to engage with
them despite their social difficulties. These peers
tend to be similarly rejected by mainstream or
prosocial groups due to their shared tendency
toward aversive behaviors. In other words, mar-
ginalized youth seek out peers they perceive to be
accepting and thus similar to them. Referred to as
the confluence model (Dishion et al. 2008), this
process underlies the formation of deviant peer
groups. These groups positively reinforce antiso-
cial values and behaviors that would otherwise be
met with rejection from prosocial youth. Deviant
peer groups also enable marginalized youth to
attain, at least from their perspective, social status.
The social augmentation hypothesis highlights
that maladaptive peer relationships are adaptive
for youth with limited social skills. Dishion
et al. (2012) evaluated the relationship between
peer marginalization, gang involvement (i.e., an
Peer Contagion/Deviancy
organized form of deviant peers), and sexual
activity in a multiethnic community middle
school sample. They found that peer marginaliza-
tion predicted gang involvement in early adoles-
cence, which in turn was a reliable predictor of
sexual activity in mid-adolescence. Early sexual
activity was unsurprisingly strongly associated
with having children by late adolescence. Thus,
aggregation into deviant peer groups such as
gangs may provide marginalized youth with
increased access to early sexual partners.
Supporting the social augmentation hypothesis,
this longitudinal analysis suggests significant
long-term costs to youth rejected by prosocial
peers despite some immediate benefits of deviant
peer affiliation.
Description
Adolescence is a period characterized by
increased susceptibility to peer influence. Chil-
dren transitioning into adolescence seek auton-
omy from their parents by spending more time
with peers and, thereby, tend to receive less paren-
tal supervision. This process typically corre-
sponds with increasing peer influence and
decreasing parental influence. While such social
relationships are critical to positive adjustment,
peers may also contribute to negative outcomes.
Peer contagion refers to a process of mutual influ-
ence that occurs between youth. This includes the
influence of behaviors and emotions with negative
developmental consequences (Dishion and
Tipsord 2011). Deviant behaviors disrupt multiple
domains of development and are associated with
socio-emotional impairment, crime, and sub-
stance use (Dishion and Patterson 2016). Coer-
cion and deviancy training are two mechanisms of
peer contagion that contribute to the development
of conduct problems. Although both represent
mechanisms of peer influence, they are distinct
processes with unique outcomes (Piehler 2016).
Coercion
Coercion is a bi-directional process through
which behaviors are negatively reinforced (i.e.,
strengthened by stopping, removing, or otherwise
Peer Contagion/Deviancy
avoiding an unpleasant outcome). This often
involves one individual using an aversive or
unpleasant behavior to influence the behavior of
another individual. Successful use of coercion to
achieve a desired outcome is reinforcing to the
individual using this aversive strategy and, as
such, increases the likelihood of using this tactic
again in the future. Coercion occurs in all rela-
tionship types and is often initially learned
through parent-child interactions. In the parent-
child relationship, a parent reacts emotionally in
response to their child’s negative behavior. The
child escalates their behavior in response to the
parent, often with the goal of achieving a desired
outcome, which causes the parent to further esca-
late their behavior. This cyclical process continues
until either the parent or child, although more
often the parent, gives into the demand. In peer
relationships, on the other hand, coercion often
presents as aggression in an attempt to demon-
strate social status (i.e., dominance) or gain com-
pliance. Snyder et al. (2008) examined the
longitudinal association between conduct prob-
lems and peer coercion in a kindergarten sample.
They found that being the recipient of coercive
behaviors by peers in kindergarten predicted the
development of overt conduct problems (e.g.,
physical aggression and defiance) later in
childhood.
Deviancy Training
Deviancy training is also a bi-directional process
of influence. But in contrast to coercion, this type
of training positively reinforces (i.e., addition of a
pleasant or desirable response following a behav-
ior) deviancy. It occurs when peers positively
reinforce deviant behaviors such as conversations
about breaking rules, defiance of authority, or
substance use. This leads to laughter and
approval, which in turn increases the likelihood
of future discussion and engagement in these
behaviors (Dishion et al. 1996). Deviancy training
has been observed in early childhood (Snyder
et al. 2008) as well as adolescence (Dishion
et al. 1996). Snyder and colleagues found that
deviancy training in kindergarten predicted covert
conduct problems (e.g., stealing and lying) later in
elementary school (Snyder et al. 2008). In contrast
2175
to coercion, involvement in deviancy training
often represents attempts by youth to gain accep-
tance from peers. Deviancy training in adoles-
cence is associated with increases in conduct
problems and substance use (Piehler 2016).
Application to Couple and Family Therapy
Deviant behaviors become a source of concern for
parents when they disrupt family life and lead to
disciplinary action at school and involvement
with either the juvenile or adult justice systems.
Individual therapy (IT) may help youth learn more
effective communication skills and coping strate-
gies, but the entire family can benefit from
addressing the youth’s behavioral problems. Cou-
ple and family therapists are in a unique position
to help these families prevent behavioral problems
from worsening and thereby reduce the likelihood
of lifelong involvement with the justice system.
Multisystemic therapy (MST) is an effective
approach in addressing behavior problems as
they pertain to the family (Huey et al. 2000).
MST incorporates features of strategic family
therapy, structural family, and cognitive-
behavioral therapy (CBT).
The goal of MST is to improve youth’s ability
to choose peers and their family’s ability to mon-
itor behaviors. MST has three steps. Youth and
invested parties (e.g., parents, peers, and school
officials) are interviewed about behavioral prob- P
lems and potential causes in the first step. In the
second step, youth’s personal strengths and other
positive attributes that can be used to address
previously identified behavioral problems. In col-
laboration with their parents, youth set achievable
goals (e.g., regular school attendance or less con-
tact with deviant peers) they would like to accom-
plish in therapy in the third step. Progress toward
identified goals is carefully monitored by the ther-
apist. The therapist also collaborates with invested
parties to remove obstacles that may prevent
youth from achieving their goals. Schaeffer and
Borduin (2005) compared the criminal activity
between youth (i.e., average age of 14 years)
who participated in either MST or IT. They
found that youth who participated in MST had
significantly lower rates of recidivism at follow-
up (i.e., average age of 28 years) compared to their
2176
counterparts who participated in IT. In addition,
youth who participated in MST had 54% fewer
arrests and 57% fewer days of confinement in
adult detention facilities. This longitudinal analy-
sis suggests that MST is effective in reducing
criminal activity among deviant youth.
Clinical Example
Jean and Michael, both in their early 40s, and their
adolescent daughter Emily were referred for ther-
apy by Emily’s pediatrician due to concerns about
her persistent and worsening behavioral prob-
lems. According to Jean, Emily has been staying
out past her curfew, drinking alcohol with friends
“who are a bad influence” over the weekend, and
was recently caught skipping school. The frustra-
tion in Michael’s trembling voice was evident,
“Emily shouts and swears at us every time we
try to talk to her about these behaviors. The last
straw was when police officers brought Emily
home while she was skipping school.” Jean and
Michael’s decision to seek therapy for Emily was
prompted after nearly eight months of worsening
behavioral problems. There was hopelessness in
Jean’s voice, “We have no idea what to do any-
more.” Both Jean and Michael also expressed
concern for the consequences of Emily skipping
school, which include juvenile detention because
their state has strict truancy (i.e., being away from
school without a legitimate reason) laws.
Although Jean and Michael initially sought IT
for Emily, the therapist recommended MST
given the systemic factors influencing her
behaviors.
The intake assessment consisted of gathering
a comprehensive history of the family, including
Emily, and the behavioral problems. The thera-
pist obtained a release of information from Jean
and Michael to collaborate with administrators
at Emily’s school and the district attorney (first
step of MST). Emily revealed not feeling
accepted by peers and a desire to “fit in,”
which Jean and Michael were unaware of. The
therapist facilitated a conversation to elicit both
Emily’s individual strengths and the family’s
positive attributes (second step of MST). Jean
Peer Contagion/Deviancy
remarked that “Emily is a kindhearted young
woman who likes to help others whenever pos-
sible.” Michael agreed that “Emily has a good
heart and a lot of potential.” The therapist
encouraged Emily to set achievable goals,
which included not skipping school or associat-
ing with deviant peers and not drinking alcohol
over the weekend. The therapist closely worked
with Jean and Michael to improve their moni-
toring of Emily’s activities with peers both
inside and outside of their home, which is crit-
ical to progress. The therapist also collaborated
with Emily’s parents and school administrators
to plan after-school activities in which she could
participate in lieu of associating with deviant
peers (third step of MST).
Cross-References
▶ Adolescents in Couple and Family Therapy
▶ Assessment in Couple and Family Therapy
▶ Brief Strategic Family Therapy
▶ Children in Couple and Family Therapy
▶ Cognitive-Behavioral Family Therapy
▶ Conduct Disorders in Couple and Family
Therapy
▶ Helping the Noncompliant Child
▶ Multisystemic Family Therapy
▶ Parenting in Families
References
Deković, M. (1999). Risk and protective factors in the
development of problem behavior during adolescence.
Journal of Youth and Adolescence, 28(6), 667–685.
https://doi.org/10.1023/a:1021635516758.
Dishion, T. J., & Patterson, G. R. (2016). The development
and ecology of problem behavior: Linking etiology,
prevention, and treatment. In D. Cicchetti (Ed.), Devel-
opmental psychopathology, risk, resilience, and inter-
ventions (Vol. 3, pp. 647–678). Hoboken: Wiley.
Dishion, T. J., & Tipsord, J. M. (2011). Peer contagion in
child and adolescent social and emotional development.
Annual Review of Psychology, 62, 189–214. https://doi.
org/10.1146/annurev.psych.093008.100412.
Dishion, T. J., Spracklen, K. M., Andrews, D. W., &
Patterson, G. R. (1996). Deviancy training in male ado-
lescent friendships. Behavior Therapy, 27(3), 373–390.
https://doi.org/10.1016/S0005-7894(96)80023-2.
Penn, Peggy
Dishion, T. J., Piehler, T. F., & Myers, M. W. (2008).
Dynamics and ecology of adolescent peer influence.
In M. J. Prinstein & K. A. Dodge (Eds.), Understand-
ing peer influence in children and adolescents
(pp. 72–93). New York: Guilford Press.
Dishion, T. J., Ha, T., & Véronneau, M. H. (2012). An
ecological analysis of the effects of deviant peer clus-
tering on sexual promiscuity, problem behavior, and
childbearing from early adolescence to adulthood: An
enhancement of the life history framework. Develop-
mental Psychology, 48(3), 703–717. https://doi.org/
10.1037/a0027304.
Huey, S. J., Henggeler, S. W., Brondino, M. J., & Pickrel,
S. G. (2000). Mechanisms of change in multisystemic
therapy: Reducing delinquent behavior through therapist
adherence and improved family and peer functioning.
Journal of Consulting and Clinical Psychology, 68(3),
451–467. https://doi.org/10.1037/0022-006X.68.3.451.
Piehler, T. F. (2016). Coercion and contagion in child and
adolescent peer relationships. In T. J. Dishion &
J. J. Snyder (Eds.), The oxford handbook of coercive
relationship dynamics (pp. 129–139). New York:
Oxford University Press.
Schaeffer, C. M., & Borduin, C. M. (2005). Long-term
follow-up to a randomized trial of multisystemic therapy
with serious and violent juvenile offenders. Journal of
Consulting and Clinical Psychology, 73(3), 445–453.
https://doi.org/10.1037/0022-006X.73.3.445.
Snyder, J., Schrepferman, L., McEachern, A., Barner, S.,
Johnson, K., & Provines, J. (2008). Peer deviancy
training and peer coercion: Dual processes associated
with early-onset conduct problems. Child Develop-
ment, 79(2), 252–268. https://doi.org/10.1111/j.1467-
8624.2007.01124.x.
Penn, Peggy
Margarita Tarragona
PositivaMente and Grupo Campos Elíseos,
Mexico City, Mexico
Name
Peggy Penn (1931–2012)
Introduction
Peggy Penn was an innovative practitioner and the-
orist in Family Therapy and a leader in the develop-
ment of conversational and dialogical therapies. She
trained many family therapists at the Ackerman
2177
Institute for the Family, where she worked during
most of her career, as well as in her international
workshops. Awriter and poet herself, Penn created a
unique approach that integrates texts written by the
clients into the therapeutic process.
Career
Penn’s first career was as an actress, and at the
time she used her maiden name, Peggy Maurer.
She later received her Master of Social Work from
the Hunter School of Social Work in New York
City. Penn also collaborated with Erik Erikson
studying play in children and worked at the Aus-
ten Riggs Nursery School as a therapist. Penn was
a supervising faculty member of the Ackerman
Institute for the Family, where she served as the
Director of Training from 1986 through 1992. She
co-created clinical research projects on chronic
illness, trauma, gender, violence, and the use of
language and writing in therapy. In 1988, Penn
received an award from the American Association
for Marriage and Family Therapy for her distin-
guished contributions to the field. She was a mem-
ber of the Taos Institute and in 2008, she obtained
her PhD from Tilburg University.
Contributions to Profession P
Penn was a pioneer in many areas of
family and couple therapy; she explored the implica-
tions of cybernetics, constructivism, and social
constructionism for therapeutic practice, and she
was a leader in the development of therapeutic
approaches that center around language and conver-
sation. She was part of the first generation of family
therapists that included a gender perspective in their
work. With Marcia Sheinberg, Virginia Goldner,
and Gillian Walker, she co-founded the Gender
and Violence Project at the Ackerman Institute, in
which they integrated a feminist awareness of gen-
der and an emphasis on accountability with a sys-
temic view. They worked with both men and
women in couples in which men exerted violence,
something that was unusual and the time. Penn was
also among the first therapists to work in family
2178
therapy with people who live with chronic illness
and their family members.
Penn played a leading role in the introduction
of the Milan Systemic approach to the United
States and worldwide. She further developed the
work of the Milan Associates through her writ-
ings about “circular questions” and “future
questions.” These were innovative ways of
conducting therapeutic inquiries that focus on
the different perceptions of various family
members and on possible imagined futures for
clients. She was part of an international network
of therapists who were interested in conversa-
tion, dialogue, writing, and stories. Penn collab-
orated closely with Tom Andersen, the
Norwegian psychiatrist who created reflecting
teams, and was one of the first people to work
with reflecting teams in the United States, using
them in therapy and in supervision.
Peggy Penn won the first Dickinson Award
for innovative poetry. Her poetry collection So
Close (2001b) was a Foreword Book of the Year
finalist. Language was a central theme in Penn’s
work and language was where her passion for
literature and poetry converged with her work as
a therapist. In the early 1990s, Penn co-founded
the Language and Writing Project at the
Ackerman Institute with Marilyn Frankfurt and
was later joined by Sally Witte, Joan
DeGregorio, and Patricia Booth. I (Margarita
Tarragona) was also fortunate to be part of that
team from 1995 to 1998. Penn and her group
developed an approach in which clients were
encouraged to write between sessions and
bring their writings to their next meeting,
where they would read them out loud. The ther-
apists would interview the client who did the
writing, as well as other family members about
their reactions to the writing, and their
responses were often meaningful and generative
for the therapeutic process. The clients’ writings
became, in Penn and Frankfurt’s words, “partic-
ipant texts” in the therapy. One of Penn’s many
contributions was the “return letter,” a response
written by the client in the voice of the recipient
of a letter, as if they had received it. In her book
Joined Imaginations (2009), Penn presents
many examples of how language and writing
Perel, Esther
can be used in therapy, and it is a testament of
her unique and poetic way of being a family and
couple’s therapist.
Cross-References
▶ Ackerman Institute for the Family
▶ Collaborative and Dialogic Therapy with
Couples and Families
▶ Micropolitics and Poetics in Couple and Family
Therapy
▶ Milan Systemic Family Therapy
▶ Narrative Family Therapy
▶ Open Dialogue Family Therapy
▶ Reflecting Team in Couple and Family Therapy
References
Boscolo, L., Ceccin, G. C., Hoffman, L., & Penn, P. (1987).
Milan systemic family therapy: Conversations in theory
and practice. New York: Basic Books.
Goldner, V., Penn, P., Sheinberg, M., & Walker, G. (1990).
Love and violence: Gender paradoxes in volatile
attachments. Family Process, 29(4), 343–364.
Penn, P. (1982). Circular questioning. Family Process,
21(3), 267–280.
Penn, P. (1985). Feed-forward: Future questions, future
maps. Family Process, 24(3), 299–310.
Penn, P. (1998). Rape flashbacks: Constructing a new
narrative. Family Process, 37(3), 299–310.
Penn, P. (2001a). Chronic illness: Trauma, language, and
writing: Breaking the silence. Family Process, 40(1),
33–52.
Penn, P. (2001b). So Close. Fort Lee: Cavankerry Press.
Penn, P. (2009). Joined imaginations: Writing and language
in therapy. Chagrin Falls: Taos Institute Publications.
Penn, P., & Frankfurt, M. (1994). Creating a participant
text: Writing, multiple voices, narrative multiplicity.
Family Process, 33(3), 217–231.
Perel, Esther
Kimberly Sharky
Enliven Chicago, Chicago, IL, USA
Name
Esther Perel
Perel, Esther
Introduction
Esther Perel is highly regarded as a thought leader
and progressive voice in the field of couple and
family therapy, known for her profound contribu-
tions on the topics of eroticism in long-term love
as well as infidelity in the modern age. The richly
multicultural perspective she brings to her clinical
work, teaching, and lecturing around the globe is a
defining characteristic of her voice in our field,
influenced by her unique fluency in nine lan-
guages and ability to connect deeply with clients
from many backgrounds.
Career
Perel began her clinical career by earning her
Bachelor’s degree in Educational Psychology,
French Literature, and Linguistics at Hebrew Uni-
versity, followed by graduate studies at Lesley
University where she earned her Master’s degree
in Expressive Arts Therapies.
Perel’s clinical work began with a focus on cross-
cultural dynamics within families as a student and
supervisee of Dr. Salvador Minuchin. Perel’s early
clinical thinking is notably influenced by being born
in Belgium to Holocaust-survivors who, as Perel has
been quoted, “joined other survivors in being faced
with the choice of becoming a person who merely
did not die or a person who chose to live.” This
perspective carried over to her work with couples,
witnessing a difference between those who found in
their relationship a place to fully live and grow
together over time and those who expect from love
a simple promise of comfort and security above
all else.
Beyond her writing and lecturing, Perel is an
AASECT-certified sex therapy supervisor; a
Licensed Marriage and Family Therapist; and a
member of the American Family Therapy Acad-
emy, The Society for Sex Therapy and Research,
as well as the American Association of Sex Edu-
cators, Counselors, and Therapists. Since 1984,
she has maintained a private practice in New York
City, where she raised her two children with hus-
band, Jack Saul, an equally accomplished clini-
cian and respected thought leader in the clinical
2179
trauma community. In addition to her work in
private practice, she also serves on the faculty of
The Family Studies Unit, Department of Psychia-
try, New York University Medical Center and The
International Trauma Studies Program at Colum-
bia University.
Contributions to Profession
Perel’s transition from intercultural couple and fam-
ily therapy to a focus on sexuality and eroticism
began while writing an article for the Psychotherapy
Networker titled “Erotic Intelligence,” sparking
viral interest in the topic by readers within the clin-
ical and lay communities alike. Clearly striking a
chord by highlighting a modern dilemma of long-
term love, Perel’s first book, Mating in Captivity,
articulated the inherent conflict in even thriving
marriages between the emotional safety and comfort
of an enduring bond of intimacy, and the desire for
passion and eroticism, which calls for a willingness
to experience vulnerability and the potential risks.
Perel’s contributions struck a chord with readers,
propelling her onto the global stage as a highly
sought after teacher and speaker. To date, her two
TED talks, “The Secret to Desire in a Long-term
Relationship” (February 2013) and “Rethinking
Infidelity . . . a talk for anyone who has loved”
(May 2015) have reached over 16 million viewers. P
The New York Times, in a cover story, named her
the most important game changer on sexuality and
relationships since Dr. Ruth.
While Perel’s appeal within the broader society
is undeniable, her influence within the clinical
community is equally profound. Her work has
inspired a more nuanced dialogue among clini-
cians, infusing a greater appreciation for cultural
complexities and a call for therapists to create
more in-depth exploration of the intricacies of
eroticism in the therapy room. Perel’s own clinical
style is decidedly active, influenced by her early
career in theater and appreciation for psycho-
drama as a tool. She believes that couples should
leave her office feeling different about themselves
and each other and expects the bulk of those shifts
to occur under her direction within the therapy
session, rather than in the form of behavioral
2180
homework or assignments to be completed
between sessions. Perel approaches her clinical
work as a true artist, acknowledging that her
insights and thinking weave into a continually
evolving process, one that is difficult to learn
from as a clinician if what is being sought is a
recipe of techniques or clearly mapped out
session-by-session playlist of clinical tools.
Rather, Perel challenges clinicians to look beyond
their own perspectives and biases while also turn-
ing on its head the long-held beliefs by many
couples therapists that a thriving sexual connec-
tion should come naturally to those who care
deeply for one another and who exhibit positive
relating skills.
In recent years, Esther Perel has turned her
focus to exploring the equally complex topic of
infidelity with her newest book, The State of
Affairs: Cheating in the Age of Transparency
(Harper Collins, 2017). Perel offers a much-
needed expansion of the narrative on affairs that
challenges clinicians to extend their assessment
beyond the often overly simplified roles of victim
and perpetrator. In Perel’s signature cross-cultural
style, the notion of infidelity as the ultimate
betrayal and catalyst for immediate dissolution
of a marriage is also more deeply explored and
examined against the ways these relational conun-
drums are addressed in other Western cultures.
Cross-References
▶ Infidelity in Couples
▶ Intercultural Couples and Families in Couple
and Family Therapy
▶ Marriage
▶ Psychodrama in Family Therapy
▶ Sexuality in Couples
References
Perel, E. (2003). Erotic intelligence: Reconciling sensual-
ity and domesticity. The Psychotherapy Networker.
Perel, E. (2006). Mating in captivity: Unlocking erotic
intelligence. New York: Harper Collins.
Perel, E. (2017). The state of affairs: Cheating in the age of
transparency. Harper Collins.
Person of the Therapist in Couple and Family Therapy
Perel, E., & TED. (2013). The secret to desire in a long-
term relationship. New York: TEDSalon.
Perel, E., & TED. (2015). Rethinking infidelity . . . a talk for
anyone who has ever loved. TED.
Person of the Therapist in
Couple and Family Therapy
Michael E. Sude
Department of Psychology, La Salle University,
Philadelphia, PA, USA
Name of Concept
Person of the Therapist in Couple and Family
Therapy
Synonyms
Self of the Therapist; Use of Self
Introduction
Research on the effectiveness of therapy shows
that the person of the therapist is a significant
and consistent common factor for outcome,
regardless of therapeutic approach. Although
there fails to be a universal definition, the person
of the therapist usually refers to the therapist’s
beliefs, values, experiences, and sociocultural
identity. It also includes the ways that the therapist
can be emotionally triggered, as well as how
therapists use themselves to self-disclose or relate
to clients’ experiences. Although early family
therapy theorists focused on resolving personal
issues so that they would not contaminate the
therapy process, contemporary theorists focus
more on how the person of the therapist can be a
barrier as well as a resource in clinical practice.
Research on the person of the therapist is limited,
but several studies were conducted over the last
decade on the training and practice of the person
of the couple and family therapist. This entry
Person of the Therapist in Couple and Family Therapy
explores the theoretical rationale, components,
methods of training, and contemporary clinical
applications of the person of the therapist in cou-
ple and family therapy.
Theoretical Context for Concept
The concept of the person of the therapist can be
traced back many years before the field of couple
and family therapy even existed. Sigmund Freud
believed that therapists’ beliefs and reactions
were vital to the therapy process, and he devel-
oped a psychoanalytic training model that
included self-analysis for moments when thera-
pists experienced countertransference. Therapists
experience countertransference when they are
emotionally reactive with clients that may remind
them of significant people or experiences in their
personal lives. Contemporary psychoanalysts
still focus on the importance of countertransfer-
ence to the therapy process. Early humanistic
psychologists, such as Carl Rogers, also stressed
the importance of the person of the therapist as
well as the therapeutic relationship.
Despite its roots in psychology, the person of
the therapist has developed much more in the
field of couple and family therapy. Pioneering
couple and family therapists such as Carl
Whitaker, Murray Bowen, and Virginia Satir
believed that if therapists could address and
resolve personal issues, they would have much
more freedom of choice for how to conceptualize
and treat client-families. Whitaker self-disclosed
frequently as a form of intervention, Bowen
trained family therapists to address issues in
their families of origin, and Satir valued the
therapeutic relationship as well as how therapists
used self to emotionally connect with clients.
Contemporary, postmodern family therapy
theorists such as Tom Andersen, Michael White,
and Harlene Anderson believe that the person of
the therapist is ever present in therapeutic interac-
tions, whether she or he is aware of it or not.
Cheon and Murphy (2007) state that the person
of the therapist from a postmodern perspective
can be developed by increasing self-awareness
and self-knowledge, as well as self-disclosing
2181
with the goal of reducing power skews and
co-generating new meanings and possibilities for
clients. For example, narrative family therapists
must be conscious of what stories they privilege
over others. They must pay close attention to
how sociocultural power affects clients, the ther-
apist, and the therapeutic relationship. They must
also be socially conscious of how dominant soci-
etal narratives may be contributing to clients’
stories and limiting more hopeful narratives.
They can then use their selves to deconstruct
oppressive social discourses and help client-
families identify how those dominant societal dis-
courses have been oppressive in their lives and
relationships.
Description
The person of the therapist, at its core, is the
idea that there is no way to not be oneself as a
clinician. It is in direct opposition to the idea
that therapists should be neutral, emotionless,
and void of opinions. The therapist makes choices
about what questions to ask, what realities to
privilege, and what thoughts and feelings to
share with clients. The therapist is not a robot
that is preprogrammed to ask predetermined ques-
tions and respond in predetermined ways. She or
he is a living, breathing human being with beliefs, P
values, emotions, cultural heritage, and personal
experiences that contribute to her or his lived
experience, inside and outside of the therapy
space.
Although the importance of the person of the
therapist may be obvious to some therapists and
trainees, many psychotherapists are trained to
keep their personhood out of the therapy space
as much as possible. Therapists that minimize the
importance of the person of the therapist may
believe that exposing one’s personhood has the
potential to contaminate clients’ perceptions of
the therapist, interfere with treatment by focusing
on the therapist instead of the clients, as well as
put the therapist at greater risk for ethical viola-
tions related to clinical boundaries. Blow et al.
(2007) note that the medical model, which has
heavily influenced couple and family therapy in
2182
the managed care age, focuses much more on the
treatment that is delivered than who delivers the
treatment. Manualized treatments, developed in
response to the demand for evidence-based ther-
apy with measurable outcomes, often attempt to
minimize therapist influence and variability. This
assumes that the person of the therapist is not
important, and that clinical interventions can be
effective no matter who facilitates them.
From a common factors lens, the person of the
therapist is vitally important. Common factors
are aspects of treatment that are common to
many different models of therapy. These include
client, therapist, and therapeutic relationship vari-
ables, among others. Proponents of a common
factors approach cite research that consistently
shows that the therapeutic alliance accounts for
at least twice as much variance in therapy out-
come as therapeutic techniques. Because the per-
son of the therapist is a significant component of
the therapeutic alliance, Fife et al. (2014) state that
who therapists are as people and how they relate
to their clients is ultimately what makes effective
therapy. From this perspective, techniques and
skills are only effective when the therapeutic rela-
tionship is solid, which hinders on the therapist’s
“way of being.” Way of being refers to a thera-
pist’s stance that places clients’ needs first and
approaches them with genuine curiosity and
care, often conveyed through the therapist’s
words and audiovisual cues such as tone, body
language, and timing. When clients experience
the therapist as warm, supportive, caring, and
interested, they form a strong therapeutic alliance
that provides opportunity for techniques and skills
to be helpful.
Person of the Therapist Training
The person of the therapist is discussed most
often as a valuable part of couple and family
therapy training. Timm and Blow (1999) note
that terms such as “self of the therapist work”
have long been associated with training therapists
to increase self-awareness and to learn how to
use their selves in session. Supporters of self of
the therapist training agree that engaging in this
type of personal and professional development is
essential for trainees and therapists to blossom
Person of the Therapist in Couple and Family Therapy
into effective clinicians. Self of the therapist
work can occur in university courses, practicum,
clinical supervision, and independent workshops,
and may include a variety of formal assignments,
experiential activities, as well as discussions
about self-awareness, self-knowledge, sociocul-
tural identity, and use of self in practice.
One of the common criticisms of self of the
therapist training is that it is too similar to therapy,
and thus creates a dual relationship between
trainers and trainees. Even though the ultimate
goal is for the benefit of one’s clients, self of the
therapist work will likely resemble therapy at
times. Trainers and supervisors may ask personal
questions of trainees about their own beliefs and
experiences, but they never actually become ther-
apists for their trainees. In other words, particular
moments in a relationship do not necessarily
define the entire relationship. To give a parallel
example, an adult child and parent may look and
act like friends at times; however, the parent-child
relationship never goes away completely. The
parent-child relationship is still asymmetrical,
even though at times they may talk and act like
peers. Self of the therapist training relationships
are similar in this way. Trainees will do their
own personal growth in these relationships, and
while it may be therapeutic, it is not therapy.
Although several, independent self of the
therapist activities are published in the couple
and family therapy literature, the most prominent
is the Person of the Therapist Training (POTT)
model developed by Harry Aponte and colleagues
(Aponte & Kissil 2014, 2016). The POTT model
focuses on therapists knowing themselves, the
ability to access their inner experiences, and
the intentional use of themselves in therapy.
In POTT, therapists learn to accept themselves as
human beings with insecurities, fears, and imper-
fections. The POTT model helps each trainee
identify her or his own “signature theme.”
Signature themes are core personal issues that
result from each trainee’s experiences of being
relationally wounded. Therapists learn to work
with their signature themes in training and to
draw on them as therapeutic resources in therapy
sessions. Aponte and Kissil (2014) note four
common themes that therapists typically identify
Person of the Therapist in Couple and Family Therapy
with including a lack of value or self-worth, as
well as fear of vulnerability, rejection, and losing
control. Signature themes are often the same or
similar to the core issues that clients are dealing
with, so becoming more sensitive, attuned, and
empathetic to one’s own core issues often helps
therapists to be able to do the same with clients.
However, because everyone’s signature themes
differ in terms of their specific relationships,
experiences, and circumstances, therapists can
learn to differentiate their own core issues from
those of their clients.
Recent research on the POTT model (Niño
et al. 2015, 2016) shows that trainees believe
that the model has been beneficial to their
personal and professional growth, and ultimately
their clinical work. Niño et al. (2015) studied
perceived professional gains of POTT which
included increased abilities to self-reflect, as well
as heightened awareness of potential resources,
values, and limitations as a clinician. Trainees
also reported that the POTT model helped them
to be more comfortable with experiencing,
acknowledging, tracking, managing, and utilizing
their emotions as therapeutic tools in their clinical
work. It also directly helped their perception of
their clinical work including increased profes-
sional self-confidence, improved clinical skills,
an increased ability to use one’s voice in session,
more freedom to take clinical risks, as well as
better professional boundaries. Finally, trainees
also reported that they were able to have more
empathy and acceptance for their own personal
struggles and relational wounds, as well as the
ability to utilize their own imperfections and
sources of pain to connect with clients’ experi-
ences. In a similar study focused on how POTT
contributed to the therapeutic relationship, Niño
et al. (2016) found that therapists were much more
able to have empathy for their clients’ experi-
ences, as well as be open to be emotionally
engaged and affected by their clients’ stories
because of the work they had done in connecting
with and building empathy for their own experi-
ences. Furthermore, trainees found that POTT
helped them manage countertransference, build
and manage multiple therapeutic alliances in the
client-system, view their clients from a more
2183
hopeful perspective by focusing on clients’
strengths and resources, as well as genuinely
bond and care for their clients.
Application of Concept in Couple and
Family Therapy
Utilizing the person of the therapist may be more
difficult in couple and family therapy than it is
in individual therapy. There is often more complex-
ity in couple and family therapy as compared to
individual therapy including building alliances
with multiple members of the client system. For
example, Roberts (2005) notes that disclosures by
couple and family therapists have the potential to be
helpful to one member of a client-system and harm-
ful to another. Although there may be more oppor-
tunities to use self to relate to clients with couples
and families, the process can be more challenging.
This section explores different ways to use the per-
son of the therapist with clients.
Couple and family therapists need to find ways to
use self to build relationships with multiple mem-
bers of a client-system, because the therapeutic rela-
tionship can be what makes or breaks the experience
for clients. Michelle Baldwin’s (2000) edited book,
The Use of Self in Therapy, states that when people
report positive experiences in therapy, they often
describe the person of the therapist as warm, sup- P
portive, caring, etc. In contrast, when people have
negative experiences in therapy, they often refer to
the person of the therapist as preprogrammed,
robotic, and disinterested. Clients want their thera-
pists to be human beings in addition to service pro-
viders, which is why most people refer friends and
family to therapists because of who they are as
people, not what type of therapy they do.
Stone Fish (2002) relays a story about working
with a client that was struggling with parenting.
The client runs into the therapist in the supermar-
ket when the therapist was exhausted, frustrated,
overwhelmed, and void of patience, and witnesses
the therapist in one of her most human moments.
The therapist is caught screaming at her son and
displaying exactly the type of behavior that the
client struggles with. In the next session, the client
reports feeling much better, and references what
2184
she witnessed in the supermarket. The client
shares that the therapist was a “myth” to her
before this chance encounter, someone who “had
it all figured out” and could not possibly under-
stand how much she was struggling to parent her
daughter. However, after seeing how over-
whelmed and imperfect the therapist was, she
felt relieved and empowered. Stone Fish states
that since that experience, she brings much more
of herself to the therapy space because she learned
that “it is me, not the image of professionalism
I once thought I was conveying, that people find
helpful and healing” (p. 37).
The Therapist’s Inner Conversation
Peter Rober conceptualized and developed one way
that the therapist uses self in practice called the
therapist’s inner conversation (Rober 1999, 2011).
The therapist’s inner conversation is an internal
exchange between the experiencing self of the ther-
apist and the professional role of the therapist, aimed
at discovering ways to open space in conversations
with clients. Rober makes a distinction between the
experiencing self (the thoughts, feelings, biases that
the therapist experiences during session) and the
professional role of the therapist (how the therapist
selectively chooses which parts of the self to con-
tribute to therapeutic conversations in an effort to be
healing). The professional role makes meaning of
information gathered by the experiencing self to
form narratives and hypotheses about what is hap-
pening for clients in and out of therapy. Frediani and
Rober (2016) studied novice therapists’ experiences
of their inner conversations in sessions with couples
or families and found that novice therapists experi-
ence several types of reflections related to self (e.g.,
self-criticism), the therapy process (e.g., curiosity,
frustration, powerlessness, relief), feelings about
family members (e.g., irritation), as well as manag-
ing the session and their own emotions.
Self-Disclosure
Self-disclosure is a highly provocative and
controversial way to use the person of the thera-
pist. Self-disclosure may be intentional or
unintentional (as in the case of running into a
client at the supermarket). Roberts (2005)
explores the potential benefits and risks for
Person of the Therapist in Couple and Family Therapy
intentional self-disclosures in couple and family
therapy and provides guidelines for purposefully
self-disclosing with clients. As a guiding princi-
ple, therapists need to self-disclosure in ways that
are directed at ultimately helping with clients’
concerns and that are not oppressive or harmful
to clients. In addition to being helpful to one
member of the system and hurtful to another,
disclosures have the potential to be both helpful
and harmful simultaneously to the same person.
The therapist must always be mindful of her or his
position of power and influence in the therapist
role, as self-disclosures have the potential to over-
power client stories or lead clients to feel like they
need to reverse roles and take care of the therapist.
These possibilities are often far from the inten-
tions of the disclosure but are potential conse-
quences of using the person of the therapist in
this way.
In order to avoid doing harm, one thing that
therapists can do is to encourage clients to ask
questions of the therapist at the start and through-
out the therapy process. Clients are often curious
about the person that they are sharing significant
parts of their lives with, and encouraging them to
ask questions is a good way for clients to get to
know who they are working with. This does not
mean that the therapist must answer every client
question, but giving clients permission to be curi-
ous and ask is what is important. Another recom-
mendation is to share a small piece about one self
and see how the clients react to decide whether or
not it would be helpful to share a bit more. For
example, if the clients continue to ask questions
about a therapist’s experience with something
they are currently dealing with, therapists can
continue to self-disclose and direct their disclo-
sure to the clients’ circumstances (Roberts 2005).
A third guideline is for therapists to be con-
scious of their own potential emotional reactions
to their self-disclosures to ensure that they remain
emotionally present with clients and are not
requesting that clients emotionally care for them.
Therapists often need some emotional distance
from what they disclose so that they are not shar-
ing emotional raw spots. Therapists should also be
open to any and all reactions that clients have to
their self-disclosures and be open to addressing
Person of the Therapist in Couple and Family Therapy
clients’ needs no matter what reaction they have.
It may also be helpful for therapists to share strug-
gles that they have had in their lives and how they
have wrestled with them, as opposed to focusing
on solutions. This allows space for the therapist
and clients to co-construct solutions that may fit
the clients’ needs without making suggestions
about what would be best. In sum, therapists that
choose to self-disclose must assess how it would
be helpful to the clients, as well as whether the
self-disclosure could be too similar to a client’s
story or too emotionally raw to share (Roberts
2005).
Sociocultural Identity
Watts-Jones (2010) notes that the person of
the therapist has traditionally lacked focus on
issues of power and privilege related to sociocul-
tural identity (e.g., gender, race, class, religion,
sexual orientation, etc.). In response, Watt-Jones
describes a self-disclosure practice called location
of self. Location of self involves the therapist self-
disclosing pieces of her or his sociocultural iden-
tity. The therapist self-discloses in order to open a
conversation about the sociocultural similarities
and differences between the therapist and the
client-family, and how these similarities and dif-
ferences may impact the therapeutic relationship
and the therapy process.
The process of locating self assumes that socio-
cultural power and privilege matter in the therapy
process and that socially oppressive forces exist in
the air that we all breathe. However, sharing one’s
own social location can lead people to feel vul-
nerable and uncomfortable. The therapist must
open this conversation because the therapist sits
in the position of power in the therapy room, and
thus bears the burden of locating self before invit-
ing clients to locate their sociocultural identities.
The therapist can begin this conversation in the
opening session or after a few sessions to try to
help assure more comfort for clients. Although
the therapist tends to focus on how blending
identities could benefit clinical work, clients may
raise potential drawbacks or concerns as well.
Watts-Jones (2010) states that “Making identities
transparent is an invitation to clients to participate
with the therapist in being mindful of how our
2185
mix of experiences may at times create tension,
misunderstanding, or frustration and to talk about
it. It extends the collaboration” (p. 413).
Clinical Example
Maria, a bilingual, cis-gender, female family ther-
apist of Latin descent, met with a working class,
white, Christian family that consisted of a mother,
stepfather, and their 15-year-old daughter, Lisa. In
the first session, mom describes Lisa as “a good
kid that had fallen into the wrong crowd.” Mom
describes her concerns about their daughter’s
experimentation with alcohol and other drugs, as
well as her relationship with her 16-year-old boy-
friend, Eddie. Mom makes a subtle comment
about Eddie’s father being incarcerated, and
stepdad makes reference to the fact that Eddie
“had an accent” and “probably spoke Spanish at
home.” Lisa remains quiet with her head down for
most of the session, listening to her parents
describe their concerns. Maria asks to meet with
Lisa alone for the second session, and Lisa agrees
that she would like to have the chance to speak
without her parents present. In this session, Lisa
shares that all her parents do is criticize her and
that she can never please them. She also reports
that Eddie has been pressuring her to have sex
with him for weeks, and that he has screamed at P
her and called her nasty names several times while
drunk if she rejects his sexual advances.
Maria describes the case to her clinical super-
visor during their next meeting, and she tells her
supervisor that she is worried that Lisa does not
have anywhere where she feels valued. The super-
visor validates Maria’s concerns, and asks why
she doesn’t believe that the mother and stepfather
value and care about her. Maria states that the
parents were very critical and close-minded, and
that she does not have much hope of joining well
with them. The supervisor is surprised by this
comment as she often experiences Maria as very
hopeful and particularly skilled at joining with
both adults and children. The supervisor mentions
that the parents brought Lisa to treatment because
they are concerned, and notes that it sounds like
they have some reason to be concerned based on
2186
what Lisa reported about Eddie. The supervisor
then asks what is happening for Maria as she talks
about this case.
Maria responds by sharing both the connection
she feels to this case as well as the reactivity she
experiences. In discussing Maria’s experience of
the parents, she is able to identify the racism
imbedded in the parents’ comments about Eddie.
Maria shares that it felt like the parents were
talking about her when they made the comments
about Eddie. She admits that she shut down her
curiosity and compassion for the parents as soon
as they began to reveal their racist beliefs and
wonders if she can learn to respect people who
have those beliefs.
The supervisor validates Maria’s experiences
and conveys how painful and difficult it must be to
continue to encounter racism, even in her own
office. The therapist then asks how the parents
will learn to be open to new possibilities if their
therapist is not open to the possibility that she can
learn to appreciate them. Maria understands now
that she can only expand the parents’ capabilities
to be open to Maria’s beliefs by being open to their
beliefs but is still doubting that she can have
empathy for them. The supervisor wonders if she
can shift her reactivity to curiosity and can explore
the parents’ stories and experiences. When Maria
asks what the supervisor means, she replies,
“Well, instead of asking yourself the rhetorical
question ‘What is with these people and why are
they so critical and oppressive?’, explore the same
question with them from a place of curiosity.”
The supervisor wonders aloud if there is any-
thing that Maria is aware of about the parents that
she can relate to or identify with already. After
thinking about it some, Maria states that she ima-
gines that it is difficult for them to feel valued
because they are poor. She states that she can
relate to struggling to find places that she feels
valued in the world, and wonders if the parents
may have similar experiences. The supervisor
asks Maria if she would be willing to explore
this with the parents in order to connect with and
better understand their experiences and begin to
build a therapeutic relationship with them.
Maria reports that she believes she has some
hope of connecting with the parents now, and then
Person of the Therapist in Couple and Family Therapy
expresses another concern about her reactions to
Lisa’s relationship with Eddie. She reports that
she has mixed feelings about Eddie. On the one
hand, she feels a pull to advocate for him to be
treated fairly because she relates to him as a Latin
woman. On the other hand, Lisa’s description of
him frightens her because it reminds her of a
relationship she had when she was in high school.
The supervisor asks if she would be willing to
share some about this romantic relationship
and how Eddie reminds her of her ex. Maria
shares that her first serious boyfriend was physi-
cally, verbally, and emotionally abusive. She
described a similar experience of how he would
intimidate her, call her names, and pressure her
into having sex with him. She reports that she
eventually gave in to his advances and always
regretted not standing up for herself more in that
relationship, and now feels some responsibility to
not let that happen to Lisa.
The supervisor validates her experience and
thanks her for sharing, and then asks how she
might use her personal experience to be helpful
to Lisa. Maria responds that she has only just met
Lisa and her family and does not feel comfortable
self-disclosing something this vulnerable with
them. The supervisor wonders if there is a way
to utilize her experiences without actually self-
disclosing. The supervisor then asks Maria to
internally connect with the teenager that used to
be her that was in a similar situation to Lisa. The
supervisor asks what that adolescent girl would
have needed if she had shared this with a therapist
when she was younger. Maria says that she would
need someone to just listen and empathize with
her and not tell her what she would do. The super-
visor asks if it would be okay if a therapist shared
some concerns or fears that she had without actu-
ally telling her what to do. Maria agrees that this
would be okay, and that it would have validated
some of the concerns she already had about the
relationship. The supervisor then asks if it would
have been helpful to develop some options
together about what she could do without
directing her in one specific direction. Maria
agrees that she would have welcomed this. The
supervisor then asks her to reconnect with her
current adult self and think about if she could
Person of the Therapist Training Model, The
be therapeutic with Lisa in these ways. Maria
reports that she can, and that it was helpful to
see how she could utilize her hurtful experience
as a resource for working with Lisa without actu-
ally disclosing anything. Lisa thanks her supervi-
sor and leaves the supervision meeting full of
hope and encouragement that the most therapeutic
thing that she can do to work with this family is to
simply be herself.
Cross-References
▶ Aponte, Harry J.
▶ Common Factors in Couple and Family
Therapy
▶ Countertransference in Couples Therapy
▶ Person of the Therapist Training Model, The
▶ Self of the Therapist Training in Couple and
Family Therapy
▶ Therapeutic Alliance in Couple and Family
Therapy
▶ Therapist Position in Couple and Family
Therapy
References
Aponte, H. J., & Kissil, K. (2014). “If I can grapple with
this I can truly be of use in the therapy room”: Using the
therapist’s own emotional struggles to facilitate effec-
tive therapy. Journal of Marital and Family Therapy,
40, 152–164. https://doi.org/10.1111/jmft.12011.
Aponte, H. J., & Kissil, K. (Eds.). (2016). The person of the
therapist training model: Mastering the use of self.
New York: Routledge.
Baldwin, M. (Ed.). (2000). The use of self in therapy
(2nd ed.). New York: The Haworth Press.
Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who
delivers the treatment more important than the treat-
ment itself? The role of the therapist in common factors.
Journal of Marital and Family Therapy, 33, 298–317.
https://doi.org/10.1111/j.1752-0606.2007.00029.x.
Cheon, H.-S., & Murphy, M. J. (2007). The self-of-the-
therapist awakened: Postmodern approaches to the use
of self in marriage and family therapy. Journal of Fem-
inist Family Therapy, 19, 1–16. https://doi.org/
10.1300/J086v19n01_01.
Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014).
The therapeutic pyramid: A common factors synthesis
of techniques, alliance, and way of being. Journal of
Marital and Family Therapy, 40, 20–33. https://doi.
org/10.1111/jmft.12041.
2187
Frediani, G., & Rober, P. (2016). What novice family
therapists experience during a session. . .A qualitative
study of novice therapists’ inner conversations during
the session. Journal of Marital and Family Therapy,
42, 481–494. https://doi.org/10.1111/jmft.12149.
Niño, A., Kissil, K., & Apolinar Claudio, F. L. (2015).
Perceived professional gains of master’s level students
following a person-of-the-therapist training program:
A retrospective content analysis. Journal of Marital
and Family Therapy, 41, 163–176. https://doi.org/
10.1111/jmft.12051.
Niño, A., Kissil, K., & Cooke, L. (2016). Training for
connection: Students’ perceptions of the effects of the
person-of-the-therapist training on their therapeutic
relationships. Journal of Marital and Family Therapy,
42, 599–614. https://doi.org/10.1111/jmft.12167.
Rober, P. (1999). The therapist’s inner conversation in
family therapy practice: Some ideas about the self of
the therapist, therapeutic impasse, and the process of
reflection. Family Process, 38, 209–228. https://doi.
org/10.1111/j.1545-5300.1999.00209.x.
Rober, P. (2011). The therapist’s experiencing in
family therapy practice. Journal of Family Therapy,
33, 233–255. https://doi.org/10.1111/j.1467-6427.
2010.00502.x.
Roberts, J. (2005). Transparency and self-disclosure
in family therapy: Dangers and possibilities. Family
Process, 44, 45–63. https://doi.org/10.1111/j.1545-
5300.2005.00041.x.
Stone Fish, L. (2002). Nightmare in aisle 6. Psychotherapy
Networker, 26(2), 36–37.
Timm, T. M., & Blow, A. J. (1999). Self-of-the-therapist
work: A balance between removing restraints and iden-
tifying resources. Contemporary Family Therapy, 21,
331–351. https://doi.org/10.1023/A:1021960315503.
Watts-Jones, D. (2010). Location of self: Opening the door
to dialogue on intersectionality in the therapy process. P
Family Process, 49, 405–420. https://doi.org/10.1111/
j.1545-5300.2010.01330.x.
Person of the Therapist
Training Model, The
Harry Aponte1 and Karni Kissil2
1
Drexel University, Philadelphia, PA, USA
2
Jupiter, FL, USA
Introduction
The Concept
The Person of the Therapist Training Model rep-
resents a concept within the province of the use of
2188
self in therapy that contains a combination of
certain particular features:
1. Although the training goals consider the per-
sonal growth and development of the therapist,
the model’s primary emphasis is on the thera-
pists’ ability to make purposeful and skillful
use of their personal selves and life experiences
within the professional role of therapist – the
therapeutic relationship, the assessment pro-
cess, and the implementation of interventions.
2. The personal use of self includes all aspects of
what the therapist brings of the personal self
into the therapeutic process with the clients but
with special attention to therapists’ own emo-
tional “woundedness,” which enables empathy
and resonance with clients’ “woundedness.”
3. The training aspect of the model evinces itself
through a systematic process and structure that
aims to have therapists:
(a) Recognize who they are and what they
bring of their personal selves, good and
bad, to the therapeutic encounter, enabling
them to be open and vulnerable within
themselves while simultaneously well-
grounded and differentiated when engaged
with clients.
(b) Not only gain insight into themselves but
also develop an acceptance and comfort
with themselves, especially with their per-
sonal emotional vulnerabilities, that frees
them to make positive, selective, and
active use of all aspects of self as needed
to lend depth of the presence, perception,
and sensitivity along with self-possession
and power to their technical skills.
Theoretical Context
Attention to work on the emotional life of the self
of the individual who is conducting therapy
started with Sigmund Freud’s (1910) expectation
that aspiring analysts undergo their own psycho-
analysis as part of their training. With the birth of
systemically based therapies, Murray Bowen
(1972) and Virginia Satir (2000) stand out as pro-
ponents of working on nascent family therapists’
Person of the Therapist Training Model, The
resolving personal issues and differentiating
themselves as a basic part of their training. Aponte
and Joan Winter in their “person practice” model
(Aponte and Winter 2013) put their focus on
bridging the work on self with the mastery of the
technical or “external” tools of the trade. Aponte
(Aponte et al. 2009), in Drexel University’s Cou-
ple and Family Therapy Department in Philadel-
phia, developed a systematized approach to the
training of beginning therapists in the use of self in
couple and family therapy, the Person of the Ther-
apist Training (POTT) Model, that prioritizes cli-
nicians’ making the fullest use of their personal
selves, in particular of their emotional vulnerabil-
ities, in all aspects of the therapeutic process – the
relationship, assessment, and interventions. While
the work on self in the training of therapists has
traditionally focused primarily on helping thera-
pists resolve personal emotional issues that inter-
fere with their clinical effectiveness, the POTT
Model emphasizes therapists’ in the present ther-
apeutic moment making purposeful and strategic
use within their therapy models of their personal
core emotional issues, life experiences (good and
bad), and their values/world views.
The special attention to therapists’ use of
their emotional vulnerabilities is based on the
premise that it is through these personal issues
of theirs that therapists are best prepared to
relate to the emotional struggles of their clients.
Thus, their training aims at therapists’ coming
to better know themselves, to have ready access
to their inner experiences when engaged with
clients, and to gain greater mastery in the pur-
poseful use of their personal selves in the
moment when actively engaged with clients.
While the experience of this POTT training
commonly leads to personal change and growth
in therapists, the thrust of the training is to
enrich, enliven, and power the technical skills
of the therapist with the personal resources of
the therapist’s whole person. The training is
model neutral and serves as foundation to the
core formation of the person who aspires to
connect with clients, understand and intuit
their feelings and relational dynamics, and
reach in and touch their pain and hurts along
with their potential to change.
Person of the Therapist Training Model, The
Description
The POTT Model is based on the premise that at
its core the therapeutic relationship is a personal
process that takes place between the therapist and
client within a therapeutic context. POTT further
assumes that therapists are capable of developing
an expertise in how they purposefully and proac-
tively use themselves personally within the thera-
peutic process in order to provide competent and
effective care to their clients (Aponte and Kissil
2016). POTT trains therapists to selectively use all
of themselves with particular attention to their
signature themes, which are the central pillars of
the model. The idea of the signature theme is
based on two assumptions: One, we all carry
within us a particular psychological issue that is
at the heart of our human woundedness, coloring
our emotional and relational functioning through-
out our lives. Two, for therapists to be able to
relate most effectively to their clients, they must
be able to selectively open themselves up in judi-
cious vulnerability so they can feel and experience
something of their clients’ pain and struggles.
Therapists’ signature themes with their deriva-
tives (other personal issues that spin off from the
original core issue) are the media through which
therapists make these connections with their cli-
ents’ struggles. We all live with our unique strug-
gles with ourselves and with life. The signature
theme has an underlying core, such as feelings of
low self-esteem with derivatives like a fear of
vulnerability and defensive derivatives such as
the need for control in relationships to avoid
being rejected. These core themes are universal
enough to enable therapists to identify and empa-
thize with most clients. Social factors such as race
and ethnicity may contextualize these issues, but
the underlying universal feelings such as fear of
rejection may allow a therapist to still bridge
emotionally with clients who have different life
experiences due to their particular social
locations.
The POTT Model takes a unique stance regard-
ing the value of core issues by not just suggesting
that signature themes are resources that can
enhance therapists’ effectiveness but also by plac-
ing learning to work through signature themes at
2189
the very heart of the training of therapists in the
use of self. The signature themes are not narrowly
viewed as hindering therapy but rather, whatever
challenges they present are potentially valuable
resources, enabling therapists to work effectively
by identifying with and differentiating from their
clients (individuals or families). Accepting their
personal vulnerabilities opens therapists to empa-
thize with their own selves. This then facilitates
their reaching within themselves to connect
through a wound of their own to their client’s
wound, which in turn allows for a cognitive and
emotional identification that may enable them to
better understand and empathize with a client’s
woundedness and understand the hurt from
within – the common painful human element ther-
apist and client share. It is that common human
factor that allows the therapist to intuit what cli-
ents may not even be conscious of in their painful
experience. The therapist may have insight about
some core aspect of his/her own analogous expe-
rience that throws light on the clients’ experiences
even when many of the surrounding circum-
stances differ significantly for each party. The
more self-accepting and knowledgeable therapists
are about the underlying dynamics of their own
life-struggles, the more adept will they be at dis-
covering where to connect with their various cli-
ents’ differing experiences. Moreover, therapists’
expertise about their clients’ challenges derives P
not just from the common woundedness itself,
but also from the dynamically evolving life jour-
neys of confronting and wrestling with ups and
downs of those challenges. The implication, of
course, is that therapists who commit to
contending with their personal challenges bring
to the therapeutic encounter not just empathy but
also the wisdom derived from the failures and
successes of their struggles with their own
demons. Throughout the training, therapists
work on learning to master the use of their core
issues and related struggles with their issues in all
aspects of the therapy process: from connecting
empathically, to understanding at vulnerable
depths, and to intervening with intuitive timeli-
ness, sensitivity, and appropriateness.
As previously stated, the POTT approach is
not tied to any one model of therapy. It considers
2190
the human connection and process through
which all therapies are implemented a common
factor of the therapeutic method (Sprenkle et al.
2009); however, the models of therapy vary how
they value the relevance of the human connec-
tion to therapeutic outcomes. POTT posits that
all therapists work with clients from within a
relationship that elicits trust and cooperation
and that therapists need to be accountable for
how they relate and conduct themselves with
clients, which requires self-awareness and self-
discipline. The POTT Model encourages thera-
pists to work towards resolution of personal
issues because of the insight they gain about
themselves and the freedom they achieve to
access more of themselves for use in their
work. However, realistically speaking, our cli-
ents get who we are today, flaws and all, and not
who we aspire to be when our issues may no
longer be such limiting and crippling “issues”
for us. Therefore, therapists are called to reach
deep within themselves to be prepared to use the
whole of who they are today, resolved and
unresolved, to the benefit of their clients.
Application of the Concept to Couple
and Family Therapy
The POTT program has been integrated into sev-
eral couple and family therapy programs in the
USA and abroad. This section describes its inte-
gration into the Drexel Couple and Family Ther-
apy graduate program as this is the longest-
running academically based POTT program.
Since its inception in this particular academic
setting in 2005, POTT has been implemented as
a 2-h weekly experiential class that runs through
the first academic year of the master’s program.
This class is typically taught by two instructors,
one of which is Dr. Harry Aponte, the developer
of POTT. Ideally, there are no more than 12 stu-
dents in class. The approach to the training is that
it is a boot camp – the intense attitudinal and
emotional preparation of the would-be therapists
to best prepare them to evolve into individuals
who have the self-awareness, self-access, and
self-discipline to master the use of themselves
Person of the Therapist Training Model, The
within the demands of the therapeutic process,
whatever their chosen model of therapy.
The training includes several stages, trans-
itioning from the personal to the clinical:
1. Trainees become oriented to what it means to
do therapy through their own flawed and vul-
nerable human selves in the personal connec-
tions they make with clients in the therapeutic
process through readings and discussion but
also by observing videos of therapists’ strate-
gically and purposefully using themselves in
clinical situations.
2. Trainees start the active component of their
training by working individually in the pres-
ence of their cohorts with the course leaders
on identifying and exploring their signature
themes, the lifelong struggles permeating
various areas of their life. They look to
understand the origins and actual manifesta-
tions of their personal issues in their personal
lives and hypothesize how their core issues
may affect their clinical performance.
Conducting these explorations in the group
context helps to normalize their life struggles
and create a sense of shared humanity among
the class cohort, which promotes self-
acceptance and reduction of shame. In addi-
tion, taking turns exploring their issues in the
group contexts facilitates the students’ abili-
ties to empathize with their fellow trainees’
struggles, which in turn hopefully translates
into their gaining the ability to better empa-
thize in the future with their clients and their
clients’ issues. They struggle as their clients
struggle. The common human bond between
them and their clients becomes more evident,
understandable, and accessible.
3. The next phase of training moves into the
clinical application of the insights the students
gained and their emotional reorientations about
themselves and their issues. Trainees present
on actual cases from their internships through
video and discussion, and also receive feed-
back about themselves through supervised in-
the-moment role plays of clinical situations
performed by fellow students. With the help
of the course leaders, the students glimpse
Person of the Therapist Training Model, The
ways their signature theme(s) and other per-
sonal factors play out in interchanges with their
“clients” and also how their own issues and life
experiences may be used to enhance therapeu-
tic effectiveness. In the last phase of the train-
ing, each student receives a live supervision
session using a mock case performed by actors
in a simulation lab (simlab). During these
simlab sessions, the effects of the signature
themes and other personal factors are directly
observed in the student’s interaction with cli-
ents, and the instructors provide live feedback
to the trainee throughout the session. The stu-
dents take turns being supervised with the
mock family while the rest of the class
observes the process through closed-circuit
TV. At the end of each session, the actors
provide feedback to the therapist-student
about how they experienced the student in
relating to them, understanding them, and
intervening with them. After that, the trainees
who observed the session share how/what they
witnessed in that clinical experience resonated
with them. Students also journal weekly after
every class from the beginning of the year to
the final class, reflecting on how/what they
observed and experienced in the class affected
them personally as well as their clinical think-
ing. The journals, with the use of the ongoing
feedback on their journals from their instruc-
tors, are meant to train the students to observe
and reflect on themselves – on their personal
reactions and their thinking from a professional
perspective.
4. At the end of the 9-month training, students are
asked to write their reflections on the profes-
sional and personal changes they have under-
gone over the course of their training. The goal
of this assignment is to help trainees articulate
for themselves what changes they have expe-
rienced personally and professionally during
the 9-month training.
Evidence Supporting the Model
Three recent qualitative studies on POTT sup-
port the perceived effectiveness of the training
2191
(Apolinar Claudio 2016; Niño et al. 2015,
2016). The first study, conducted by Niño and
her colleagues (2015), explored the professional
gains that first year master level MFT students
reported following the completion of a 9-month
POTT training. Findings suggest that students
experienced significant transformations in sev-
eral areas related to self, including increase in
self-knowledge and self-acceptance of flaws
and vulnerabilities, access to their inner selves,
and increased ability to purposefully use them-
selves in therapeutic encounters to connect,
assess, and intervene. All three areas of change
(self-knowledge and acceptance, self-access,
and intentional use of self in therapy) are
directly targeted by POTT. The second study,
conducted by Niño and her colleagues (Niño
et al. 2016) explored the perceived effects of
POTT on MFT students’ ability to create posi-
tive therapeutic relationships with their clients.
Participants in the study reported having a clear
pathway for creating positive therapeutic rela-
tionships, which in turn contributed to their
feeling confident and skilled in their ability to
do so.
The third study, conducted by Apolinar
Claudio (2016) used grounded theory to explore
the perceived impact of POTT on clinical effec-
tiveness in a sample of POTT postgraduates.
The generated theory revealed that postgradu- P
ates developed a purposeful therapeutic pres-
ence; participants believed that their presence,
way of being, and the way that they provided
therapy had been transformed. The therapeutic
stance they embodied was self-accepting,
self-aware, compassionate, empathic, and
grounded. Therefore, they believed that the ther-
apy they provided was decisive, thoughtful,
compassionate, self-aware, and connected to
self. These findings suggest that the gains stu-
dents make as a result of the training carried over
to their clinical work postgraduation. Additional
studies on POTT are currently being conducted;
POTT is being studied as a training that pro-
motes self-care in therapists, and there is also
an outcome study on its way (supported by a
grant from the American Foundation for Suicide
Prevention).
2192
Case Example
A student’s final paper written at the end of the
year’s training helps to bring to life the concept of
the POTT Model. Portions are quoted here with
accompanying commentary. The student is a sin-
gle Caucasian woman in her 20s, called here Vic-
toria, who evolved from a quiet, retiring presence
at the beginning of the academic year into an
intensely involved and articulate participant in
the class dynamics by the end of the course. Her
clinical practicum was in a medical setting. Some
aspects of her paper are altered to protect her
identity. With respect to this paper, she wanted
to give voice to her words for reasons that will
become evident. For the purpose of this end-of-
the-year assignment, students were asked to iden-
tify their signature themes and to provide a clini-
cal example of how they used their emotional
vulnerabilities and life experience to lend human-
ity, sensitivity, and power to their clinical work as
specifically related to the therapeutic relationship,
assessment, and interventions. Victoria’s voice is
presented in italics.
This week’s [class] presentation [observing the
supervision of a student’s session with a family
simulated by actors] related to my signature theme
of not being “good enough,” as well as my deriva-
tive issue of unintentionally withdrawing from situ-
ations. . . Given that over the years I have become
much more accustomed to being silent, I have real-
ized [during the POTT course] that I withdraw
during two extremes: when I am completely over-
whelmed or when the session is moving somewhat
slow. . . I know this default to silence is the result of
years of being forced to accept what is happening to
me, as well as being criticized by my family for
standing up for myself. Therefore, I have been
almost crafted by my family to be “seen and not
heard,” which has certainly transferred into my
abilities as a therapist. I feel as if my voice has
been lost, and I am slowly taking it back, which is
uncomfortable for most people, and scary for
myself. . .
Growing up, I did not have a voice. I was worth-
less because when I was not being raped by my
cousin, I was being criticized/verbally abused by
my parents. I learned quite early to not make a
sound, not have any emotion, and to do whatever
was necessary to protect myself. Therefore,
I essentially learned to be a “robot” – do as I am
told and do not question it. The only difference,
though, is that I did have emotions, I did have things
Person of the Therapist Training Model, The
I needed to say, but I kept it all inside. . . This
default, therefore, seems to be one of the main
struggles I have when trying to connect with indi-
viduals, as well as when I assess and intervene. I am
so used to being criticized, taken advantage of, and
truthfully, hurt, that my body keeps itself quiet in
order to protect itself from what could happen.
At the beginning of the course, Victoria did not
reveal the extent of her childhood trauma and
abuse. As the class process progressed, she felt
safer to share more of her story. Students are told
up front that they should only reveal what they
feel comfortable sharing and what they think
about themselves that may have an impact on
their clinical work. As students take turns pre-
senting to the class leaders on their signature
themes, they have a chance to experience their
issues treated as “normal” to the human condition
and as potential assets to their capacity to under-
stand and relate to their clients’ “woundedness.”
In terms of relationship [with clients] in my clinical
work, I know I have to believe in myself, trust my
instincts, and believe my voice is important and has
meaning if I am going to work through this self-
inflicted silencing. . . I know I can obviously talk
with anyone, but actually making the connection
and being vulnerable is quite another story. . . As
for assessment and intervene [sic], I still struggle at
times with knowing what to do with all of the intense
emotions I feel during sessions. Again, I have a
difficult time putting what my mind is thinking and
what my heart is feeling into words. . . I am con-
stantly doubting my knowledge, thereby silencing
myself because that is all I have ever
known – defeat, silence, violence, criticism.
Victoria was in personal therapy during the time
she was in class, but here she is addressing her issues
in the context of her clinical work. She grappled
with her issues in class with the support and under-
standing of the class leaders, along with what she
reflected about herself when witnessing other stu-
dents in the small class (ten) speaking to their per-
sonal pain and struggles. All this gave her
perspective and helped normalize her own sense of
what it means to struggle with personal issues, even
extremely sensitive and painful ones within the
context of the therapeutic process with her clients.
The clinical example I will provide is of an 82-year-
old African American woman, who came to the
surgery clinic to discuss getting a biopsy of her
right breast. This woman is divorced, has one living
Person of the Therapist Training Model, The
son. . . as well as one deceased son, who was a
firefighter and died during service. [She] is receiv-
ing social security, although she does work from
time to time. If I had to describe [her] in one word, it
would be sass – then maybe passive
aggressive – but I love it because she certainly put
the one resident at the clinic (who is extremely
condescending) in his place. This woman was
extremely vocal, suspicious of [these] two white
individuals coming into the room . . . and certainly
did not like to be asked a question more than once.
To be completely honest, I was incredibly intimi-
dated at first – I seriously thought I was just going
to leave the room when the resident left, and not
engage my usual routine of joining, assessing,
intervening, etc., but I caught myself wanting to
withdraw, and therefore forced myself to try to
build a connection with [her], which I think I was
able to do successfully.
Victoria, whose most difficult challenge is to
engage and speak up to a powerful individual, was
able to confront the racial tension in the room and
force herself not only to stay in the room with her
client but to be genuinely, personally present with
her. She dug further within herself and discovered
a deeper level of personal challenge to her desire
to form a real human connection with her client.
She was mobilizing all she had learned about
opening herself within herself as she strove to
achieve a real human connection with her client.
As for the [therapeutic] relationship, I felt myself
wanting to keep this woman at a distance because
she seemed rather abrasive, and uncomfortably like
my father. . . But [she] asked me an interesting
question that honestly took me by surprise and
seemed somewhat out of the blue. . . “Why are you
doing this [therapy]?” In the few, brief seconds it
took me to respond, I asked myself if I should be
vulnerable – tell the truth – if I should just give some
made-up answer to quell her concerns. And I chose
the former – be vulnerable. Considering that [she]
is much older than me, I felt that out of respect (and
that perhaps she was looking for a human connec-
tion in the hospital), I literally said this to her: “I
have danced with the darkness most of my life, and
left myself feeling hollow through silence, so
I decided to be the lighthouse the Ramsays are
searching for” (Virginia Woolf reference). And this
woman understood – she happened to be a Virginia
Woolf fan. I know that I may have been disclosing
too much, but I thought knowing why I wanted to be
a therapist would enable [her] to trust me, which it
did. That moment also enabled me to trust myself,
which helped the conversation to blossom. . . [Her]
anger completely melted, and it was a beautiful
2193
thing to see. I saw [her] this past week, and once
again, while she was short with everyone else, we
held hands, checked in real quick (because her
biopsy results were supposed to have been com-
pleted by pathology and they were not), and wished
each other the best with a hug.
Victoria allowed herself to come in touch
with the social and personal walls within her that
stood in the way of her risking an authentic rela-
tionship with her client and had the will and cour-
age to selectively risk sharing something
profoundly personal of herself, which she intui-
tively felt would touch this woman. She was well
aware of her learning in class that the relationship
is the sine qua non condition to engage the thera-
peutic process. It is the door that opens the thera-
pist to reliable assessment and effective
intervention.
As for assessment and intervention, I did not feel
like my voice was not valued, internally or exter-
nally, which made it easier and more motivating to
speak and just discuss the client’s life. I did not feel
the internal battle that surrounds being vulnerable
and using my voice. . . I just felt – freedom. Freedom
to speak what I was thinking, even if I was fuzzy and
unsure about certain things, freedom to ask ques-
tions about her life, freedom to infuse some of my
sense of humor during the session (which
worked – she laughed). Ultimately, just freedom to
be myself as a therapist who is wounded, but wants
badly to help others. . . This was an incredible
experience because I was able to track my emotions P
during the assessment (which surprisingly did not
include feeling overwhelmed), as well as attain
great confidence when intervening.
The intervention that felt most natural and gen-
uine was when I normalized this woman’s fear of
having cancer. Given what I have previously said
about [her], about being aggressive and confron-
tational with the resident, one would not imagine
fear being underneath. However, I know this game
very well because I play it myself. With certain
individuals, such as my parents . . ., anger, frustra-
tion, and confrontation are the visible feelings,
while fear – fear of abandonment, fear of being
hurt, fear of being genuine – are the issues that
hide deeper. And I saw this woman. I saw in her
eyes, because I have seen those same eyes in the
mirror staring back so often. I tried my best to
normalize this fear, and I told [her] that she needs
to have compassion for herself because even though
she is in her 80s, cancer is still frightening. When
I said that, of course I was thinking of my own
shortcomings in having compassion for my younger
self, but instead of thinking of the situation
2194
negatively (which I normally do), I saw it in a
positive light because I honestly (and finally)
believe that I deserve and am worthy of that com-
passion. So, I truly believe I was genuine when
I said that statement to [her]. I felt it inside of me,
that it came from my soul, as opposed to my
head – I believed and finally felt it – which I think
is another step in removing the chains that have
paralyzed me for so many years. Little by little, the
layers are opening and embracing recovery, which
is a step in the right direction, I think. This woman,
without even knowing it probably, pushed me to be
vulnerable, which I truly appreciate and am grate-
ful for.
Victoria was able to put into practice what we
had worked for all year that “therapy is not a
conversation, but an experience.” She had
achieved a level of comfort with herself, with all
of her past pain and hurts, that she could be so
selectively vulnerable that she could see herself in
this woman who was so different from her, in age,
race and temperament. While well-grounded in
her own journey, she could see elements from it
that opened her eyes and heart to the woman’s
own vulnerability, enabling the therapeutic pro-
cess to reach deeply into a powerful experience
for both therapist and client.
References
Apolinar Claudio, F. (2016). Perceived impact of Person-
of-the-Therapist Training (POTT) model on Drexel
University Master of Family Therapy postgraduates’
clinical work: A grounded theory study. Unpublished
Dissertation.
Aponte, H. J., & Kissil, K. (Eds.). (2016). The person of the
therapist training model: Mastering the use of self.
New York: Routledge.
Aponte, H. J., & Winter, J. E. (2013). The person and
practice of the therapist: Treatment and training. In
M. Baldwin (Ed.), The use of self in therapy (3rd ed.,
pp. 141–165). New York: Routledge.
Aponte, H. J., Powell, F. D., Brooks, S., Watson, M. F.,
Litzke, C., Lawless, J., & Johnson, E. (2009). Training
the person of the therapist in an academic setting.
Journal of Marital and Family Therapy, 35, 381–394.
Bowen, M. (1972). Toward a differentiation of a self in
one’s family. In J. L. Framo (Ed.), Family interaction
(pp. 111–173). New York: Springer.
Freud, S. (1910). Future prospects of psychoanalytic ther-
apy. In J. Strachey (Ed.), The standard ed. of the com-
plete works of Sigmund Freud (pp. 139–151). London:
Hogarth.
Personality in Couple and Family Therapy
Niño, A., Kissil, K., & Aponte, H. J. (2014). Exploring the
person-of-the-therapist for better joining, assessment,
and intervention. In R. A. Bean, S. D. Davis, & M. P.
Davey (Eds.), Increasing competence and self-
awareness (pp. 9–13). Hoboken: Wiley.
Niño, A., Kissil, K., & Apolinar Claudio, F. (2015). Per-
ceived professional gains of master level students fol-
lowing a Person of the Therapist Training Program:
A retrospective content analysis. Journal of Marital
and Family Therapy, 41(2), 163–176. https://doi.org/
10.1111/jmft.12051.
Satir, V. (2000). The therapist story. In M. Baldwin (Ed.),
The use of self in therapy (2nd ed., pp. 17–28).
New York: Haworth.
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009).
Common factors in couple and family therapy: The
overlooked foundation for effective practice.
New York: Guilford.
Personality in Couple and
Family Therapy
Jeffrey J. Magnavita
Glastonbury, CT, USA
Introduction and Generic Concepts
We are fascinated with other people and ourselves,
wondering why we behave in certain predictable
and unpredictable ways. We are curious about our
similarities and unique differences. What attracts us
to our mates? What makes some relationships stand
the test of time and others falter and dissolve? Why
do children from the same family often show dra-
matic variations in behavior and characteristics?
Who we are – how we think, feel, perceive the
world, relate to others, make meaning out of the
world, and our identity – are all components of our
personality. The concept of personality has been
central to the science of psychology, as well as
fundamental to the practice of psychotherapy.
Humankind’s interest in personality likely began
not far from our inception and development of con-
sciousness and has evolved over thousands of years.
Over the past century and half, our understanding of
personality and disorders of personality has
advanced dramatically. We will review some of the
essential developments.
Personality in Couple and Family Therapy
The construct of personality continues to
evolve over time, and various theories of person-
ality have been developed, some of which have
gone out of favor as new scientific evidence has
accrued. Evidence of interest in personality is
found in earliest documented history. Early Egyp-
tians showed a fascination for a link between the
uterus and emotionality, later called hysteria by
the Greeks (Alexander and Selesnick 1966).
Later, the Greeks developed a theory of personal-
ity based on four humors, elements of which can
be seen in some contemporary biological and
psychological personality theories (Millon and
Davis 1996). Approaches to treatment were also
developed and practiced. The Egyptians utilized a
system of treatment based on soul-searching on
the part of ill patients (Alexander and Selesnick
1966). The use of the word psychotherapy was
first seen in the writings of Hippolyte Bernheim
(1891) in his work entitled Hypnotisme, Sugges-
tion, Psychotherapie (Jackson 1999). It is impor-
tant to keep in mind when we review
contemporary treatment, later in this entry, that
in order to understand and effectively address
personality dysfunction in clinical practice, in
addition to grounding in theories of personality,
one must also have an understanding of
psychopathology – including diagnostic systems
and of course models of treatment. We continue
with brief review of theories of personality. So
keep in mind that understanding and treating per-
sonality in couple and family therapy requires
broad knowledge of personality theories, ground-
ing in psychopathology and psychodiagnositics
(including individual and systemic), an under-
standing of how personality is expressed and
becomes dysfunctional in family and social sys-
tems, and finally knowledge and training in
approaches to treatment. We begin with a brief
review of personality theories.
Theories of Personality and Prominent
Associated Figures
There are a number of theories of personality,
developed by various pioneering figures, which
have been developed and continue to be useful to
2195
understanding personality. The major theoretical
models of personality include psychodynamic,
interpersonal, behavioral, cognitive, neurobiolog-
ical, systemic, and factor models, which are more
descriptive in nature (Magnavita 2012). These
include the following:
(1) Psychodynamic/psychoanalytic models of per-
sonality. Sigmund Freud (1966), who was the
founder of psychoanalysis, undertook the most
ambitious articulation of personality in the early
twentieth century. His psychoanalytic or psy-
chodynamic theory sought to discover the intra-
psychic dynamics of how our minds operate
and influence our behavior, as well as forms of
psychopathology. His theory of personality was
based on his postulation that humans progress
through various stages of psychosexual devel-
opment and the way in which these are navi-
gated and resolved shape our personality.
Ultimately this aspect of his theory was not
substantiated, and yet many aspects of his com-
prehensive theory such as his notion that most
of what drives our behavior is unconscious or
part of our implicit memory system has been
supported by neuroscientific findings (LeDoux
2015). In essence, this model postulates that our
character traits cohere into our unique personal-
ity, influenced by genetics and development.
Psychodynamic theory emphasizes intrapsychic P
structures that occur in the domain of an indi-
vidual’s mind and brain.
(2) Interpersonal models of personality. Emerg-
ing in part from dissatisfaction with the
emphasis in psychoanalytic theory on intra-
psychic process, interpersonal theorists, the
most notable of who are Harry Stack Sullivan
(1953), Timothy Leary (1957), and later
Lorna Smith Benjamin (1996), sought to
understand the way in which personality is
shaped by our relationships. Our patterns of
relating to others become stable over time,
cohering into relational schemata, thus shap-
ing our current and future relationships. Inter-
personal theory emphasizes dyadic
relationships. This dyadic lens widens the
frame offering insight in the ways in which a
couple dynamics operate.
2196
(3) Behavioral models of personality. Behavior
theory pioneered by B. F. Skinner (1953),
John B. Watson (1913), and Edward Thorn-
dike (1931) emphasized the need to empiri-
cally build a science of behavior based on
observable and thus measureable phenome-
non. Behavior theorists eschewed the notion
of personality and instead built a paradigm of
human behavior based on the contingencies
that create habits and patterns of behavior. So
while the concept of personality is not recog-
nized, personality is essentially complex habit
patterns, which operate under the principles of
learning. Learning is represented by two
essential types of conditioning – classical
pioneered by Ivan Pavlov (1927) and instru-
mental or operant by Thorndike and Skinner –
and were viewed as the building blocks of all
behavior, and by understanding the contin-
gencies between stimuli, response, and rein-
forcement, the patterns of more complex
behavior could be understood. The domain
level of the behaviorist primarily represents
the brain-environment interaction.
(4) Cognitive and cognitive-behavior models of
personality. Pioneers such as Albert Ellis
(1961), Aron Beck (1975, Beck et al. 2003),
and others created a revolution when they
introduced the idea that between the stimulus
and response studied by behaviorist, there also
existed beliefs that shaped behavior. This the-
oretical development emerged in part from
cognitive science with its emphasis on infor-
mation processing. These cognitions encoded
in us from early in life become templates that
are enduring and create a consistent self called
early maladaptive schema (Young et al. 2003).
There are various cognitive schema identified
by Beck et al. (2003) and Young (1999) that
describe the common beliefs, which cohere
into somewhat fixed schema that account for
personality dysfunction.
(5) Systemic models of personality. A revolution
occurred in the 1950s when information sci-
ence, cybernetics, and system theory were
emerging from computer science. A major
paradigmatic shift occurred changing our
understanding of complex phenomenon with
Personality in Couple and Family Therapy
Ludwig von Bertalanffy’s (1968) formulation
of system theory. Angyal (1941) was the first
theorist who introduced the concept of “per-
sonality system” and wrote:
Personality can be regarded as a hierarchy of sys-
tems. In the larger personality organization the sig-
nificant positions are occupied by constituents
which themselves are also systems; the constituents
of the secondary system may also be systems; and
so on. Thus, personality may be considered as a
hierarchy with the total personality at the top;
below it follow the subsystems of the first order,
second order, third order, and so on. When one
studies connections in such a hierarchy from the
dynamic point of view, it is useful to distinguish
the dynamics within a given subsystem and
between systems of different orders. (pp. 286–287)
Angyal also emphasized the cultural aspects of
personality, and Bronfenbrenner (1969) cre-
ated a nested structure framework of the total
ecological system allow us to categorize and
view systems from micro- to macrostructures
and processes. These nested structures are like
Russian dolls with each domain enveloped and
interacting with others.
System theory has been adopted by a num-
ber of personality theorists to better understand
the interrelationships among the component
domains of personality (Mayer 2004, 2005,
2006; Magnavita 2005). In these models, per-
sonality is seen as a system embedded and
expressed in various domains. Personality sys-
tematics (Magnavita 2005b, 2011) was applied
to the study of personality and is the term used
to describe the ways in which the component
domains of various levels of the
biopsychosocial system operate, continually
shaping the expression of personality.
(6) Neurobiological models of personality. Neu-
roscience has advanced our understanding of
the neurobiological underpinnings of human
behavior and personality (LeDoux 2002).
While Freud sought to establish a scientifi-
cally grounded theory of personality based
on brain science, he realized that the tools,
which were later developed by neuroscien-
tists, had not yet sufficiently advanced for
that purpose. There are a number of theories
of personality that have emerged from this
Personality in Couple and Family Therapy
neurobiological perspective. The most prom-
inent neurobiological models of personality
are in essence factor theories, which posit
that certain underlying brain systems – struc-
tures, circuits, and neurotransmitters – are
dominant in each of us and serve as the sub-
strate for our personality traits (Buss and
Plomin 1975; Depue 1996; Cloninger 1986).
These models represent initial attempts to
show how the brain circuits influence the
expression and shape of personality. Contem-
porary neuroscience, using more sophisti-
cated tools, has contributed to our
understanding of many important component
systems upon which our behavior is
expressed. Neuroscientists have made
remarkable advances in illuminating impor-
tant underlying circuits that are responsible
for our emotions, anxiety, defensive patterns,
and responses to stress (LeDoux 2015).
(7) Factor models of personality. Taking a differ-
ent approach from the theories presented, fac-
tor models offer a different lens to view
personality and personality disorders (Costa
and Widiger 2002). Based on a vast amount of
research, the basic elements of personality
tend to cohere around three to five basic fac-
tors, with the Five-Factor Model the follow-
ing well-established factors – extraversion,
agreeableness, conscientiousness, neuroti-
cism, and openness to experience (McCrae
and Costa 1987).
Psychopathological Expressions: Personality
Dysfunction and Disorders
The study of personality disorders or dysfunc-
tional personality began in earnest in the 1980s
in part fueled by the development of the modern
diagnostic and classification system of mental
disorders (APA 1980), which offered a separate
category called Axis II to diagnose personality
disorders and articulated nine types in three clus-
ters (Cluster A, paranoid, schizoid, schizotypal;
Cluster B, borderline, narcissistic, antisocial; and
Cluster C, avoidant, dependent, obsessive-
compulsive). The more severe being Cluster A,
then B, with C usually the least severe form.
Others which many find clinically useful such as
2197
passive-aggressive were excluded. This atheoret-
ical categorical system spawned a fruitful period
of research and the development of a number of
approaches to the treatment of personality disor-
ders (Magnavita 2004). A personality disorder is
characterized by patterns of thought and behavior,
which is fixed over time and can include distur-
bances in emotional regulation, interpersonal rela-
tions, identity, perception, and thinking. As stated
they range in severity from milder to severe man-
ifestations. Since personality evolves over time,
and during adolescence can be unstable, the for-
mal diagnosis of personality disorder was primar-
ily used for adults, but exceptions could be made
for children and adolescents.
Personality Dysfunction in Children and
Adolescents
The diagnosis of personality disorders in children
and adolescents is a somewhat controversial issue
(Freeman and Reinecke 2007). Personality dys-
function, which in part may be fueled by
unresolved trauma, seems to be transmitted from
generation to generation in a multigenerational
transmission process. Whether a clinician
believes in the formal diagnosis or personality
disorders or not, it is nevertheless useful to utilize
a systemic framework for understanding expres-
sions of maladaptive behavior, which appear fixed
and are expressed in multigenerational patterns. P
While it is beyond the scope of this entry to more
fully articulate and review, it should be noted that
trauma is seen by many as the pathway to person-
ality dysfunction and the family systems which
perpetuate these relational patterns should be
identified and treated often using a trauma-
focused treatment as part of the approach
(Magnavita 2007). These being said, one must
also take into account the neurobiological basis
of temperament and how these interrelate to care-
givers, thus forming various attachment systems
and types.
Approaches to Treatment and Psychotherapy
of Personality Dysfunction
Emerging from the various theories of person-
ality are approaches to psychotherapy (Lebow
2008). A number of treatment of evidence-
2198
based treatment approaches have been devel-
oped and include Cognitive-Behavioral Ther-
apy (CBT), Dialectic Behavior Therapy (DBT)
(Linehan 1993), Cognitive Therapy (Beck and
Freeman 1990), Mentalization-Based Treatment
(Bateman and Fonagay 2016), Transference-
Focused Therapy (Yeomans et al. 2002), and
Short-Term Dynamic Therapy (STDP)
(Davanloo 1980; Magnavita 1997; Messer and
Abass 2010). It should be underscored that the
treatment of personality disorders using couples
and family modalities of treatment is still in
early stages of development. The predominant
modality (i.e., individual, group, couples, fam-
ily) for treating personality disorders is individ-
ual psychotherapy followed by group
psychotherapy.
Treating Personality and Personality
Disorders in Couples and Family Therapy
The field of family therapy until recently, by in
large, did not view the construct of personality
as essential (MacFarlane 2004). This may
derive from the assumption made by many pio-
neers in system theory that individual psycho-
pathology is an expression of systemic
dysfunction and needs to be understood in con-
text. However, a more flexible approach has
evolved. Overall, the use of couple and family
therapy to address those with personality dys-
function relies on annexing various elements of
a spectrum of approaches (Lancucci and Foley
2014). Domain systems and subsystems such as
the attachment, defense, affective, cognitive,
interpersonal shape and alter the expression of
personality (Magnavita and Anchin 2014).
More recently, clinical theorists have begun to
recognize the importance of having an under-
standing the interrelationships among intrapsy-
chic, interpersonal, triadic, and sociocultural
domains of personality. Interventions include
various techniques from a spectrum of
evidence-based approaches and from broad cat-
egories of defensive, affective, cognitive,
dyadic, triadic, and mesosystem restructuring
(Magnavita and Anchin 2014). This unified
Personality in Couple and Family Therapy
framework affords clinicians the flexibility
of shift frames from the micro-viewing intrapsy-
chic processes to increasingly more
macro-dyadic, triadic, and sociocultural
(Magnavita 2005).
Couples Therapy for Personality Dysfunction
Based on anecdotal evidence and accumulated
case reports, it is likely that a high percentage of
couples with chronic conflict suffer from person-
ality dysfunction. Most of those who have person-
ality dysfunction also suffer from interpersonal
difficulties (Lebow and Uliaszek 2010). It has
been reported in the literature that individuals
with personality dysfunction often attract partners
who also suffer from these disorders. While there
are currently no evidence-based approaches to
treating personality dysfunction using couples
psychotherapy, there have been a spectrum of
approaches, which have been documented, and
these are primarily integrative and unified
approaches. These approaches share a systemic
foundation which blends and flexibly incorporates
various components, techniques, and methods
from the many approaches. Most approaches fol-
low a standard format: “(1) engagement (i.e.,
establishing a working therapeutic alliance),
(2) assessment and formulation, (3) rebalancing
the couple relationship, (4) modifying individual
dynamics, and (5) maintenance and termination
(Sperry 2004, p. 155)”.
Family Therapy for Personality Dysfunction
Just as there may be a higher incidence of per-
sonality dysfunction in couples with severe and
chronic conflict, dysfunctional family systems
of which various types have been identified
(Magnavita 2002) may also upon closer inspec-
tion have members who suffer from the spec-
trum of personality disorders along with
co-occurring clinical syndromes (Magnavita
and Macfarlane 2004). Some clinical innovators
have developed innovative approaches using
family therapy to treat borderline personality
(Everett et al. 1989). The family system can
provide “a stable holding environment that can
Personality in Couple and Family Therapy
mitigate some of the difficulties associated with
PDs” (Lebow and Uliaszek 2010, p. 195). Fam-
ily therapy shows promise as a vital but
underutilized modality in the treatment of per-
sonality dysfunction. The family system offers a
rich matrix to observe and model new forms of
more adaptive communication and to alter the
processes that give rise to personality dysfunc-
tion through the selected use of various types of
restructuring.
Psychoeducation
A critical part of working with family systems with
individual suffering from personality dysfunction
includes an emphasis on psychoeducation. Treat-
ments that better educate family members in
understanding and responding appropriately and
compassionately seem to be useful. Many clinicians
work with personality dysfunction using individual
psychotherapy and ignore the impact on both
the family as well as the family on the individual.
A systemic approach affords clinicians the opportu-
nity to understand the bidirectional nature of
personality expression within the component
domain systems.
The Bidirectionality Between Individual
Personality and Family System
The formal classification of personality disor-
ders emerged in the 1980s with the publication
of the Diagnostic and Statistical Manual of
Mental Disorders by the American Psychiatric
Association (1980) resulting in resurgence of
research and novel approaches for treating per-
sonality disorders. This increased interest in
identifying and treating personality, along with
greater research funding, led to a rapid growth
in the field. Along with this trend occurred
increased public awareness and understanding
of personality disorders. A number of books
have been published for the lay public providing
psychoeducation for those who believe they are
in a relationship or have a family member who
suffers from personality disorder. There is accu-
mulating evidence that in families with mem-
bers diagnosed with personality disorder, there
2199
is a higher incidence of family conflict, sexual
abuse, and neglect (Magnavita 2004). It is
apparent that families with members suffering
from personality dysfunction create challenges
for various system including the family and
social systems.
Clinical Example of Application of
Theory in Couple and Family Therapy
The couple in their 50s entered treatment
because of marital conflict and concerns about
their children’s behavior. During the course of
the initial session, a history of the dyadic issues
was taken and indicated that the husband who is
a CEO of a large company was irritable, con-
trolling, and demanding of his wife’s attention
to the point that she had began to withdraw and
feel inadequate. The couple’s three children
were highly achieving students who were suf-
fering from an array of behavioral, anxiety, and
eating disorders. The husband was adamant
about his perception that if his wife was not
functioning at the level he expected and that
she needed to be more responsive to his needs
and family responsibilities. Further history of
the husband and wife revealed that the husband
lost his father when he was 6 years old and was
elevated to a position in his family of the ideal- P
ized son who would meet the needs of his griev-
ing mother while being constantly showered
with love and affirmed about his brilliance and
exceptionality. The wife at an early age became
the emotional caretaker of her alcoholic mother,
which resulted in a reversal of the parent-child
dyad and a state of neglect for her daughter. At
first, they were an “ideal match,” as she was able
to devote her emotional resources to
co-regulating her husband devoting her energy
to meeting his needs. Their relationship began
to gradually decline with the arrival of each
child who took more of the resources and shifted
the dynamics of the dyad. She felt more
neglected and increasingly withdrawn in
response to his narcissistic demands.
2200
This configuration of a person with a narcissis-
tic personality dysfunction paired with a partner
with dependent or borderline personality dysfunc-
tion is common. The results of these pairing often
lead to ongoing marital conflict with multiple
symptom expressions such as anxiety, depression,
and substance abuse and relational disturbances
such as extramarital affairs, as each of them seek
to meet their needs. The first stage of treatment
was to engage the couple in a process of self and
other exploration in a safe space. As the couple is
able to establish a safe mode of communication
with the co-regulation of the therapist, other treat-
ment modalities can be offered. In this case, a
combination of individual psychotherapy, couples
therapy, and family therapy can be used to assist
the family members in advancing personality
adaptation and developing greater capacity for
intimacy and closeness. Various approaches to
psychotherapy can be utilized in a unifying frame-
work to address the specific needs of each member
of the system as they emerge.
Challenges and Ethical Issues
The treatment of personality dysfunction and in
particular the more severely personality-
disordered individual presents many challenges
for the clinician. Using multiple modalities such
as individual, couple, group, and family can
engender intense feelings in members of the
system. It is of utmost importance to be cogni-
zant of ethical issues (Magnavita et al. 2010).
While there are inherent challenges that are
inevitable when undertaking a course of indi-
vidual psychotherapy, adopting a systemic
approach using other modalities such as couples
and family therapy certainly increases complex-
ity, and it is critical to be well versed in clinical
decision-making (Magnavita 2016). The com-
prehensive treatment of personality dysfunction
is likely to be multisystematic using various
treatment modalities, elements of various
approaches, with a keen eye toward maintaining
a therapeutic alliance and identifying ruptures
when they can occur so they can be mended
(Muran et al. 2010).
Personality in Couple and Family Therapy
References
Alexander, F. G., & Selesnick, S.T. (1966). The history of
psychiatry: an evaluation of psychiatric thought and
practice from prehistoric times to present New York:
Harper & Row.
American Psychiatric Association. (1980). Diagnostic and
statistical manual of mental disorders (3rd ed.).
Washington, DC: Author.
Angyal, A. (1941). Foundations for a science of personal-
ity. New York: Commonwealth Fund.
Batemen, A., & Fonagy, P. (2016). Mentalization-based
treatment for personality disorders: A practical guide.
Oxford: Oxford University Press.
Beck, A. T. (1975). Cognitive therapy and emotional dis-
orders. Madison: International Universities Press, Inc.
Beck, A. T., Freeman, A., Davis, D. D., & Associates
(2004). Cognitive therapy of personality disorders
(2nd ed.). New York. The Guilford Press.
Beck, A. T., Freman, A., & Associates (1990). Cognitive
therapy of personality disorders. New York: Guilford
Press.
Beck, A. T., Freedman, A., & Davis, D. D. (2003). Cogni-
tive therapy of personality disorders. New York:
Guilford Press.
Benjamin, L. S. (1996). Interpersonal diagnosis and treat-
ment of personality disorders. New York: Guilford Press.
Bernheim, H. (1891). Hypnotisme, suggestion,
pscyhotherapie: Etudes nouvelles. Paris: Octave Doin.
Bronfenbrenner, U. (1969). The ecology of developmental
process: Experiments by nature and design. Cam-
bridge, MA: Harvard Press.
Buss, A. H., & Plomin, R. (1975). A temperament theory of
personality development. New York: Wiley.
Cloninger, C. R. (1986). A unified biosocial theory of
personality and its role in the development of anxiety
states. Psychiatric Developments, 3, 167–226.
Costa, P. T., & Widiger, T. A. (Eds.). (2002). Personality
disorders in the five-factor model of personality
(2nd ed.). Washington, DC: American Psychological
Association.
Davanloo, H. (1980). Intensive short-term dynamic psy-
chotherapy. New York: Jason Aronson, Inc.
Depue, R. A. (1996). A neurobiological framework for
the structure of personality and emotion: Implica-
tions for personality disorders. In J. F. Clarking &
M. F. Lenzenweger (Eds.), Major theories of person-
ality disorders (pp. 347–390). New York: Guilford
Press.
Ellis, A. (1961). A guide to rational living. Englewood
Cliffs: Prentice-Hall.
Everett, C., Halperin, S., Volgy, S., & Wissler, A. (1989).
Treating the borderline family: A systemic approach.
San Diego: The Psychological Corporation.
Freeman, A., & Reinecke, M. A. (Eds.). (2007). Personal-
ity disorders in childhood and adolescence. Hoboken:
Wiley.
Personality in Couple and Family Therapy
Freud, S. (1966). The complete introductory lectures on
psychoanalysis (Ed. and trans: Strachey, J.). New York:
Norton.
IN, J. J. Magnavita (Ed.). Evidence based treatment of
personality (pp. 193–221). Washington, DC: American
Psychological Association.
Jackson, S. W. (1999). Care of the psyche: A history of
psychological healing. New Haven: Yale University
Press.
Lancucci, J., & Foley, G. (2014). Couples therapy:
Treating selected personality disordered couples within
a dynamic framework. Innovations in Clinical Neuro-
science, 11, 3–4.
Leary, T. (1957). Interpersonal diagnosis of personality:
A functional theory for personality evaluation.
New York: Wiley.
Lebow, J. (Ed.). (2008). Twenty-first century psychother-
apies: Contemporary approaches to theory and prac-
tice. Hoboken: Wiley.
Lebow, J. L., & Uliaszek, A. A. (2010). Couples and family
therapy for personality disorders. American Psycho-
logical Association, Washington DC.
LeDoux, J. E. (2002). Synaptic self: How our brains
become who we are. New York: Viking.
LeDoux, J. E. (2015). Anxious: Understanding the brain to
understand and treat anxiety fear and anxiety.
New York: Penguin Books.
Linehan, M. M. (1993). Cognitive-behavioral treatment of
borderline personality disorder. New York: Guilford
Press.
MacFarlane, M. M. (Ed.). (2004). Family treatment of
personality disorders: Advances in clinical practice.
Binghamton: The Haworth Press, Inc.
Magnavita, J. J. (1997). Restructuring personality disor-
ders: A short-term dynamic approach. New York:
Guilford Press.
Magnavita, J. J. (2002). Relational therapy for personality
disorders. Hoboken: Wiley.
Magnavita, J. J. (Ed.). (2004). Handbook of personality
disorders: Theory and practice. Hoboken: Wiley.
Magnavita, J. J. (2005a). Personality-guided relational
therapy: A unified approach. Washington, DC: Amer-
ican Psychological Association.
Magnavita, J. J. (2005b). Systems theory foundations of
personality, psychopathology, and psychotherapy. In
S. Strack (Ed.), Handbook of personality and psycho-
pathology (pp. 140–163). Hoboken: Wiley.
Magnavita, J. J. (2007). A systemic family perspective on
child and adolescent personality disorders. In A. Freeman
& M. A. Reinecke (Eds.), Personality disorders in child-
hood and adolescence (pp. 131–181). Hoboken: Wiley.
Magnavita, J. J. (2011). Reflections on personality system-
atics and a unified clinical science. In L. La‘Abate (Ed.),
Paradigms in theory construction (pp. 207–216).
New York: Springer.
Magnavita, J. J. (2012). Theories of personality. San
Diego: Bridgepoint Education, Inc.
2201
Magnavita, J. J. (Ed.). (2016). Clinical decision making in
mental health practice. Washington, DC: American
Psychological Association.
Magnavita, J. J., & Anchin, J. C. (2014). Unifying psycho-
therapy: Principles, process and evidence from clinical
science. New York: Springer.
Magnavita, J. J., & MacFarlane, M. M. (2004). Family
treatment of personality disorders: Historical overview
and current perspectives. In M. M. MacFarlane (Ed.),
Family treatment of personality disorders: Advances in
clinical practice (pp. 3–39). Binghamton: The Haworth
Press, Inc.
Magnavita, J. J., Levy, K. N., Critchfield, K. L., & Lebow,
J. L. (2010). Ethical considerations in the treatment of
personality dysfunction: Using evidence, principles
and clinical judgment. Professional Psychology:
Research and Practice, 41(1), 64–74.
Mayer, J. D. (2004). A classification system for the data of
personality psychology and adjoining fields. Review of
General Psychology, 8(3), 208–219.
Mayer, J. D. (2005). A tale of two visions: Can a new view
of personality help integrate psychology? American
Psychologist, 60(4), 294–307.
Mayer, J. D. (2006). Personality: A systems approach.
Durham: Rubber Duck Publishing.
McCrae, R. R., & Costa, P. T. (1987). Validation of the five-
factor model of personality across instruments and
observers. Journal of Personality and Social Psychol-
ogy, 52(1), 81–90.
Messer, S. B., & Abbass, A. A. (2010). Evidence-based
psychodynamic therapy with personality disorders. In
J. J. Magnavita (Ed.), Evidence-based treatment of
personality dysfunction: Principles, methods, and pro-
cess (pp. 79–111). Washington, DC: American Psycho-
logical Association.
Millon, T., & Davis, R. D. (1996). Disorders of Personal-
ity: DSM-IV and beyond (2nd ed.). Hoboken, NJ: John P
Wiley & Sons.
Muran, J. C., Eubanks-Carter, C., & Safran, J. D. (2010).
A relational approach to the treatment of personality
dysfunction. In J. J. Magnavita (Ed.), Evidence-based
treatment of personality dysfunction: Principles,
methods, and processes (pp. 167–192). Washington,
DC: American Psychological Association.
Pavlov, I. P. (1927). Conditioned reflexes: An investigation
of the physiological activity of the cerebral cortex.
(trans and ed.: Anrep, G. V.). London: Oxford Univer-
sity Press.
Skinner, B. F. (1953). Science and human behavior.
New York: The Free Press.
Sperry, L. (2004). Family therapy with a histrionic-
compulsive couple. In M. M. MacFarllane (Ed.), Fam-
ily treatment of personality disorders: Advances in
clinical practice (pp. 149–172). New York: The Haw-
orth Press, Inc..
Sullivan, H. S. (1953). Interpersonal theory of psychiatry.
New York: Norton.
2202
Thorndike, E. L. (1931). Human learning. New York: The
century company.
von Bertalanffy, L. (1968). General system theory: Foun-
dations, development, and application. New York:
Braziller.
Watson, J. B. (1913). Psychology as the behaviorist views
it. Psychological Review, 20, 158–177.
Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F. (2002). A
primer for transference- focused therapy for borderline
personality disorders. Northvale: Jason Aronson.
Young, J. E. (1999). Cognitive therapy for personality
disorders: A schema-focused approach (3rd ed.). Sara-
sota: Professional Resource Press.
Young, J. E., Klesko, J. S., & Weishaar, M. E. (2003).
Schema therapy: A practitioner’s guide. New York:
Guilford Press.
Perturbation in Couple and
Family Therapy
Ruoxi Chen, Jason P. Austin and Jarodd W.
Hundley
Marriage and Family Therapy and Counseling
Studies, University of Louisiana at Monroe,
Monroe, LA, USA
Name of Concept
Perturbation in Couple and Family Therapy
Introduction
Perturbation is a hallmark of many foundational
schools in couple and family therapy. Couple and
family therapists commonly use perturbing inter-
ventions in their clinical practice to challenge and
rebalance problematic couple and family dynamics.
Theoretical Framework
Grounded in cybernetic theory (Bateson 1972), per-
turbation leads to second-order change through a
shift in rule systems, resulting in the resolution of
the presenting problem(s). Perturbation is tradition-
ally associated with strategic, Mental Research Insti-
tute (MRI), and Milan family therapy approaches.
Strategic therapists often “perturb” family systems
with paradoxical prescriptions and/or directives, by,
Perturbation in Couple and Family Therapy
for instance, assigning clients ordeal tasks related to
but more severe than the problem they seek to
change (Haley 1984). MRI therapists employ
reframing or symptom prescription to interrupt cli-
ents’ problematic interactional sequences to force a
systemic reorganization (Fisch et al. 1982). Milan
family therapists use circular questions and counter-
paradox as interventions to disrupt what they term
“family games” (Palazzoli and Boscolo 1994).
Rationale
Following cybernetic theory, the therapist is an
outside force who intervenes in the family sys-
tem and observes the effect (Keeney and Ross
1983). A perturbing intervention often restricts
the behaviors in relation to the presenting prob-
lem, requiring members of the system to shift
how they respond to one another. Thus, the
underlying processes inherent in problematic
interactions between members are challenged
and renegotiated. This change establishes a
new homeostasis that enables members of the
system to confront their issues in a more flexible
manner, and to engage in more constructive
interactions. In comparison, from a structural
lens, a structurally plastic system undergoes
structural changes as it reacts to outside pertur-
bations, and such interactions alter the system’s
future behaviors (Dell 1985; Maturana 1975).
Description
A therapist may design a tailored intervention to
disrupt the current problematic homeostatic patterns
within a family system and challenge the members
of the system to negotiate a new way of interacting
with one another, effectively creating new norms.
Clients often present with problems or issues they
have failed to solve using normal emotional, behav-
ioral, and/or interactional strategies. Perturbations
can push the system into creating new rules, freeing
members from the restrictions of previous
governing rules.
In practice, a therapist would first approach the
clients with the goal of understanding their cultural
beliefs, the history of their presenting problem(s),
and their understanding of the role of these problems
Perverse Triangles in Family Systems Theory
in the system. The therapist observes the client
system’s interactional patterns in relation to the pre-
senting problems, such as the emotional and behav-
ioral responses of each member to one another when
the presenting problem surfaces. Based on these
observations, the therapist formulates systemic
hypotheses. The therapist focuses on the entire cou-
ple or family unit, not any client in isolation. After
identifying the problematic interactions, the thera-
pist then devises specific interventions to perturb the
family system.
Case Example
Consider the case of James, 10 years old, and his
parents, Greg and Sara. James contracted H1N1
when he was eight, falling severely ill and recov-
ering only after months of medical treatment. Since
his recovery, Sara experienced anxiety in relation
to James’ health, repeatedly taking him to the doc-
tor for evaluation and restricting his outside and
social activities, and eventually deciding to home-
school him. Sara, a small business owner, gradually
lost many of her business clients, and grew angry
with Greg for not sharing her concern with James’
health. James also started exhibiting behavioral
problems at home.
The therapist hypothesized that the underlying
assumption that Sara was the only person invested
in Greg’s health and capable of caring for Greg
appropriately was constricting the family system.
Hence, the therapist asked Greg to devote 2 h daily
to supervise James playing with other children at a
community recreational center while Sara focused
on her business. Greg’s task, more specifically, was
to actively monitor James’ health, noting any symp-
toms such as dizziness and nausea and recording
James’ temperature every half an hour. Both parents
agreed to their tasks. Sara later reported reduced
anxiety over James’ health, and feeling more
connected with Greg. She also reported progress
with her business and wanted to devote more time
to expand it. Sharing more time with his peers,
James’ problematic behaviors at home abated.
In this example, James’ severe illness disrupted
the system and created a problematic homeostasis.
The therapist redirected Sara to attend to her busi-
ness and Greg to assume a more involved role with
2203
James’ caretaking, thereby pushing the family into a
new homeostasis that enabled James’ growth and
development.
Cross-References
▶ Milan Systemic Family Therapy
▶ MRI Brief Family Therapy
▶ Strategic Family Therapy
▶ Structural Family Therapy
References
Bateson, G. (1972). Steps to an ecology of mind: Collected
essays in anthropology, psychiatry, evolution, and epis-
temology. Northvale: University of Chicago.
Dell, P. F. (1985). Understanding Bateson and Maturana:
Toward a biological foundation for the social sciences.
Journal of Marital and Family Therapy, 11, 1–20.
Fisch, R., Weakland, J. H., & Segal, L. (1982). The tactics of
change: Doing therapy briefly. San Francisco: Jossey-
Bass.
Haley, J. (1984). Ordeal therapy. San Francisco: Jossey-Bass.
Keeney, B. P., & Ross, J. M. (1983). Cybernetics of brief
family therapy. Journal of Marital and Family Therapy,
9, 375–382.
Maturana, H. R. (1975). The organization of the living:
A theory of the living organization. International Jour-
nal of Man-Machine Studies, 7, 313–332.
Palazzoli, M. S., & Boscolo, L. (1994). Paradox and
counterparadox: A new model in the therapy of the
family in schizophrenic transaction. New York: P
Rowman & Littlefield.
Perverse Triangles in Family
Systems Theory
Laura M. Frey
Couple and Family Therapy Program, Kent
School of Social Work, University of Louisville,
Louisville, KY, USA
Name of Concept
Perverse Triangles in Family Systems Theory
Laura M. Frey, Couple and Family Therapy Program, Kent
School of Social Work. University of Louisville.
2204
Introduction
Several family therapy approaches – Bowen’s
transgenerational model (Bowen 1981), struc-
tural family theory (Minuchin 1974), and stra-
tegic family therapy (Hoffman 1981) – use the
term triangle to describe a pathological interac-
tion pattern. While triangle primarily refers to a
three-person subsystem within the family, Jay
Haley used the term perverse triangle to repre-
sent a specific form of triangular dysfunction
within a system.
Theoretical Context for Concept
A perverse triangle has its roots in family systems
theory which proposes that families are interac-
tional systems that self-correct to maintain
homeostasis (Whitchurch and Constantine
1993). In other words, family members change
their behavior or interact in ways that provide a
sense of stability. This cyclical system utilizes
members’ interactions to indicate whether things
are calm and predictable (negative feedback) or
dynamic and necessitating adjustment (positive
feedback).
A triangle serves as a specific type of three-
person feedback system. Typically, a triangle
occurs when tension grows between two family
members. To reduce the tension, one person
brings in a third family member to form a dyad
within the triangle. This dyad likely takes the form
of confiding in a family member or asking that
family member to take one’s side in an argument.
For example, a son that has continually argued
with his wife may confide in his wife’s mother to
gain support. The mother-in-law then chastises
her daughter for not supporting her husband,
which leads the wife to acquiesce, thereby reduc-
ing the tension.
Description
Jay Haley (1967) described a perverse triangle
using three characteristics. First, two people
within the triangle must be from a different
Perverse Triangles in Family Systems Theory
generation than the third. The cross-generational
nature yields an unequal power dynamic among
the three members. Second, one individual must
form a coalition with one of the persons from a
different generation. Finally, the two people
involved deny the coalition exists. When these
characteristics are present, the perverse triangle
breaches the natural hierarchy in a covert way.
Haley (1967) argued that perverse triangles, if
left untreated, will generate a pathological family
system that experiences continual conflict, symp-
tomatic distress requiring community attention
(e.g., violence), or divorce.
Application of Perverse Triangles in
Couple and Family Therapy
Perverse triangles can be addressed using a vari-
ety of family therapy models. For both structural
and strategic approaches, techniques are used to
realign the hierarchy to place the parents con-
jointly above the children. Part of this process
involves making the perverse triangle overt (e.g.,
through family mapping), so that all family mem-
bers are aware of the coalition. Subsequent inter-
ventions could include enactments and
unbalancing techniques to reestablish clear
boundaries and effective communication. Strate-
gic interventions may focus on directives, ordeal
therapy, or pretend techniques to challenge mem-
bers’ automatic responses to one another. By
inserting new behaviors, the therapist hopes to
engage in a positive feedback loop that disrupts
homeostasis, which in turn will allow for new
behaviors that break the dysfunctional cycle
within the triangle.
Clinical Example
Sara and Lisa are married with a teenage daughter,
Rebecca. Sara and Lisa have recently been argu-
ing about Lisa’s job, which requires out-of-town
travel 2–3 weeks a month. Lisa’s absence is hard
on their relationship, causing frequent arguments.
Sara describes Lisa as emotionally unresponsive
when she tries to discuss her unhappiness. During
PFLAG
a family assessment, the therapist quickly learns
that Rebecca is very angry with Lisa. Rebecca
states she cannot understand why Lisa leaves her
family to “fend for themselves,” and the therapist
later uncovers that Sara has been relying on
Rebecca for emotional support in Lisa’s absence.
This week, when Lisa asked why Rebecca was
upset, Rebecca stated that she “would know what
was wrong if she was here.” Lisa suspected that
Rebecca knew that she and Sara had argued earlier
that day, but when Lisa confronted Sara about it,
she stated Rebecca “has a right to be mad if she
wants.”
The therapist quickly explains the presence of
a perverse triangle prevents Lisa and Sara from
reconciling their relationship and limits Lisa’s
ability to parent Rebecca. The therapist explicitly
details how Sara’s reliance on Rebecca’s emo-
tional support makes it hard for Rebecca to respect
and connect with Lisa herself. The therapist also
describes that Lisa feels betrayed when Sara con-
fides in Rebecca, causing her to be impatient
during their arguments. Additionally, the therapist
informs Lisa that her angry demeanor toward Sara
likely exacerbates Sara’s belief that Lisa is
unresponsive. After overtly discussing the effects
of the perverse triangle, the family agrees to con-
tinue family therapy in order to restore the hierar-
chy and strengthen their emotional connections.
Cross-References
▶ Coalition in Structural Family Therapy
▶ Detriangulation in Couple and Family Therapy
▶ Feedback in Family Systems Theory
References
Bowen, M. (1981). Family therapy in clinical practice.
New York: Jason Aronson.
Haley, J. (1967). Toward a theory of pathological systems.
In G. Zuk & I. Boszormenyi-Nagy (Eds.), Family ther-
apy and disturbed families (pp. 11–27). Palo Alto:
Science and Behavior Books.
Hoffman, L. (1981). Foundations of family therapy:
A conceptual framework for systems change.
New York: Basic Books.
2205
Minuchin, S. (1974). Families and family therapy. Cam-
bridge, MA: Harvard University Press.
Whitchurch, G. G., & Constantine, L. L. (1993). Systems
theory. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R.
Schumm, & S. K. Steinmetz (Eds.), Sourcebook of
family theories and methods: A contextual approach
(pp. 325–352). New York: Springer.
PFLAG
Craig Rodriguez-Seijas and Marvin R. Goldfried
Stony Brook University, Stony Brook, NY, USA
Name of Organization of Institution
PFLAG (formerly Parents, Families and Friends
of Lesbians and Gays)
Introduction
In 1972, Jeanne Manford carried a sign that read
“PARENTS OF GAYS UNITE IN SUPPORT
OF OUR CHILDREN” as she marched in the
New York City Gay Pride Parade. On March
26, 1973, Manford held a peer support meeting
for other parents – like herself – learning to deal
with their child’s coming out. From these hum- P
ble beginnings, representatives of several simi-
lar support groups came together in 1981 to
form Parents, Families and Friends of Lesbians
and Gays (PFLAG). Though the group has since
changed its name to simply PFLAG to more
accurately reflect its focus on inclusivity of sup-
port for all sexual and gender minorities,
PFLAG currently functions as a support net-
work, advocacy group, and public education
institution whose reach can be felt at both the
national and international levels.
The process of accepting a child’s disclosure
of an LGBTQ identity can indeed be a difficult
one and has been considered comparable to typ-
ical experiences of mourning, parallel to the
stages associated with the development of sex-
ual minority identity and similar to psychologi-
cal growth that follows a traumatic experience.
2206
Although family therapy is one means of
addressing such issues, support groups like
PFLAG are an invaluable resource for parents,
and other family members and friends, in the
process of acceptance of their LGBTQ
loved ones.
Location
PFLAG National Office
1828 L Street, NW, Suite 660
Washington, DC 20036
Telephone: (202) 467-8180
Website: www.pflag.org
Prominent Associated Figures
PFLAG has found support from many celebrities
and prominent figures. Cher was the keynote
speaker at the 1997 PFLAG annual conference.
In 2009, President Barack Obama recounted
PFLAG’s history, referring to it as “the story of
America.” PFLAG has consistently partnered
with celebrities to increase advocacy for accep-
tance and equal rights for LGBT persons. For
instance, through its Stay Close Campaign
(www.stayclose.org), PFLAG partners with
celebrities (e.g., Cindi Lauper) to highlight the
importance of acceptance and support of LGBT
family members.
Contributions
PFLAG, a grassroots organization, was founded
in humble beginnings. Based on Washington,
D.C., PFLAG is governed by a 21-member
board of directors. PFLAG’s outreach surpasses
peer support meetings, further providing online
and telephone outreach to family members and
friends in need of assistance in accepting their
LGBTQ loved ones. PFLAG’s scope is not lim-
ited to peer support, but its mission is threefold:
PFLAG
support, public education, and advocacy for equal
rights and complete inclusion for sexual and gen-
der minority individuals. It holds yearly national
conferences for the provision of support and train-
ing to advance the fostering of PFLAG’s educa-
tional and advocacy agendas. PFLAG further
functions as a clearinghouse for information
related to LGBTQ issues. The national group
encourages public education on LGBTQ issues
through its publication of brochures and the pro-
vision of speakers. It further advocates for sexual
and gender minority persons through its support
for local lobbying against discriminatory legisla-
tion, its organization of interfaith dialogues on
LGBTQ issues, and by responding to antigay
media campaigns.
Although a therapists’ awareness of common
reactions to a child’s disclosure of his/her LGBTQ
identity can be helpful in assisting a family in
traversing such a complex period, the interactions
afforded by PFLAG can be powerful in encourag-
ing acceptance. PFLAG members and support
groups provide opportunities for parents and fam-
ily members to view the possibilities of accepting
their LGBTQ loved ones, to understand that their
feelings and reactions to the disclosure are com-
mon, and to interact with other LGBTQ individ-
uals who might be experiencing similar emotions
as their own loved ones. It is, thus, a unique and
valuable resource through which parents, family
members, and friends might find greater ease in
fully accepting and affirming their LGBTQ loved
ones. There are more than 380 PFLAG chapters
nationwide; PFLAG also provides telephone and
online support for those in need through their
website (www.pflag.org).
Cross-References
▶ Institute for Family and Sexuality Studies,
Leuven
▶ LGBT in Couple and Family Therapy
▶ Transgender People in Couple and Family
Therapy
Phenomenology and Family Therapy
Phenomenology and Family
Therapy
Anthony Rose1 and Paul Murray2
1
Counseling Psychology Doctoral Student,
Brigham Young University, Provo, UT, USA
2
West Vancouver, BC, Canada
Name of Theory
Phenomenology and Family Therapy
Introduction
The term “phenomenology” simply refers to what
the word itself suggests: the study of phenomena, or
more explicitly, the study of our experience of things
(Becker 1992). Brute reality, for all human beings, is
existence, being, and consciousness (Smith 2018).
This initial state of existence, familiar to all living
creatures, is where phenomenology begins.
Prominent Associated Figures
Popularized by German philosopher Edmund Hus-
serl (1859–1938), phenomenology sees human
experience as the bedrock of both existence and
knowledge: as Jean-Paul Sartre (1905–1980), a dis-
ciple of Husserl, famously asserted, “existence pre-
cedes essence.” In other words, for Husserl and
Sartre, phenomenology could be seen as an onto-
logical statement, or, more properly, ontology could
be seen as phenomenological statement: before we
consider abstract concepts, before we form a world-
view, before we consciously interact with the world,
we exist, and we experience.
Description
The “raw data” of phenomenology, therefore, is
simply consciousness, imagination, emotional
2207
states, and the objects of our direct attention,
from a first-person perspective (Smith 2018).
These objects could be the constituents of the
objective, external world (i.e., our physical sur-
roundings, via our sensory perceptions of taste,
touch, smell, sight, and sound), or our subjective
daily thoughts. Even these very words at this
present moment are part of the package, both
internally (in the mind) and externally (on the
page or screen).
In fact, the dualistic subject/object dichotomy
eventually breaks down for the phenomenologist
because both are so intimately intertwined in daily
ephemeral experience. We do not know what it is
like to experience the world “objectively” because
we can never experience it as anything other than
ourselves and always tie certain meanings to this
experience. Therefore, the meanings we attach to
the objects of our attention are just as important to
the phenomenologist as the objects or events
themselves and are just as comprising of an indi-
vidual’s reality (opening the door for the scientific
study of such concepts as love, beauty, and spiri-
tuality). This lens or structure towards which we
direct (or “intend”) our experience was referred to
by Husserl as “intentionality” and can fluctuate
between the internal world and the external world
(Smith 2018).
P
Relevance to Couple and Family Therapy
A phenomenological perspective in family therapy
involves looking at the lived experience of family
members from their own perspective, including
their present understanding (or, memories) of their
past experiences (Dahl and Boss 2005). Whatever is
most present in the consciousness of family mem-
bers on an existential, moment-by-moment basis,
and the ways in which they have drawn connections
between their experiences, are up for study and
consideration by phenomenologists.
Because of the variety of individuals in the
family, there are also a variety of experiences;
even the same event can be understood differently
by different members of a family. Grass may be
2208
conceived as yellow to someone living in the
desert, mud red instead of brown; even the “objec-
tive” world has subjective elements (evidently,
phenomenology possesses strong philosophical
links with other like-minded ideologies such as
postmodernism, hermeneutics, and social
constructionism). Consequently, phenomenolo-
gists are not directly concerned with the objective
“facts” of the family but instead are interested in
the experiences of the individuals in the family,
even if these experiences may depart from the
“objective” world. Understanding the world and
experiences of family members is key (Dahl and
Boss 2005).
Such diversity is vitally important to remem-
ber, if working from this perspective, and phe-
nomenology therefore lends itself well to recent
efforts in psychotherapy at multiculturalism.
Like multiculturalism, phenomenology
acknowledges that our backgrounds, culture,
and religious beliefs can make a fundamental
difference in who and what we are as people
and how we interact with our surroundings.
With this recognition, family therapists must
be accordingly sensitive and open-minded
towards their clients, regardless of the client’s
position or status in the family, and philosoph-
ically should not value one experience over
another, even if there are tensions. Because
experience is so personal and individualized,
phenomenology can be quite personal and indi-
vidualized (though it must be understood that
experience can nonetheless be shared and stud-
ied; Embree and Moran 2004).
Thus, in addition to having ontological
implications, phenomenology holds unique
epistemological implications for family thera-
pists: we learn and know not merely by reading
or pondering abstractly but by living, experienc-
ing, and engaging (Smith 2018). A simple
example would be baking a cake: even if we
are using exactly the same recipe, our tenth
attempt at a cake will almost certainly be better
than our first attempt, regardless of how well we
“know the recipe.” Moreover, we do not really
know what it is like to see the stars at night in
Ecuador unless we have seen them for
Phenomenology and Family Therapy
ourselves, no matter how many books we have
read or conversations we have had on the sub-
ject. Although reading recipes, textbooks, or
engaging in conversations are not irrelevant –
because they are part of experience – actually
doing something and experiencing it for oneself
is the most compelling way to learn about it
from the phenomenologist’s perspective. Expe-
rience changes perceptions and actions.
Clinical Application of Theory in Couples
and Families
All this clearly has implications for family ther-
apy. For the phenomenologist, individual human
experience should be at the forefront of both
counseling and research. Family counselors
should seek to understand their clients’ personal
experiences. In light of this, some argue that – in
phenomenological terms – family therapy should
be seen as more of a conversation than an inter-
vention. From the phenomenological perspective,
context is key, and every individual family mem-
ber (as well as the counselor) has a proper voice,
as an experiencing human being. The goal for the
counselor is to make this taken-for-granted con-
text of family members explicit. The counselor
can learn something about how the family mem-
bers interact with one another at home but can also
experience how they interact in her/his presence,
being receptive to the here-and-now (Dahl and
Boss 2005).
Consistent with this, the researcher or coun-
selor’s own experience will infallibly be present in
their own work: they are not exempt or detached
from what is happening around them. We cannot
detach ourselves from consciousness, to objec-
tively observe consciousness. No one is
completely neutral or objective, and self-
reflection and awareness become of the utmost
importance to family counselors and researchers
(Dahl and Boss 2005). Consequently, even while
writing this entry, the authors have had to take
their own backgrounds, biases, and tendencies
into consideration.
Phenomenology and Family Therapy
Phenomenology also makes sense of empa-
thy in counseling, insofar as counselors may
indeed have shared experiences with clients,
and may “know what they are going through”
(for instance, as a son, a daughter, or a parent
themselves), although there are limits to this.
We can never truly know (or, phenomenologi-
cally know) what it is like to experience the
world as anyone other than ourselves.
A degree of humility is expected from a family
therapist (Dahl and Boss 2005).
Moreover, using phenomenology as the
starting point, more authentic description and
information is potentially possible than from a
traditional subject/object or quantitative perspec-
tive, especially when working with families
(Gehart et al. 2001). Questions a counselor or
researcher applying phenomenological principles
might ask are: “what is it like to be a member of
this family?” or “what experiences can you derive
from being a wife/husband/mother/father/sister/
brother/daughter/son?” Due to the often intensely
personal nature of being a family member, and the
layers that go along with it, phenomenology could
be a particularly apt toolbox for psychologists in
the area.
We can further see how phenomenology goes
hand in hand with qualitative research methods,
which seek detailed, personal statements about
experience (entailing large amounts of data,
time, and effort; Gehart et al. 2001). Indeed,
family therapists and researchers applying phe-
nomenological principles, though somewhat
limited in quantity, have presented some prom-
ising results. For instance, researchers have used
phenomenological methods to capture the expe-
riences of religious families (Garland 2002),
African-American grandmothers (Gibson
2002), and families with children diagnosed
with diabetes (Wennick and Hallström 2006).
Though sample sizes may be smaller in such
studies, leading to a lack of breadth, there is a
tremendous amount of depth to be captured by
phenomenological studies, depth that
simply cannot be captured by research which
does not tap into the lived experiences of these
people.
2209
Overall, the hope is that phenomenological
principles will provide family members with
opportunities to get their voices heard, and for
healing to take place, and will provide family
therapists with a sensitive, robust framework to
view their clients and themselves. The focus is on
the here-and-now, and what it means to be an
experiencing individual in the family, and an
experiencing counselor. In phenomenology,
there is hope for those who are struggling: what
is emboldening about Sartre’s statement is that, if
existence does precede essence, then we are not
bound by our current forms or patterns, but have
definite freedom, freedom to change.
Cross-References
▶ Hermeneutics in Relation to Family Systems
Theory
▶ Qualitative Research in Couple and Family
Therapy
References
Becker, C. S. (1992). Living and relating: An introduction
to phenomenology. Newbury Park: Sage.
Dahl, C. M., & Boss, P. (2005). The use of phenomenology
for family therapy research. Research Methods in
Family Therapy, 2, 63–84.
P
Embree, L., & Moran, D. (Eds.). (2004). Phenomenology:
Critical concepts in philosophy. London: Routledge.
Garland, D. A. (2002). Faith narratives of congregants and
their families. Review of Religious Research, 44(1),
68–92.
Gehart, D. R., Ratliff, D. A., & Lyle, R. R. (2001).
Qualitative research in family therapy: A substantive
and methodological review. Journal of Marital and
Family Therapy, 27(2), 261–274.
Gibson, P. A. (2002). Caregiving role affects family rela-
tionships of African American grandmothers as new
mothers again: A phenomenological perspective. Jour-
nal of Marital and Family Therapy, 28(3), 341–353.
Smith, D. W. (2018). Phenomenology. In E. Zalta (Ed.),
Stanford encyclopedia of philosophy. Retrieved from:
https://plato.stanford.edu/entries/phenomenology/
Wennick, A., & Hallström, I. (2006). Swedish families’
lived experience when a child is first diagnosed as
having insulin-dependent diabetes mellitus: An ongo-
ing learning process. Journal of Family Nursing, 12(4),
368–389.
2210
Philadelphia Child Guidance
Clinic
Combrinck-Graham Lee
LifeBridge Community Services, Bridgeport,
CT, USA
Introduction
The Philadelphia Child Guidance Clinic (PCGC)
was founded in 1926, the third clinic devoted to
care of children, following IJR in Chicago, in
1909, and the Judge Baker Guidance Clinic in
Boston. PCGC was initially psychoanalytically
oriented, and as late as 1967, there were still
couches in all the offices!
The Child Guidance Clinic was located in
South Philadelphia next door to Children’s
Hospital of Philadelphia (CHOP), both moved
to a fancy new building in the University of
Pennsylvania Medical complex in 1974. The
7 years between Minuchin’s arrival in Philadel-
phia and the Clinic’s move to its new location
were the most fruitful in developing the theo-
ries, practice, and research of Structural Family
Therapy. The next 7 years after the move allo-
wed for some elaboration, but more importantly
were the years of disseminating these ideas and
practices through practica, workshops, and
internships.
The major figures at the clinic during
the Minuchin era were Salvador Minuchin, him-
self, Jay Haley, Braulio Montalvo, and Bernice
Rosman. But the activity at the Clinic attracted
many others: prominent visitors and presenters
included: Nathan Ackerman, Virginia Satir, Carl
Whittaker, and Murray Bowen, while Peggy
Papp visited regularly for several years, Rachel
Hare-Mustin worked at the clinic before
branching off on her own, and Lynne Hoffman,
too, seemed to be honing her skills there before
branching off. For some time, Chloe Madanes
and Marianne Walters were associated with an
important program to support indigenous
workers in the community; Harry Aponte
worked with the clinic school connection and
Philadelphia Child Guidance Clinic
eventually became Director of the Clinic; Avner
Barcai, visiting from Israel, spent a year working
with Minuchin on the psychosomatic work;
Lester Baker, a pediatrician from CHOP, collab-
orated in the psychosomatic work.
The Philadelphia Child Guidance Clinic
became the site of the significant development of
probably the most comprehensible system of
Family Therapy – Structural Family Therapy,
which was a visible, mappable, and understand-
able system, even though it is not systematic, in
the sense that there are discrete steps to follow.
Essentially, the model articulated the significant
concepts of Joining and Enactment, and a frame-
work that described “boundaries” between indi-
viduals, the recognition of subsystems in families,
and the differentiation of subsystems according to
hierarchies. Although these concepts underlie
the practice of Structural Family Therapy, there
were no rigid rules of process.
There were a number of observation rooms
and one-way mirrors in the old clinic on
Bainbridge Street in South Philadelphia. When
the Clinic moved, in 1974 to the brand new
building, there were many more. Supervision
and training occurred with observation and the
opportunity to review video tapes. The under-
lying concept of family work, which is working
with what you can see rather than what you
guess about what is going on in people’s
heads, was embodied in the teaching and super-
vision. The work was about what one could see.
And the supervision and teaching furthered this
kind of engagement and participation with what
was happening. In live supervision, it was com-
mon for the supervisor to call in to the therapist
or even ask to speak with a family member. It
was also common for the supervisor to actually
join the session for an intervention. And it was
also common to invite a family member or two
to join the group behind the mirror to observe
what was going on. Observing was the source of
understanding, then offering an intervention
and observing the response, these were the hall-
marks of family therapy as developed, prac-
ticed, and taught at the Philadelphia Child
Guidance Clinic under the direction of Salvador
Minuchin.
Philadelphia Child Guidance Clinic
History of PCGC
The arrival of Salvador Minuchin in (1967) fresh
from his experience at the Wiltwyck School for
Boys and the publication of Families of the Slums
ushered in the era of family Therapy at PCGC.
Minuchin brought his colleagues and co-authors
with him – Braulio Montalvo and Bernice
Rosman. Montalvo studied Minuchin’s work on
video tape, and through this, identified interven-
tions which became the foundations of Structural
Family Therapy. In the early days, he would go
over a tape and say to Minuchin, “did you see
what you did there?” And in one famous instance
Minuchin placed a standing ashtray between an
anxious man and his wife, and Montalvo froze
that moment as a concrete illustration of a struc-
tural intervention. This became identified as a
“boundary.” Boundaries are basic to Structural
Family Therapy. In another famous tape Minuchin
made a boundary in the family of a girl with eating
peculiarities, by turning her chair to face him,
bringing his closer to her, and leaving her parents
farther away. The tape was called, “Between you
and me” meaning between the child and
Minuchin, thus helping the girl to disembroil her-
self from her attention-gathering mother.
When I first arrived at PCGC, several programs
were in place. There was an intervention in a local
school, and there was an anthropological study of
the relatively poor, mostly Black, community/
neighborhood around the Clinic’s South Philadel-
phia location. These programs were in tune with the
heyday of the Community Mental Health Move-
ment and provided experience and background for
a program for training community based “indige-
nous” family therapists who were HS graduates.
Led by Gerald Ford, the trainers, all of whom are
important figures in family therapy, were Jay Haley,
who had come from CA to be with Minuchin,
Chloe Madanes, who married Jay Haley, and sub-
sequently moved with him to Washington, D.C. to
found a center for Strategic Family Therapy, Harry
Aponte, and Maryanne Walters.
With an emerging language and associated
practice of Structural Family Therapy, Minuchin
began his famous research on “Psychosomatic
Families.” As the Clinic was next door to the
2211
Children’s hospital of Philadelphia (CHOP),
there was the opportunity to collaborate closely
with the pediatricians around children quite sick
with diabetes, asthma, and anorexia. To elaborate
models that proposed dysfunctional parent child
triads, there were interviews featuring getting par-
ents to disagree while being observed by their
child, then bringing the child into the room, and
see what happened. Though the research claims
have been challenged by others looking at data,
those who observed through the one-way mirror
never had a doubt that when a diabetic child
watched her parents arguing, all three having con-
tinuous measurements of free fatty acids showed
increases. But when the child went into the room
with her parents, their FFAs dropped while hers
continued to rise, so much that she needed to be
taken to CHOP because of ketoacidosis. And the
physiological changes mirrored the interactional
changes – that is, the parents stopped arguing/
fighting and focused on the child, illustrating one
of the hypothetical triads – the Detouring Protec-
tive Triad that seemed to be common in psycho-
somatic families. Though the physiological
parameters of this relationship pattern were not
easily identified in asthma or anorexia, the inter-
personal patterns were the same.
Minuchin’s work was in collaboration with a
visiting child psychiatrist from Israel, Avner
Barcai, and, of course, continued to use the P
research skills of Bernice Rosman.
Through this time there were visits from dis-
tinguished family therapists: Nathan Ackerman,
Virginia Satir, Carl Whittaker, Don Block, Murray
Bowen, Olga Silverstein, and Betty Carter, and a
more regular presence of Peggy Papp. There were
workshops and practica and conferences. It was a
center where people came to study and learn.
Several, such as Celia Falicov, studied and then
moved on to be influential in Chicago and then
San Diego. Fred Gottlieb, a Child Psychiatrist,
studied and took family models to the Child Psy-
chiatry Department at UCLA.
Kalman Flomenhaft came to develop the
Teachers of Family Therapy program where
folks with home base at PCGC would go to
CMHCs around Pennsylvania and teach family
therapy practice.
2212
In 1975, PCGC moved into a new building
which had been built cheek by jowl with the new
CHOP and both located on the campus of the
University of Pennsylvania Medical School. The
new PCGC now had an inpatient unit, a large space
with classrooms for a “school,” and another space
for a therapeutic preschool. Both Minuchin and
Haley were concerned about what an inpatient
unit might do to the PCGC identity, both concerned
about the conflict between the medical model
represented by hospital, and the interpersonal,
family-oriented model that had been thriving
since Minuchin’s arrival in the late 1960s.
Minuchin hired Lee Combrinck-Graham to be
the Inpatient Director, and she immediately joined
forces with the newly hired Principal of the
School, Wayne Higley, and together they
reconceived and renamed their programs, now
called The Intramural Program with inpatient,
and an intensive outpatient program usually pre-
ceded and succeeded with outpatient family work.
The day program for both inpatients and intensive
outpatients was the same in a psychoeducation
program designed by Higley. There were obser-
vation rooms for each of the classrooms, a space
used for parents to observe their children or chil-
dren to observe their class when they couldn’t be
in it, and the educational piece was connected
closely with problems presented by the child and
family – so that, for example, a behavior distur-
bance in a young adolescent who couldn’t read
was addressed by his working with a reading
specialist and learning the delight of reading.
In collaboration with Minuchin, the inpatient
unit had been designed with two apartments, each
with accommodations for parents and up to two
children, with kitchen, bath, etc. They also had
observation rooms. The parents could go out to
work and take their children to school, while the
IP joined the psychoeducational program during
the day. But the opportunity to work intensively
on daily interaction with the family was remark-
ably effective.
The other requirement for the Intramural Pro-
gram as designed by Combrinck-Graham and
Higley, and later joined by Arlene Kelly, who
became director of Child Life, was the expected
continuity of treatment from outpatient to
Philadelphia Child Guidance Clinic
inpatient. The family’s outpatient clinician was
expected to work with the family while they
were engaged in these more intensive levels of
care – but this became impractical, because fam-
ilies came from all over the area. Then there were
designated admissions clinicians who would go to
where the children and families were, to evaluate
and help plan the admission.
With evolving regulations, the flow of children
from inpatient to intensive outpatient in the same
program was complicated by their having to be
discharged from one and admitted to the other,
even though it was the same staff and treatment
plan, and the regulations surrounding apartments –
who were the patients, how would it be paid for,
continued to plague the program and finally
ended it.
While PCGC was struggling with its identity as
now a child psychiatric hospital with a basic fam-
ily systems orientation, with the new outpatient
facility there were many therapy rooms with
observation rooms and opportunities for teaching
and learning and research.
The heyday of the clinic as a center of family
therapy waned in the context of the tension
between PCGC and the Regional Council of
Child Psychiatry, as the Council questioned
whether PCGC was doing child psychiatry and
qualified to have a program to train fellows in
child psychiatry. This tension was characterized
in a famous paper “The Undeclared War between
Family Therapy and Child Psychiatry.” by John
McDermott and Walter Char, neither of whom had
ever been to PCGC, but who worried in an impor-
tant publication about the compatibility. As things
developed, there was tension within PCGC
between the child psychiatry training director,
Charles Malone, who had come from Boston to
the clinic to work with Minuchin. And as tensions
grew, Minuchin tired of University politics, with-
drew as Director of the Division of Child Psychi-
atry at the U of P, and gave the job to Malone.
Malone then exercised the university backed
power to try to take over the Clinic, and when
this didn’t work he left, even before the move to
the new building. An NIMH site visit of the child
psychiatry program ended with Minuchin hiring a
rather traditional “Professor” of Child Psychiatry,
Piercy, Fred
Marshall Schechter, and then Minuchin left Phil-
adelphia and went to NYC. Harry Aponte became
Director of the Clinic, furthering the programs
with the indigenous family therapists in the com-
munity, and focusing on school consultations.
When Aponte left the Clinic, Ronald Liebman,
once a protégé of Minuchin’s, became Director.
Lee Combrinck-Graham left to run the MFT pro-
gram at Hahnemann University. And gradually
the Clinic became more closely involved with
CHOP so that eventually it was taken over by
CHOP and ceased to exist as a separate entity.
Contributions
The Philadelphia Child Guidance Clinic has had a
long and distinguished place in the world of fam-
ily therapy and child psychiatry. The work
conducted there by Minuchin and his colleagues
has been highly instrumental in establishing fam-
ily therapy as a viable treatment for children. The
most recognized and perhaps most important
model of family therapy, Structural Family Ther-
apy, was developed and disseminated at PCGC.
Various training programs, influential training
tapes, and important books and articles were writ-
ten at PCGC. Minuchin’s books are among the
most widely read and recognized in the field of
family therapy. Scores of professionals were
trained in the post graduate program. They all
left and spread the word about Structural Family
Therapy. Many of them, themselves, became
prominent in the field. For example, Multi-
dimensional Family Therapy, developed by How-
ard Liddle, has roots in Structural Family
Therapy. Minuchin, himself, towered over the
field of family therapy and served as a vocal and
influential leader. There can be little doubt that the
field of family therapy would not have advanced
as it did without the existence of The Philadelphia
Child Guidance Clinic.
Cross-References
▶ Aponte, Harry J.
▶ Lee, Combrinck-Graham
2213
▶ Minuchin, Salvador
▶ Montalvo, Braulio
▶ Structural Family Therapy
References
McDermott, J. F., & Char, W. (1974) The Undeclared War
Between Child and Family Therapy. JAACP, 13(3),
422–436.
Minuchin, S. (1974). Families and family therapy.
Cambridge, MA: Harvard University Press.
Minuchin, S., Montalvo, B., Guerney, B. G., Jr., Rosman,
B. L., & Schumer, B. (1967). Families of the slums: An
exploration of their structure and treatment. New York:
Basic Books.
Minuchin, S., Rosman, B. L., & Baker, L. (1978).
Psychosomatic families: Anorexia nervosa context.
Cambridge, MA: Harvard University Press.
Piercy, Fred
Sean D. Davis
California School of Professional Psychology,
Alliant International University, Sacramento, CA,
USA
Introduction
P
Dr. Piercy is a professor of family therapy in the
Marriage and Family Therapy Doctoral Program,
Department of Human Development, Virginia
Tech, Blacksburg, VA, and the current editor of
the Journal of Marital and Family Therapy
Career
Dr. Piercy received a B.A. in psychology from
Wake Forest University, a master’s in counseling
from the University of South Carolina, and a
Ph.D. in counselor education from the University
of Florida. He came to Virginia Tech in 2000,
where he spent 8 years as department head of the
Department of Human Development and 3 years
as associate dean of research and graduate studies
in the College of Liberal Arts and Human
2214
Sciences before returning to full-time teaching.
Prior to coming to Virginia Tech in 2000,
Dr. Piercy spent 18 years teaching family therapy
at Purdue University and, before that, 7 years as a
family therapy educator at East Texas State Uni-
versity (now Texas A&M Commerce). Prior to
that, while in the Army, Dr. Piercy worked in
mental health clinics in Ft. Benning, Georgia and
Seoul, Korea. For 20 years, during his time in
Texas and Indiana, Dr. Piercy also had a small
private practice and consulted with a number of
mental health agencies. He has collaborated
extensively with colleagues from the University
of Indonesia and Atma Jaya University
(in Jakarta, Indonesia).
Contributions to Profession
Dr. Piercy has served two times on the Board of
Directors of the American Association for Mar-
riage and Family Therapy (AAMFT) and as the
chair of the Commission on Accreditation for
Marriage and Family Therapy Education. He is
also a member and fellow in both AAMFT and
the American Psychological Association
(Division 43). He is currently the editor of the
Journal of Marital and Family Therapy, the larg-
est family therapy journal in the world and the
flagship journal of the American Association for
Marriage and Family Therapy.
Dr. Piercy’s scholarship has involved family
therapy education, family therapy of substance
abuse, HIV social science research and preven-
tion, qualitative research and evaluation, infidel-
ity treatment, and couples enrichment, as well as
other topics. He has written over 185 published
journal articles and book chapters, five books,
and 43 funded grants. He is the coeditor of
Research Methods in Family Therapy (2nd Edi-
tion) (with Douglas Sprenkle, Guilford Press,
2005) and Handbook for the Clinical Treatment
of Infidelity (with Katherine Hertlein and Joseph
Wetchler, Haworth Press, 2005) and coauthor of
Family Therapy Sourcebook (with Douglas
Sprenkle, Joseph Wetchler, and associates;
Guilford Press, 1986, 1996) and Stop Marital
Fights Before They Start (with Norman Lobsenz,
Piercy, Fred
Berkley Press, 1994). Dr. Piercy also has written
for the popular press in magazines such as
Reader’s Digest and Saturday Evening Post and
wrote a newspaper column, Family Matters, for
the Lafayette Courier for 2 years.
Dr. Piercy has won national, university, and
college teaching awards, as well as college awards
for administration, outreach, and graduate student
advising. He is the recipient of the 2015 Lifetime
Achievement Award of the American Family Ther-
apy Academy, AAMFT’s 2007 Outstanding Con-
tribution to Marriage and Family Therapy Award,
and Virginia Tech’s 2007 Alumni Award for Out-
standing Graduate Student Advising. He also won
NCFR’s 2013 Kathleen Briggs Graduate Student
Advising Award. Dr. Piercy has always enjoyed
mentoring doctoral students. He was the doctoral
chair for the 1980, 1981, 1982, 1984, 1985, 1986,
1993, 1994, 1995, 2002, 2005, 2006, and 2007
winners of the nationally competitive Graduate Stu-
dent Research Award of the American Association
for Marriage and Family Therapy. He also chaired
the doctoral committee of the 1986, 1988, 1990,
2006, 2010, 2011, 2012, 2014, and 2016 winners of
the AAMFT Dissertation Award. Finally, he chaired
the 2013 winner of Virginia Tech’s Outstanding
Dissertation Award in the Social Sciences, Busi-
ness, Education, and Humanities.
Cross-References
▶ American Association for Marriage and Family
Therapy (AAMFT)
▶ Journal of Marital and Family Therapy
References
Dattilio, F., Piercy, F., & Davis, S. (2014). The divide
between “evidence-based” approaches and practi-
tioners of traditional theories of family therapy. Journal
of Marital and Family Therapy, 40, 5–16. https://doi.
org/10.1111/jmft.12032.
Davis, S., & Piercy, F. (2007). What clients of couple
therapy model developers and their former students
say about change, part I: Model dependent common
factors across three models. Journal of Marital and
Family Therapy, 33(3), 318–343.
Pinsof, William M.
Gambrel, L. E., & Piercy, F. P. (2014). Mindfulness-based
relationship education for couples expecting their first
child – part 1: A randomized mixed-methods program
evaluation. Journal of Marital and Family Therapy.
https://doi.org/10.1111/jmft.12066.
Hertlein, K., & Piercy, F. (2008). Therapists’ assessment
and treatment of Internet infidelity cases. Journal of
Marital and Family Therapy, 34(4), 481–497.
Piercy, F. P., & Lobsenz, N. (1994). Stop marital fights
before they start. New York: Berkley Books.
Piercy, F. P., Sprenkle, D., Wetchler, J., & Associates.
(1996). Family therapy sourcebook (2nd ed.). New
York: Guilford.
Piercy, F., Hertlein, K., & Wetchler, J. (Eds.). (2005).
Handbook for the clinical treatment of infidelity. New
York: Haworth.
Piercy, F., Banker, J., Traylor, R., Krug, S., Castanos, C.,
Cole, E., Ciafardini, A., Jordal, C., Rodgers, B., Stewart,
S., & Goodwin, A. (2008). A Virginia Tech MFT ethics
class reflects on the shootings at Virginia Tech. Journal
of Marital and Family Therapy, 34(2), 210–226.
Piercy, F. P., Chang, W., Palit, M., Jaramillo-Sierra, A.,
Chen, R., Karimi, H., Martosudarmo, C., & Antonio,
A. (2013). Cross-national research in family therapy:
One encouraging approach. Journal of Family Psycho-
therapy, 24, 296–305. https://doi.org/10.1080/
08975353.2013.849559.
Piercy, F., Earl, R., Aldrich, R., Nguyen, H., Steelman, S.,
Haugen, E., Riger, D., Tsokodayi, R., West, J., Keskin,
Y., & Gary, E. (2016). Most and least meaningful
learning experiences in family therapy education. Jour-
nal of Marital and Family Therapy. https://doi.org/
10.1111/jmft.12176.
Sprenkle, D., & Piercy, F. (2005). Research methods in
family therapy (2nd ed.). New York: Guilford
(Reprinted in Korean by Hawoo Publishers in 2010).
Pinsof, William M.
Jay L. Lebow
The Family Institute at Northwestern
University, Center for Applied Psychological
and Family Studies, Northwestern University,
Evanston, IL, USA
Introduction
William M. Pinsof is a prominent family psychol-
ogist who has been an outstanding theorist,
researcher, and practitioner. He nurtured the Fam-
ily Institute at Northwestern into prominence and
is best known for his work on the integrative
2215
systemic therapy (IST) model and the measures
the Systemic Therapy Inventory of Change
(STIC) and the Integrative Psychotherapy Alli-
ance Scales.
Career
William Pinsof received his PhD in clinical psy-
chology from York University in Toronto,
Ontario, Canada. He subsequently joined the
staff of the Family Institute of Chicago (later
the Family Institute at Northwestern) in the
1970s and became the President of the Family
Institute in 1986. In 1990 he transformed and
reorganized the Family Institute of Chicago into
The Family Institute at Northwestern University.
He was the CEO and President of the Family
Institute at Northwestern from 1986 to 2016,
growing it from a small (annual budget under
$500,000) to a university-affiliated mid-sized
not-for-profit organization (annual budget $15
million). In 2016, Bill left the Family Institute
and created Pinsof Family Systems as a base to
continue his clinical work and expand his prac-
tice into family business consulting and
counseling.
Dr. Pinsof is a fellow of the American Psycho-
logical Association and a Diplomate of the Amer-
ican Board of Professional Psychology. Dr. Pinsof P
received the Distinguished Lifetime Contribution
to Family Therapy Research Award from the
American Association for Marriage and Family
Therapy in 1996, the Distinguished Contribution
to Family Therapy Theory and Practice Award
from the American Family Therapy Academy in
2001, and the 2001 Family Psychologist of the
Year from the American Psychological Associa-
tion Society for Couple and Family Psychology.
In 2016, he received a special commendation
from the American Psychological Association
for his contribution to the field.
Contributions to Profession
Dr. Pinsof has made several key contributions to
the fields of couple and family therapy, family
2216
science, psychotherapy, and psychotherapy
research. His integrative problem-centered ther-
apy model was a very early prominent integrative
therapy. That therapy then served as much of the
basis for integrative systemic therapy (IST), a
widely disseminated therapy. This work also
served more broadly to move the field of couple
and family therapy toward integrative practice.
On another front, Pinsof pioneered and popular-
ized the utilization of progress measures in cou-
ple and family therapy. His Systemic Therapy
Inventory of Change (STIC) measures are a
model of a clinically useful empirically validated
state-of-the-art systemic progress measures.
Both the multisystemic focus and electronic
feedback set the STIC apart, allowing therapists
and clients to set clearer goals, assess progress in
real time, and make informed treatment choices.
Pinsof also conducted a randomized clinical trial
which showed the use of the STIC positively
impacted on therapy outcome. Earlier, Pinsof devel-
oped the Integrative Psychotherapy Alliance Scales
to track psychotherapy alliance, which in revised
form became part of the STIC measurement. He
also conducted a number of seminal research stud-
ies on the therapeutic alliance in couple and family
therapy, resulting in the development of a multipar-
tite model of therapeutic alliance.
Pinsof has written a number of key books,
book chapters, and articles about couple and
family therapy. His work on psychotherapy inte-
gration culminated in the publication, by Basic
Books, of Integrative Problem Centered Ther-
apy: A Synthesis of Family, Individual and Bio-
logical Therapies (1995) and by APA Books
Integrative Systemic Therapy. He has also edited
four books: the 2005 volume that he coedited
with Jay Lebow, Family Psychology: The Art of
the Science, published by Oxford University
Press; a special issue of the Journal of Marital
and Family Therapy (1995) that he coedited with
Lyman C. Wynne, dedicated to reviewing all of
the controlled research on the outcomes of cou-
ple and family therapy; a special issue of Family
Process (Vol. 41, No. 2, summer 2002) entitled,
“Marriage in the 20th Century in Western
Pinsof, William M.
Civilization: Trends, Research, Therapy, and
Perspectives”; and the classic work he coedited
with Leslie Greenberg, The Psychotherapeutic
Process: A Research Handbook, (1986).
Bill is also renowned for his clinical work and
clinical supervision. A video in the APA video
series illustrates his work with couples.
Cross-References
▶ Integrative Problem-Centered Metaframeworks
▶ Integrative Systemic Therapy
▶ Progress Research in Couple and Family
Therapy
▶ Split Alliance in Couple and Family Therapy
▶ Systemic Therapy Inventory of Change
▶ Therapeutic Alliance in Couple and Family
Therapy
References
Greenberg, L. S., & Pinsof, W. M. (Eds.). (1986). The
psychotherapeutic process: A research handbook.
New York: Guilford Press.
Pinsof, W. M. (1995). Integrative problem-centered ther-
apy: A synthesis of family, individual, and biological
therapies. New York: Basic Books.
Pinsof, W. M., & Catherall, D. R. (1986). The integrative
psychotherapy alliance: Family, couple and individual
therapy scales. Journal of Marital & Family Therapy,
12(2), 137–151.
Pinsof, W., Breunlin, D. C., Russell, W. P., & Lebow,
J. (2011). Integrative problem-centered meta-
frameworks therapy II: Planning, conversing, and read-
ing feedback. Family Process, 50(3), 314–336. https://
doi.org/10.1111/j.1545-5300.2011.01361.x.
Pinsof, W. M., Zinbarg, R. E., Shimokawa, K., Latta,
T. A., Goldsmith, J. Z., Knobloch-Fedders, L. M.,
. . ., & Lebow, J. L. (2015). Confirming, validating,
and norming the factor structure of systemic therapy
inventory of change initial and intersession. Family
Process, 54(3), 464–484. https://doi.org/10.1111/
famp.12159.
Pinsof, W.M., Breunlin, D.C., Russell, W.P., Lebow, J.
L., Rampage C., Chambers, A.L. (2017). Integrative
systemic therapy: Metaframeworks for problem
solving with individuals, couples, and families.
Washington DC: American Psychological Associa-
tion Books.
Pittman, Frank
Pittman, Frank
Tina Pittman Wagers1 and Elizabeth Brawner
Pittman2
1
Department of Psychology and Neuroscience,
University of Colorado Boulder, Boulder, CO,
USA
2
Atlanta, GA, USA
Name
Frank Smith Pittman, III, MD
Introduction
Frank Pittman was born in Atlanta, Georgia, in
1935 and died there in 2012. His career as a psy-
chiatrist, family therapist, author, and speaker
spanned over 50 years. During that time, Pittman
made important contributions to the field of couple
and family therapy, especially in the areas of infi-
delity, the use of family therapy as an alternative to
psychiatric hospitalization, the treatment of fami-
lies in crisis and gender issues. Pittman was known
for his revolutionary treatment methods, his opti-
mism, humor, and tendency to be provocative in his
challenges of accepted conventions in the fields of
psychiatry and mental health treatment. His four
books continue to be influential, and his movie
column in the Psychotherapy Networker, which
he wrote for over 25 years, helped him earn the
title of “the Mark Twain of Psychotherapy.”
Career
Pittman was valedictorian of his high school class
in Alabama and graduated cum laude from
Washington and Lee University in 1956. He
received his MD degree from Emory University
School of Medicine (1960) where he also com-
pleted his residency in psychiatry (1964). While a
resident at Emory, he was trained in psychoanal-
ysis, but was also influenced by Nathan
2217
Ackerman, MD, one of the founders of Family
Therapy.
In 1964 Pittman joined the faculty at the Uni-
versity of Colorado Medical Center to work on an
NIMH research grant in the Family Treatment Unit
(FTU) directed by Drs. Langsley and Kaplan,
investigating the efficacy of crisis intervention and
family therapy as an alternative to psychiatric hos-
pitalization. Pittman consulted with Jay Haley, Don
Jackson, John Weakland, Paul Watzlawick, and
Virginia Satir as he embarked on this groundbreak-
ing work. In Denver from 1964 to 1968, the FTU
treated a random sample of family-based patients
who were deemed in dire need of admission to the
psychiatric inpatient service. Rather than being
admitted, patients were seen immediately by the
FTU team with their families. Outpatient treatment
continued until the crisis was resolved, symptoms
cleared, and functioning returned.
When the Denver project ended in 1968,
Pittman returned to Atlanta and joined the Depart-
ment of Psychiatry faculty at Emory University and
for a few years was Director of Psychiatric Services
at Grady Memorial Hospital, working to provide
more outpatient treatment and fewer admissions.
In 1972 he began his solo office practice seeing
mostly couples and families until retirement in 2011
following cancer surgery. His wife Betsy was office
manager and occasional co-therapist. He was also a
P
consultant to early mental health centers, to the
regional NIMH office, supervised psychiatric resi-
dents at Emory as a clinical faculty member, and
supervised psychology doctoral students as an
adjunct faculty member at Georgia State University.
Pittman was a member of AFTA (the American
Family Therapy Academy) where he was a charter
member and on the board, and AAMFT (the
American Association for Marriage and Family
Therapy) Fellow and Approved Supervisor.
Contributions to Profession
Pittman was drawn to the treatment of couples and
families very early in his career. Over the years,
Pittman made critical contributions to the field in
2218 Placater in Family Systems

the areas of treating couples and families in crisis, good friend and editor, Rich Simon of the Family
hyper masculine men, fathering and gender, and Therapy Networker (later The Psychotherapy Net-
the treatment of infidelity. He wrote about these worker). The column was a widely read and much-
areas extensively and made hundreds of national loved commentary on the portrayal of families, cou-
and international presentations on these topics. ples, gender, crises, and character in film.
Pittman’s early work with families in the Denver
Project constituted a critical development in the
Cross-References
legitimization of crisis family therapy in the treat-
ment of significantly mentally ill individuals. This
▶ American Association for Marriage and Family
project demonstrated that early crisis intervention
Therapy (AAMFT)
and outpatient brief therapy could be successful,
▶ American Family Therapy Academy (AFTA)
time and cost efficient, and far less disruptive to
▶ Family Process (Journal)
work, school, and family relationships than psychi-
▶ Gender Roles
atric hospitalization, which had been the standard
▶ Infidelity in Couples
of care up to that point in the 1960s. Pittman was
▶ Simon, Richard
the treating psychiatrist, along with team members,
social worker Kalman Flomenhaft, psychiatric
nurse Carol DeYoung and Harvard psychologist
References
Pavel Machotka. Their landmark research won
the American Psychiatric Association’s Hofheimer Pittman, F. (1987). Turning points: Treating families in
Award as well as awards from other national transition and crisis. New York: W.W. Norton.
organizations. Pittman, F. (1989). Private lies: Infidelity and the betrayal
Pittman was one of the first professionals to start of intimacy. New York: W.W. Norton.
Pittman, F. (1992). Man enough: Fathers, sons, and the
talking and writing about the crisis of infidelity, a search for masculinity. New York: G.P. Putnam’s Sons.
topic shunned by most therapists and publishers at Pittman, F. (1998). Grow up! How taking responsibility
the time. Nowhere was his ability to deal with the can make you a happy adult. New York: Golden Books.
most difficult circumstances more evident than in
his work with infidelity. Pittman’s emphasis was on
total honesty and compassion. He rejected secrets
and lies between partners, along with the popular Placater in Family Systems
notion that people should “follow their heart” and
act on their feelings with reckless abandon and Michele Baldwin
disregard for the effect on their family. Chicago Center for Family Heath, Chicago,
At a time when many psychotherapy profes- IL, USA
sionals were reinforcing clients’ notions that their
problems were caused by others, Pittman believed
that good therapy could help men and women Introduction
develop character and that engaging in responsible
behaviors toward spouses, partners, and children A placater is a person who adopts a relational
would be rewarded with feelings of honor and pattern and behavior of appeasement, deference,
integrity. and submission in interpersonal relationships
Pittman also became interested in the role of where power and decision-making are involved.
masculinity, the tyranny of hyper-masculinity, the
importance of relationships between fathers and
sons and gender equality in marriage, writing and Theoretical Context for Concept
presenting on these topics extensively.
For over 25 years, Pittman’s wrote a film column, Virginia Satir (Satir and Baldwin 1983) was the
“The Screening Room,” a collaboration with his first to describe the dysfunctional aspects of
Placater in Family Systems
placating patterns in the family system and the
impact of this on both placater and those around
him. She saw placating as one of four incongru-
ent communication styles (placating, blaming,
super-reasonable, and irrelevant) that prevent
clear and authentic communication within a rela-
tional system especially an intimate group such
as the family. For Satir (Satir et al. 1991), devel-
oping authenticity and congruence is a basic goal
of good therapy. It consists of the ability to
respond from an authentic inner place by recog-
nizing and expressing one’s true feelings, a will-
ingness to honor the feelings and needs of the
other(s), and an appreciation of the context. She
described the placater as being afraid of rejec-
tion, with low self-esteem, who attempts to
please others at the expense of his own self-
worth. Placaters act incongruently, ignoring
their own feelings while honoring both the
other person and the reality of the context. Pla-
cating is largely a habitual response, used in hope
of obtaining love or avoiding disapproval from
another, a response rooted in the dependency of
infancy, when survival depended on caretakers.
Because of the strong valence of emotional
attachment ties in the family, that fear of loss or
rejection is intense. Although the origins of pla-
cating are due to nurture, there may be a natural
predisposition.
Description
Placaters accommodate rather than standing up
for their beliefs, and as a result, their verbal and
nonverbal communications are often incongruent.
They may come across with a pleading expres-
sion, or a begging voice, and, by denying their
self-respect, give others a message that they are
not important. By looking outside of themselves
for validation, their inner experience is one of
worthlessness. Since they ignore or condemn
their own true feelings, they don’t allow others
to know what they truly want. As a result, they
often elicit impatient or dismissive responses from
those around them. Unable to express anger con-
gruently, they often exhibit passive-aggressive
behaviors.
2219
Application of Concept in Couple
and Family Therapy
Placating is seldom a presenting issue in couple
and family therapy, yet it needs to be recognized
and addressed early on. The difficulty is that
placating does not exist in isolation, but in the
context of the dysfunctional communication pat-
terns of others. The therapist needs to assist pla-
caters to become congruent by helping them to
believe that their existence is of value and that
they have the inner resources to change. This
may happen if they feel fully accepted and under-
stood by their therapist, realizing that caring can
be one of their positive attributes, if self-care is
added. The therapist can then describe some
behaviors observed in placaters, by asking them
what they really feel when they say “yes” but feel
“no.” The therapist needs to probe the yearnings
for approval and the fear of disapproval when
placaters follow their inner voice and then ask
them if they are willing to take the risk to learn a
more satisfying way to behave. Behavioral
change can then be addressed by giving them
techniques to block their automatic response by
going inside for self-validation. Placaters need to
understand how their feelings about the present
situation are triggered by past events and how to
interpret the situation in a new, authentic way.
The reactions of the family to the transformation P
of a placater into a congruent person may vary
depending on the congruence or stress styles of
other family members. This transformation may
not be a smooth process, as it may be accompa-
nied by an initial release of stored-up anger.
Occasionally, a family may include several pla-
caters. Such a family may present with low
energy, since no one seems to have their needs
and wishes met, as illustrated by the well-known
Abilene Paradox (Harvey (1974).
Clinical Example
Mary and John, married for 5 years, came into
therapy because John was very concerned about
how Mary, who was usually cheerful, had
become depressed and short-tempered after
2220
being told that he wanted to accept a job in
another city. The therapist quickly diagnosed
Mary’s placating behavior and followed the
steps described above. As a young child, Mary
felt that to get love from her mother, a demand-
ing, easily angered woman, it was necessary to
do what her mother wished, whether she wanted
to or not. She felt loved by her mother when she
pleased her and was afraid of her mother’s
explosive anger when she was displeased. John
was not an angry person, but any hint of disap-
proval on his part reactivated Mary’s fear of
displeasure from a loved one. The therapist
helped Mary recognize her difficulty in engag-
ing John over important issues and the need to
listen to her inner voice and then develop the
courage to express her true thoughts and feel-
ings. The advantage of dealing with her placat-
ing behavior in front of John is that he can better
understand her difficulty and the importance for
their marriage of communicating congruently.
The therapist helped them with that process,
focusing on how to better deal with differences
and conflict.
Cross-References
▶ Assertiveness Training in Couple and Family
Therapy
▶ Blamer Stance in Couples and Families
▶ Communication in Couples and Families
▶ Dominance and Submission in Family
Dynamics
▶ Power in Family Systems Theory
▶ Roles in Couples and Families
References
Harvey, J. B. (1974). The Abilene paradox: The manage-
ment of agreement. Organizational Dynamics., 3,
63–80.
Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The
Satir model: Family therapy and beyond. Palo Alto:
Science and Behavior Books, Inc..
Satir, V., & Baldwin, M. (1983). Satir step by step. Palo
Alto: Science and Behavior Books, Inc..
Planning Metaframeworks in Integrative Systemic Therapy
Planning Metaframeworks in
Integrative Systemic Therapy
Ryan M. Earl and Samuel Major
The Family Institute at Northwestern University,
Evanston, IL, USA
Name of Concept
Planning metaframeworks in integrative systemic
therapy
Introduction
In order to be an effective integrative therapist, one
must be able to intervene using a variety of models,
theories, ideas, and skills. Where an eclectic thera-
pist might be able to do this, an Integrative Systemic
Therapist (IST) is able to do this in a meaningful,
organized way. The planning metaframeworks
(PMFs) of IST are guidelines that organize the
wide range of systemic therapy interventions that a
therapist can use to facilitate change. There are six
PMFs: Action, Meaning/Emotion, Biobehavioral,
Family of Origin, Internal Representation, and
Self. The therapist draws from one or more of the
PMFs depending on the problem, goals, and con-
straints of a given case. Though the PMFs are
discussed in isolation here, it is important to con-
sider that they are drawn from using multiple
models of systemic therapy in conjunction with the
blueprint and hypothesizing metaframeworks of
IST in the context of the IST Essence Diagram.
Theoretical Context for Concept
Over 30 years of research and meta-analyses have
shown that virtually every model of systems ther-
apy, when used effectively, can facilitate systemic
change, symptom improvement, or even full
remediation in roughly two-thirds of clients who
seek the help of a family therapist. However, these
findings also mean that roughly one in three cli-
ents is not helped by specific models. The
Planning Metaframeworks in Integrative Systemic Therapy 2221

planning metafameworks of IST were developed, Description

in part, to answer the question, “what should a
therapist do on the 33% chance their chosen
model does not work?”
The planning metaframeworks of IST represent
the product of a shift toward integrating common
factor and general therapeutic approaches as a
means to transcend the many models of systemic
therapy. According to Pinsof et al. (2017), “A
mature psychotherapeutic field has to move beyond
specific models and the sequencing of specific
models to a perspective that incorporates strategies
and techniques from specific models into a coherent
and integrated metamodel” (p. 146). The PMFs
allow therapists to integrate principles, strategies,
and techniques from specific models, but free ther-
apists from the often constraining theoretical and
clinical assumptions of said specific models.
The major theoretical guidelines, represented
by the large arrow in Fig. 1, provide the major
principles for PMF selection. These guidelines are
highlighted in Table 1.
How to intervene with a given system and its
respective problems, from and IST perspective,
should be determined based on the strengths,
sequences, constraints, and differential causality
relative to the system and problem at hand rather
than to a specific set of ideas (i.e., one model) that
may claim to have a full understanding of human
interaction.
Rather than propose a linear sequencing of
models, where a therapist chooses another
model if their model of choice does not work,
an IST-informed approach offers a more com-
prehensive shift toward transcending the theo-
ries and interventions of systemic treatment
models. The planning metaframeworks of IST
represent this shift and offer a perspective that
incorporates strategies and techniques from spe-
cific models into a coherent and integrated meta-
model.

Metaframeworks (MFs) Contexts of Therapy

Family/ Couple/ co-
Hypothesizing MFs Planning MFs Individual
Community parent
Sequences,
organization, Action P
development
Culture, gender,
spirituality, Meaning/emotion
sequences of mind

Biology Biobehavioral

Intergenerational
patterns: sequences, Family of Origin
organization, mind

Internal
Organization of mind
representation

Development of self Self

Planning Metaframeworks in Integrative Systemic Therapy, Fig. 1 Integrative systemic therapy planning matrix.
(From Pinsof et al. 2011)
2222 Planning Metaframeworks in Integrative Systemic Therapy

Planning Metaframeworks in Integrative Systemic Therapy, Table 1 Theoretical guidelines for the planning
metaframeworks of IST
Planning guidelines Description
Failure-driven When, based on client feedback, current interventions fail to lift constraints/permit the
guideline implementation of the solution sequence, the therapist is presented with the opportunity to
shift the focus of therapy.
Interpersonal It is always preferable for a therapist to facilitate an intervention within an interpersonal
guideline context (family or couple) rather than to an individual context when possible and appropriate.
Temporal guideline Therapy should focus as close to the here-and-now as possible, though it may move toward the
past, if appropriate, as more complex or remote constraints show up.
Cost-effectiveness The therapist should begin with more direct and simple interventions and only move toward
guideline more complex interventions as needed. Until they prove otherwise, client systems are assumed
possess the ability to implement solution sequences and lift constraints with minimal
intervention.
Problem-centered The process of therapy, including hypotheses, conversations, planning, and intervention
guideline selection should always be directly or indirectly linked to the presenting problems relative to
each client/client system.
Education guideline Therapists take on a teaching role, where they provide clients/client systems with their
professional skills, knowledge, and expertise as quickly as those clients/client systems can
digest/integrate them.

Application of Concept in Couple and
Family Therapy
According to IST, therapy is and should be a
planned endeavor. Selecting and carrying out a
given intervention or intervention(s) should be
driven by a therapist’s hypotheses about the solu-
tion sequences and primary constraints that pre-
vent them relative to each and every client/client
system. Though the therapist is who ultimately
determines which intervention(s) to use, such a
selection is a product of collaboration and explicit
conversation with the client/client system.
To aid IST therapists in the process of
selecting interventions to use, the PMFs are
organized on a matrix (see Fig. 1). The PMFs
house and organize common theories of prob-
lem formation and/or problem resolution. In
other words, the interventions contained within
each respective PMF share a common focus
related to what type of change they attempt to
facilitate. Relatedly, interventions from each
PMF attempt to implement particular types of
solution sequences and/or address particular
types of constraints. For example, interventions
from the Action PMF implement new
sequences of behavior and/or address behav-
ioral constraints.
Each PMF represents a “container” for inter-
ventions, meaning that as new models are devel-
oped, interventions from them can be added to the
mix. It is important to note that the interventions
housed within a particular PMF are not organized
in any specific way, nor is any one intervention
privileged over another. Rather, the intervention a
therapist selects from a given PMF is relative to
the specific hypothesis, constraints, and feedback
in the therapeutic conversation.
The PMFs (and the interventions contained
within them) are intentionally organized in the fol-
lowing order: Action, Meaning/Emotion,
Biobehavioral, Family of Origin, Internal Represen-
tation, Self. As per the Cost-Effectiveness Guide-
line, IST therapists are encouraged to first intervene
in ways that are least “expensive” or taxing on a
client/client system. Though it is not an exact sci-
ence, IST therapists will often start by drawing from
the Action PMF, and, through reading feedback and
adhereing to the Failure-Driven Guideline, may
move “down the matrix” toward drawing interven-
tions from the Self PMF. However, if solution
sequences and/or primary constraints are obviously
evident within the purview of a particular PMF, a
therapist may start there (for example, a therapist
may intervene at the level of meaning if obvious
cognitive distortions are present).
Play in Couple and Family Therapy
Case Example
Carl and LaRae are a heterosexual couple that came
to therapy seeking help with communication and
emotional intimacy. Carl claimed that, throughout
their relationship, he has felt like his partner has
never been able to connect with him emotionally,
and that she avoids discussing serious issues in their
relationship. LaRae agreed that they lacked in emo-
tional intimacy since their relationship began, but
said she struggles with Carl’s anger and tone when
he approaches her to talk about issues.
From watching them interact through arguments
(thus illustrating their problem sequence), the thera-
pist chose to draw from the Action PMF to imple-
ment a solution sequence. The therapist facilitated a
speaker-listener exercise focused on helping Carl
and LaRae take turns clearly stating their experi-
ences using soft start-ups and “I” messages,
followed by repeating and validating each other.
After a few sessions filled with practicing
the technique, there appeared to be little success
implementing the solution sequence in therapy or
at home. Following the failure-driven guideline,
the therapist recognized that Carl and LaRae’s
failure to implement the solution sequence was
the result of a constraint. Because each client often
drew parallels between their communication fail-
ures in the relationship with their respective fam-
ily of origin experiences, the therapist read the
feedback and hypothesized that Carl and LaRae
needed to differentiate the roles that anger, grati-
tude, and emotional avoidance played in their own
families from the role they played in their current
relationship.
To lift this constraint, the therapist chose to draw
a genogram-based intervention from the Family-of-
Origin PMF. The therapist conversed with Carl and
LaRae to develop a genogram, and worked with
them to identify patterns of anger, gratitude, and
avoidance within their families of origin that were
similar to the dynamics in their current relationship.
Each of them was able to learn about the other’s
family-of-origin and gain insight into patterns of
interaction they were carrying.
After a few sessions that focused on gathering
insight into the aforementioned patterns of inter-
action, Carl and LaRae were able to notice when
2223
their experiences were driven by a remnant of
their respective families of origin rather than by
each other. With the family-of-origin-based con-
straints lifted, the therapist re-opened the Action
PMF by going back to the speaker-listener exer-
cise from before. As a result, Carl and LaRae were
more successful using soft-startups and “I” mes-
sages when communicating with each other, and
what would have turned into arguments prior to
therapy became constructive conversations.
Cross-References
▶ Blueprint for Therapy in Metaframeworks:
Transcending the Models of Family Therapy
▶ Integrative Systemic Therapy
▶ Metaframeworks: Transcending the Models of
Family Therapy
References
Pinsof, W., Breunlin, D. C., Russell, W. P., & Lebow, J.
(2011). Integrative problem-centered metaframeworks
therapy II: Planning, conversting, and reading feed-
back. Family Process, 50, 314–336.
Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L.,
Rampage, C., & Chambers, A. L. (2017). Integrative
systemic therapy: metaframeworks for problem solving
with individuals, couples, and families. Washington,
DC: American Psychological Association. P
Play in Couple and Family
Therapy
Eliana Gil1 and David A. Crenshaw2
1
Gil Institute for Trauma Recovery and
Education, Fairfax, VA, USA
2
Children’s Home of Poughkeepsie,
Poughkeepsie, NY, USA
Introduction
There are several comprehensive historical
reviews of family play therapy (Sori and Gil
2015; Miller 1994) that document consistent
2224
efforts to promote an integration of play and fam-
ily therapy approaches. Several family therapists
(Zilbach 1986, 1995; Keith and Whitaker 1981;
Irwin and Malloy 1975) and play therapists (Gil
1994, 2015; Schaefer and Carey 1994; Sori and
Sprenkle 2004) have highlighted family play ther-
apy with minimal impact. Although both groups
maintain a passing interest in integration, neither
group has made a wholehearted or spirited
embrace of the other and some have speculated
as to myriad reasons for this (Green 1994).
In spite of an apparent hesitancy from both
camps, the authors believe that a play therapy
approach can be easily and successfully integrated
with a systemic/contextual framework. Family ther-
apists value the participation of all family members
and prioritize interventions that are inclusive, deny-
ing the singular role of an “identified patient.” In
fact, system thinkers consider the impact of identi-
fied problems on all family members as well as each
family member’s contribution to creating or sustain-
ing the problem. Play therapists are more exposed
to, and familiar with, child-oriented work in which
parental responses and family dynamics are
assessed in order to work in the best interests of
the child, with or without the presence of family
members in the room. There are some notable
exceptions to this, such as Filial Therapy, which
was designed in the 1960s by family therapists
Guerney and Guerney (1987). In addition, more
recent therapy models propose dyadic treatment
that focuses and strengthens the parent-child bond
(see for example, Theraplay, Booth and Jernberg
2009, or Attachment-Focused Family Therapy,
Hughes 2009). The field of couples’ therapy has
also stayed primarily a verbal discipline, except for
a recent resurgence of the use of laughter and play to
strengthen relationships (Schwarz and Braff 2011).
Theoretical Framework
A seeming weakness of family therapy
approaches is the exclusion of young children
and the paucity of nonverbal or expressive thera-
pies to assess and treat family issues, relying more
on verbal communication. A noteworthy limita-
tion of play therapy is the reluctance of many play
Play in Couple and Family Therapy
therapists to include family members when
treating the child, often choosing instead to do
individual child-centered play therapy and mini-
mizing a contextual view. Of course there are
notable exceptions to these more typical therapist
preferences, especially Filial Therapy (Guerney
and Ryan 2013; vanFleet 1994) and Theraplay,
approaches that advocate a wider systemic lens in
actual treatment practices.
Rationale for Strategy or Intervention
The exclusion of children in family therapy has
been widely documented. Green (1994) found
that family therapists report a lack of confidence
in engaging young children in family therapy and
feel unprepared to do so. Some family therapists
confide that they shy away from all the “equip-
ment” they believe is required to do play therapy.
Conversely, play therapists may feel unprepared
to invite adults to participate in play activities and
may succumb to any slight hint of parental hesi-
tancy to play with their children. On both sides,
the lack of preparation in traditional training pro-
grams leads to clinicians feeling a sense of inad-
equacy, which in turn keeps professionals
unwilling to explore approaches that challenge
their comfort zone.
Description of the Strategy or
Intervention
Family play therapy was introduced as a way to
introduce playful interaction in the case illustra-
tion to follow. The family was tense and rigid and
their ability to use their creative problem-solving
abilities stifled as a result of the negative interac-
tions that became repetitive leaving the family
feeling helpless and frustrated.
Case Illustration
Lucius was a 4.5-year-old biracial child when Eliana
Gil first met him. He had two siblings: 7-year-old
Marcus and 12-year-old Malila. The parents,
Play in Couple and Family Therapy
Mr. and Mrs. S. were fairly young and ambitious
professionals who were not able to apply their
impressive organizational and leadership skills
with this particular child. They described Marcus
and Malila as “polite, self-motivated, calm, and
studious,” and described Lucius as “a terror, hyper,
easy to anger, and a manipulative bully” to both his
older brother and to them. During the intake session,
the therapist learned that father traveled a great deal
for work and that mother was not happy about that.
Mother was currently working and studying to fin-
ish up her Master’s degree, which she stated she had
postponed when Lucius, their unplanned child, was
born. Mrs. S. stated, “I didn’t even know I was
pregnant until the 6th month, otherwise I would
have stopped drinking sooner.” When further
inquiry was made into alcohol use, both parents
stated that their drinking was social and “not an
issue.” Parents seemed generally distant and sarcas-
tic with each other, but much more united when they
disclosed their substantive frustration towards
Lucius and the havoc he was causing in their family.
The parent’s descriptions of their children was very
polarized with Lucius the “all bad” child and the
other two a source of pride and joy.
Maternal and paternal grandparents were
uninvolved except for one yearly visit to each
side of the family for holidays. Paternal grand-
mother was in Assisted Living that she had
entered after her husband’s death and declining
health. Maternal grandparents were about 1 hour
away but apparently very busy with their own
lives, and according to mother, “not the
grandparent-types.”
Parents chose to come alone to the intake
session in spite of my inviting everyone. They
immediately told me that it would be impossible
to get a word in edge-wise had their children
been in the room. The therapist invited everyone
to the second meeting and opted to utilize family
play therapy to engage the children more fully in
the therapy process. Dr. Gil asked the family to
think about some child-friendly activity they
could bring to the session, that all their children
would enjoy. They asked for more specificity
but the therapist told them it was up to them,
since they knew their children better than
she did.
2225
Session 2. They chose to bring in a game of
Parcheesi and promptly set up the board, passed
out the chips, and got started. The first 15 min
went pretty well and then Lucius made a bad
move and his brother laughed at him. Lucius
got visibly angry and punched his brother swiftly
and hard. His brother yelled out in pain and
mother grabbed Lucius and moved him over
next to her. The brothers kept staring at each
other, while the older sister checked her phone
every 5 seconds and texted vigorously during the
game. The therapist noticed that the parents did
not set any rules and seemed comfortable with
Malila being on the phone. Malila barely looked
up when Lucius hit Marcus and Marcus let out a
yell. This continued for another 20 min with
parents becoming increasingly frustrated and
embarrassed until Dr. Gil stopped the game and
asked everyone how familiar what had just hap-
pened was for them. Malila shrugged her shoul-
der and said, “I guess it’s like home,” while
Lucius and Marcus did not respond, by that
time boiling over with anger. The parents said it
was “typical” which is why they did not take the
kids anywhere. The therapist made a few obser-
vations: (1) That Malila was on the phone the
whole time without her parents asking her to get
off. Mother blurted out, “I gave up on that years
ago.” When Dr. Gil asked the parents what it was
like for them to have Malila on the phone and not P
participating, they said “we’re used to it.” Dr. Gil
again asked how they felt and Mr. S. said, “I
don’t like it one bit.” The therapist simply
noted that she was glad to hear him be definitive
about how he felt and told mother it must have
been hard to get accustomed to a behavior she did
not like. Dr. Gil also told them that she noticed
that when Lucius hit Marcus, he was never told
not to hit his brother and there was no conse-
quence for his doing so. Mother piped up quickly
to say that Lucius “doesn’t care what we say or
do.” The therapist noted that sometimes it seems
like kids do not listen to what their parents say
but sometimes they are asking for the lesson they
need to learn, to be repeated over and over.
Mother rolled her eyes. Dr. Gil invited them to
return next week and told them that the following
session, she would suggest the play activity.
2226
Session 3. There were several very obvious fam-
ily dynamics that simply were not effective. The
parents were loath to provide immediate direc-
tives to their children because they were con-
vinced that nothing they said or did mattered.
Thus they were abdicating their parental authority
and the children were testing limits constantly.
The other major problem was that the family
members were not enjoying each other. Everyone
seemed irritable and defeated and there was an
absence of joy. Lastly, there was a level of discon-
nect among all family members, especially the
couple, and it was clear that their lack of parenting
success had taken its toll on their relationship to
each other.
Family play therapy can re-introduce emo-
tional connection, pleasure and fun, and allow
each family member to see each other differ-
ently. As such, it can break into old negative
patterns of interacting and replace them with a
positive experience of mutual enjoyment. In
addition, much family play therapy is active
and physical, and allows parents and children
alike to breathe differently, behave differently,
and activate their neurobiology so they are more
awake, attuned, and enlivened with each other
(Gil 2015).
Dr. Gil designed an intervention in which
Lucius and Marcus were given the opportunity
to lead and follow and because she heard the
family had a wonderful train set that they took
out during the holidays, the therapist opted to use
the metaphor of a train. Thus Dr. Gil provided
each of them with a choice of colored poster
boards and markers. She told each person to sit
at a table and decorate the part of the train they
were going to be and then they would all decorate
the caboose where the driver sits. This drawing,
consulting, deciding took the full 50 min. There
were few negative altercations because the thera-
pist told the parents that she would be in charge
for this session and she was quite directive about
where people sat and what they did. The therapist
had a basket at the door and asked everyone to put
their electronics in it to be returned on their way
out (Malila did not object at all, father gave up his
cell phone reluctantly saying he would have to
pick up if he got a work call).
Play in Couple and Family Therapy
The family enjoyed working on their individ-
ual projects as well as the joint project. They did
not know exactly what they were going to do with
these poster boards but they seemed to enjoy the
activity and interacted with enthusiasm. On the
way out mother commented, “Humph, they would
never act like this at home!”
Session 4. The train leaves the station.
Dr. Gil put some strings on the poster boards so
they could be worn over the shoulders and each
person chose the poster board s/he had worked
on. The therapist then told the parents to choose
one of the children to drive the train and after they
chose Malila, Dr. Gil helped her put on the drawing
of the front train. The therapist told her that she
would start and stop the train, make sure her cus-
tomers were comfortable, look out for dangers along
the road, and try to provide the smoothest ride
possible. The therapist had put some signals on
construction paper, such as, “flooding ahead,”
“tree fell on tracks,” “brake isn’t working,” and a
few others. Dr. Gil then asked Malila to decide when
it was time to take off from the station. It was
interesting to watch the boys want to go faster, or
want to pull each other off the track, but overall
everyone cooperated and the boys offered some
noises to go with the train ride. The therapist also
gave Malila a horn that she could sound whenever
she wanted and she used it only once, surprising the
passengers onboard. After they were having fun
with this train experience and got used to following
each other in orderly fashion, Dr. Gil put some of the
signs in front of Malila and she froze, not knowing
what to do. When the therapist said a tree had fallen,
she said, “Geez, where is the brake?” After a few of
these challenging directives, she was ready to give
up the driver seat. Each boy took a turn after that and
again, they did not know quite how to respond with
the challenges the therapist stated to them. Lucius,
when hearing there was a tree on the tracks, said,
“we’ll jump over it, everybody jump!” Of course the
jumping was not successful and some of the train
carts went off the rails.
Finally, the therapist asked the father to take
the driver seat and directed him and his assistant
(mother) to discuss how they would respond when
the challenges were presented. They developed a
Play in Couple and Family Therapy
plan for how to make sure the passengers were
safe and the train stayed on the tracks. At one
point, mother yelled out, “We’re coming to a
quick stop, everybody brace yourself!” The kids
pretended to come to a full stop with their bodies
and when everything went well, they all laughed
together. Dr. Gil immediately took a picture of
everyone laughing out loud. After the session,
Dr. Gil sat down in a circle on the floor and the
therapist asked everyone how their train ride had
been and the difference between driving and being
a passenger. This led to spirited conversation
about other ways they could have stayed safe.
Dr. Gil had made a little sticker badge that said,
“Successful ride,” and asked everyone to put it
on. The last request was for everyone to turn to the
person on their right and give them praise for
something they had done on the train ride. Dad
told Lucius he was proud of how creative he had
been in trying to solve problems. The kids
expressed praise to their parents for their safe
driving, Malila adding, “of course, you’ve had
all the experience in the world driving.” The ther-
apist commented that each child had done a great
job leading and following and that the parents had
“come into their own” as drivers when they turned
to each other to prepare for the challenges along
the ride. Dr. Gil gave them the poster boards and
told them they could play the game together at
home whenever they wanted and told them they
would play together the next time the therapist
saw them.
Family play therapy worked well with this
family and parents reported an improvement in
Lucius’s behaviors. A variety of other family play
therapy interventions were used such as the Fam-
ily Aquarium (Gil and Sobol 2005).
Summary
Family play therapy merges two lively and impor-
tant approaches: family (systems) therapy and play
therapy. Family therapists have contributed greatly
to our understanding of how family interactions
occur within a family context, how they influence
each other, and how there is a circular loop of
influence and effect that constantly flows between
2227
family members. Play therapists have contributed
greatly to our understanding that play is an ener-
getic, physical, and active way of helping family
members interact more positively, with the potential
to decrease resistance and open up refreshing and
powerful lines of communication. Play therapists
also remind us of the developmental needs of chil-
dren and encourage parents to find a third language
(of play, metaphor, symbol).
Parents consistently articulate to their therapists
that they find family play therapy surprising. They
state that they feel more connected to their children
as a result of playing with them in a secure setting,
releasing their own creativity and engendering feel-
ings of well-being. Children likewise, seem to enjoy
having their parents with them in a novel way. The
healing power of laughter and play has long been
documented to have healing properties with people
with chronic illness and the reasons appear clear:
Laughter and play release endorphins, encourage a
more optimistic outlook, and facilitate emotional
connections.
This family came to therapy with an “identified
patient,” as well as obvious, rigid perceptions and
negative habits of interaction. They had become
distant for many reasons but united over their
frustration with Lucius and his provocative
behavior. Lucius’s acting out elicited their par-
ent’s attention and concern, if nothing else, and
also led to them seeking outside help. P
It was clear from the outset that the parents had
abdicated their parental role to the children and
were feeling frustrated and resentful about their
lack of control over their acting-out child, whom
they had labeled “an impossible hurricane.” In
fact, Lucius needed more attention, boundaries,
and reassurance that his parents were still operat-
ing as a parental team. Lucius was likely anxious
that his father was getting away from the family
and was trying to bring him back into the fold.
Family play therapy allowed the parents to
move away from frustrating verbal directives
and abdication of power, to experience them-
selves as capable leaders, and most importantly,
made them realize that their distant relationship
and resentment was affecting their children’s
sense of safety and security. As often happens in
families, once Lucius began to settle down,
2228
Marcus started acting out for attention and his
parent’s nurturing.
The play activities, the therapist chose were
designed to externalize the issues at hand: Lead-
ership, parental authority, helping the parents pre-
pare and plan together, and forcing the issue of
creating a safe and nurturing environment for all.
Dr. Gil addressed the emotional distance in the
family by requiring them to take a train ride
together that put them in the same environment,
moving together, facing problems together, and
being nurtured together. It is important to note that
Dr. Gil designed this intervention after learning of
a family habit that everyone seemed to enjoy.
Family play therapy worked wonders for this
highly intellectualized family and the therapist pri-
oritized action and energy over exchanging hun-
dreds and hundreds of words. The family play
therapy was followed by a period of marital therapy
where similar play activities were utilized. In this
particular case, parents brought in ideas of play
activities they wanted to share with each other and
their creativity and willingness to change was with-
out boundaries. Slowly but surely, they inched back
to each other and became full marital partners and
cooperative and successful parents.
References
Booth, P., & Jernberg, A. (2009). Theraplay: Helping
parents & children build a better relationship through
attachment-based play. San Francisco: Jossey Bass.
Gil, E. (1994). Play in family therapy (1st ed.). New York:
Guilford Press.
Gil, E. (2015). Play in family therapy (2nd ed.). New York:
Guilford Press.
Gil, E., & Sobol, B. (2005). Engaging families in thera-
peutic play. In C. E. Bailey (Ed.), Children in therapy:
Using the family as a resource (pp. 341–382).
New York: W. W. Norton.
Green, R. J. (1994). Foreword. In E. Gil (Ed.), Play in
family therapy (1st ed., pp. 1–12). New York: Guilford
Press.
Guerney, L., & Guerney, B. G., Jr. (1987). Integrating child
and family therapy. Psychotherapy, 24(3S), 609–614.
Guerney, L., & Ryan, V. (2013). Group family therapy: The
complete guide to teaching parents to play therapeuti-
cally with their children. San Francisco: Jossey-Bass.
Hughes, D. A. (2009). Attachment-focused parenting:
Effective strategies to care for children. New York:
W. W. Norton.
Pluralistic Approach to Couple Therapy
Irwin, E., & Malloy, T. (1975). Family puppet interview.
Family Process, 14(2), 179–191.
Keith, D. V., & Whitaker, C. A. (1981). Play therapy:
A paradigm for work with families. Journal of Marital
and Family Therapy, 7, 243–254.
Miller, W. (1994). History, theory, and convergence. In
C. E. Schaefer & L. Carey (Eds.), Family play therapy
(pp. 3–20). Northvale: Jason Aronson.
Schaefer, C. E., & Carey, L. (1994). Family play therapy.
New York: Jason Aronson.
Schwarz, R., & Braff, E. (2011). We’re no fun anymore:
Helping couples cultivate joyful marriages through the
power of play. Hoboken, NJ: Taylor & Francis.
Sori, C. F., & Gil, E. (2015). The rationale for integrating
play and family therapy. In E. Gil (Ed.), Play in family
therapy (2nd ed., pp. 1–32). New York: Guilford Press.
Sori, C. F., & Sprenkle, D. (2004). Training family thera-
pists to work with children and families: A modified
Delphi study. Journal of Marital and Family Therapy,
30, 479–495.
VanFleet, R. (1994). Filial therapy: Strengthening parent-
child relationships through play. Practitioner’s Resource
Series. Harrisburg, PA: Family Enhancement and Play
Therapy Center. Sarasota, FL: Professional Resource.
VanFleet, R. (1994). Filial therapy: Strengthening parent-
child relationships through play. Practitioner’s resource
Series. Harrisburg, PA: Family Enhancement and Play
Therapy Center. Sarasota, FL: Professional Resource.
Zilbach, J. J. (1986). Young children in family therapy.
New York: Brunner/Mazel.
Zilbach, J. J. (1995). Young children in family therapy.
Northvale: Jason Aronson.
Pluralistic Approach to Couple
Therapy
Molly F. Gasbarrini1 and Douglas K. Snyder2
1
California School of Professional Psychology,
Alliant International University, Los Angeles,
CA, USA
2
Texas A&M University, College Station, TX,
USA
Name of Concept
Pluralism
Introduction
Pluralism reflects an approach to treatment inte-
gration which holds that there is no single
Pluralistic Approach to Couple Therapy
theoretical, epistemological, or methodological
approach that is preeminent and no one, correct
integrative system toward which the field of psy-
chotherapy is evolving. Informed pluralism com-
prises a contextually-based approach toward
therapy integration (Safran and Messer 1997). It
is distinct from (a) common factors approaches
emphasizing active but nonspecific components
of therapeutic change processes, and
(b) transtheoretical approaches attempting to
translate diverse theoretical models into a single
unifying language. Pluralism potentially accom-
modates more diverse approaches whose basic
tenets defy assimilation into a common theoretical
framework.
Theoretical Context for Concept
Arguments for a pluralistic approach to couple
therapy are based in part on (a) the limited effec-
tiveness of any single theoretical approach on
couples’ long-term response to clinical interven-
tions; (b) the diversity of couples’ presenting dif-
ficulties across individual, dyadic, and broader
systemic domains; and (c) the relation of individ-
ual differences to treatment outcome. Particularly
complex or difficult couples may benefit most
from a pluralistic strategy drawing from both con-
ceptual and technical innovations from diverse
theoretical models relevant to different compo-
nents of a couple’s struggles. That is, effective
treatment is most likely to be rendered when the
couple therapist has a solid grounding across
diverse theoretical approaches, has acquired a
rich repertoire of intervention techniques linked
to theory, engages in comprehensive assessment
of the couple and broader family system, and
selectively draws on intervention strategies across
the theoretical spectrum in a manner consistent
with an explicit case formulation.
Pluralism is similar to constructs of “empirical
pragmatism” (Goldfried and Norcross 1995),
“systematic treatment selection” (Beutler and
Clarkin 1990), and “prescriptive eclecticism”
(Norcross and Beutler 2000) characterized “. . .
by drawing on effective methods from across the-
oretical camps (eclecticism), by matching those
2229
methods to particular cases on the basis of psy-
chological science and clinical wisdom
(prescriptionism), and by adhering to an explicit
and orderly model of treatment selection . . .”
(p. 248).
Description
Snyder (1999) advocated a hierarchical model for
structuring interventions from an informed plural-
istic approach. The model proposes a progression
across six levels of intervention: (1) developing a
collaborative alliance, (2) containing disabling
relationship crises, (3) strengthening the couple
dyad, (4) promoting relevant relationship skills,
(5) challenging cognitive components of relation-
ship distress, and (6) examining developmental
sources of relationship distress. Different theoret-
ical approaches offer unique contributions to con-
ceptualizing therapeutic challenges and
formulating specific interventions at each of
these six levels. Because couple therapy often
proceeds in a nonlinear fashion, the model also
advocates flexibility of returning to earlier thera-
peutic tasks as dictated by individual or relation-
ship functioning.
Application of Concept in Couple and P
Family Therapy
When conducting couple or family therapy from a
pluralistic approach, tailoring therapeutic interven-
tions to characteristics of individual partners, their
relationship, and extended psychosocial system
differs from a priori treatment matching paradigms
in which clients are assigned to predesigned treat-
ment modalities based on initial assessment find-
ings. Instead, in an informed pluralistic approach,
“matching” proceeds on a continuous basis
throughout therapy, based not only on client and
extended relationship characteristics but also on
emergent features of the therapeutic process –
including fluctuations in the therapeutic alliance,
unanticipated disruptions by external stressors, or
interactions of evolving skill-sets with enduring
belief systems or covert interpersonal anxieties
2230
(Snyder and Balderrama-Durbin 2012). Although
the predominant mode or level of intervention for a
given session or phase of treatment may be
planned ahead of time based on an overall case
formulation, specific interventions within session
are matched to both therapist and client character-
istics in the moment. Doing so effectively requires
keen attention to aspects of the therapeutic process,
continuous awareness of both overt and covert
aspects of partners’ ongoing responses, and famil-
iarity with a broad range of specific interventions
and the theoretical underpinnings that guide their
selection and implementation.
Clinical Example
Joel and Hannah entered couple therapy following
Joel’s diagnosis of Stage III melanoma. The couple
had been married 12 years, with two sons 7 and 9,
and a long history of frequent, intense arguments
characterized by emotion dysregulation on both
partners’ parts. Hannah had experienced sexual
abuse from a paternal uncle over a 4-year period
as an adolescent. Joel reported an emotionally
abusive father and passive, detached mother.
Joel’s recent diagnosis had completely
destabilized their family functioning, overwhelm-
ing both partners emotionally and disrupting basic
meal- and bedtime routines involving their chil-
dren. Initial interventions aimed at providing a
safe environment for both partners to express
fears regarding Joel’s illness and restructuring
tasks at home – including identifying sources of
outside assistance – to better manage both emo-
tional and logistic aspects of this crisis. Given
their long history of emotion dysregulation fuel-
ing destructive arguments, basic strategies for
time-outs and conflict resolution were described
and practiced in session.
As basic elements of stabilization and contain-
ment of negative escalations were achieved, both
partners were encouraged to examine enduring per-
sonal vulnerabilities that rendered coping with Joel’s
illness particularly difficult. Hannah was both drawn
to but feared the role of emotional caretaker,
Pluralistic Approach to Couple Therapy
connecting that role to her experiences of sexual
abuse. When she detached from Joel as a way of
re-regulating emotionally, he perceived from her the
same coldness he experienced from his mother dur-
ing episodes of his father’s abuse when he felt
particularly vulnerable. Recognizing those develop-
mental sources of conflict helped both partners to
contain and separate those residual reactions from
their current challenges. When either partner was
able to label those residual reactions during current
exchanges, the other was often able to dampen their
own reactivity and offer a softened response. Over a
brief period of only a few months, Joel and Hannah
became better equipped to navigate the emotional
and logistic challenges of Joel’s illness and maintain
a more stable and protective home environment for
their sons.
Cross-References
▶ Common Factors in Couple and Family
Therapy
▶ Eclecticism in Couple and Family Therapy
▶ Integration in Couple and Family Therapy
References
Beutler, L. E., & Clarkin, J. (1990). Systematic treatment
selection: Toward targeted therapeutic interventions.
New York: Brunner/Mazel.
Goldfried, M. R., & Norcross, J. C. (1995). Integrative and
eclectic therapies in historical perspective. In B. Bongar
& L. E. Beutler (Eds.), Comprehensive textbook of
psychotherapy: Theory and practice (pp. 254–273).
New York: Oxford University Press.
Norcross, J. C., & Beutler, L. E. (2000). A prescriptive
eclectic approach to psychotherapy training. Journal of
Psychotherapy Integration, 10, 247–261.
Safran, J. D., & Messer, S. B. (1997). Psychotherapy
integration: A postmodern critique. Clinical Psychol-
ogy: Science and Practice, 4, 140–152.
Snyder, D. K. (1999). Affective reconstruction in the con-
text of a pluralistic approach to couple therapy. Clinical
Psychology: Science and Practice, 6, 348–365.
Snyder, D. K., & Balderrama-Durbin, C. (2012). Integra-
tive approaches to couple therapy: Implications for
clinical practice and research. Behavior Therapy, 43,
13–24.
Polarization in Couple and Family Therapy
Polarization in Couple and
Family Therapy
Marj Castronova
Relational Wellness Institute, Las Vegas, NV,
USA
Synonyms
Distressed couples; Impasse; Mixed-agenda cou-
ples; Vulnerability cycle
Introduction
Polarization has been sporadically noted in litera-
ture. Crosby’s (1989) edited work was founda-
tional in considering the unique treatment needs
of polarized couples. Jacobson and Christenson
(1998) conceptualized the polarization process in
their Integrative Behavioral Couples Therapy
(IBCT) as a destructive way a couple handles
conflicts of difference in their relationship.
Baucom and Atkins (2013) defined the polariza-
tion process as a behavioral affective, and cogni-
tive cycle in which unsuccessful attempts to quell
relationship distress and to enhance intimacy
backfire and result in spouses engaging in more
extreme forms of behaviors over time and feeling
increasingly hopeless, separate, and deeply dissat-
isfied (p. 150).
Adjectives used to describe the concept of
polarization include devitalized, ambivalent,
impasse, distressed, and mixed-agenda, etc.
Theoretical Context for Concept
The context of polarizing couples differs from
normal relational conflict in that multiple, unsuc-
cessful attempts to negotiate or resolve the conflict
has escalated the problem and resulted in high
levels of emotional reactivity, blame, and rela-
tional distress. Theories have been developed in
2231
an attempt to understand polarization in couples
with the majority of the work focusing on the
interaction patterns of demand/withdrawal, inti-
macy, and cognitive processes. The theoretical
perspectives also consider risk factors, such as
emotional vulnerability, level of differentiation,
empathetic ability, personality, and family-of-
origin experiences.
Description
Polarity in its simplest form is two opposite sides of
the same construct, such as stay or leave, save or
spend, for or against. Jacobson and Christensen
(1998) describe the process of polarization being
ignited when partners attempt to change one
another’s differences on a problem issue. The
attempted changes are met with resistance and the
partner’s move to negative behaviors such as yelling
or criticizing to change the other and resistance is
increased and develops into a mutually coercive
interaction pattern. As the frequency of this patterns
increases, each partner begins to believe their behav-
ior is justified and they start to vilify the other. The
polarization process occurs as the partners become
more and more entrenched in their own position of
the problem issue, differences are less tolerated, and
negotiable space is nonexistent.
P
Application of Concept in Couple and
Family Therapy
Foundational to systemic therapy theories is the idea
of negative, repetitive, recursive patterns. These pat-
terns of interaction are seen in all relationships;
however, in polarized couples they are extreme.
Rather than partners relationally acclimating, appre-
ciating differences, and navigating together resolv-
ing conflict and preserving intimacy polarized
couples are at odds with each other. Treatment
focus is on assessing the polarization process to
determine how committed the couple is to the rela-
tionships, breaking coercive and nonresponse
behavioral cycles, working with the partners to
2232
increase the levels of differentiation so they are able
to see the other’s perspective, and working with
partners to see the positive or best in their partner.
When assessing the polarized couple, three
options are provided: staying the course, separating
or divorcing, or intentionally making a commit to
work on the marriage. Should the polarized couple
choose to intentionally commit to building a health-
ier relationship, the next step is to break the nega-
tive, repetitive cycles that have created the impasse.
It is important to note that these cycles are grounded
in vulnerability and survival stances that ignited into
mutually, reinforcing cycles that have essentially
become a narrow “couple’s mold” of interaction
(Papp et al. 2013). Each partner needs to work
through their own emotional reactivity by
addressing underlying intrapersonal issues such as
insecure attachments, personal distress, family-of-
origin issues, and learn to manage their interpersonal
behaviors and reactions such as coercion, with-
drawal, and flooding. Finally, the couple must inten-
tionally learn to respond in pro-relationship ways,
such as patience, empathy, assuming the best in the
other, forgiveness, and trust.
Clinical Example
Sherrie and Dave entered therapy at an impasse in
their finances. Regardless of their attempts to
change the way they managed money it always
ended in a fight, with Sherrie seeing Dave as a
tightwad and Dave referring to Sherrie as a spend-
thrift. The therapist’s first step was to access what
Dave and Sherrie’s level of commitment was to the
relationship. While Dave and Sherrie both felt
hopeless and dissatisfied, they still desired to give
it one last shot for the sake of their children. Given
this the therapist’s next step was to map out the
couple’s redundant, negative cycle which was typ-
ically triggered by an unexpected financial gain or
expense. Sherrie would look at the emotional
meaning and how it impacted the family connect-
edness. Dave would consider the financial security
of the family’s future. For instance, Sherrie would
make her case for a family vacation and Dave
would make his case for investing the money for
the future. As the conversation escalated, Dave
Polarization in Couple and Family Therapy
would start looking at Sherrie as “careless spend-
thrift” and Sherrie would see Dave “frugal tight-
wad.” The fight would switch to personal attacks.
In considering the couple’s cycle the therapist cre-
ated an intervention called “Money Talk” that
would break the cycle, incorporate a strategy for
creating accommodating behavior, and develop a
positive view of the partner. Whenever a money
conversation came up, Sherrie and Dave were to
stop, go to separate rooms, and write about what
the other person would be thinking about the situ-
ation. David would write from a place of “as if” he
was Sherrie and Sherrie would be writing from a
place of “as if” she was Dave. After they completed
writing about the other’s perspective, they were to
come back together and be prepared to make a
decision; however, they could only choose the
other person’s perspective (meaning Dave would
defer to what Sherrie would want or Sherrie would
defer to what Dave wanted). Neither was to defer to
their own preference. If both wanted to defer to the
other person’s perspective they were to argue for
the other’s perspective. If no one wanted to defer,
they were at an impasse (just like they were prior to
therapy) and were to save the topic for the next
therapy session. If they chose the impasse option,
they were given an additional assignment to each
create a list of five positive aspects to the other’s
point of view considering their partner’s values,
family-of-origin views of money, and rationale
for the belief. The intent of the intervention was
twofold: break the negative, repetitive cycle and
create a bind where they had to see other person’s
perspective. If an impasse was still there after the
first phase of the intervention, they were then
assigned to create an intentional pro-relational
stance.
References
Baucom, J. R., & Atkins, D. C. (2013). Understanding
marital distress: Polarization process. In M. A. Fine &
F. D. Fincham (Eds.), Handbook of family theories:
A content-based approach (pp. 145–166). New York:
Routledge.
Crosby, J. F. (1989). When one wants out and the other
doesn’t: Doing therapy with polarized couples.
New York: Brunner/Mazel.
Polyamory
Jacobson, M. S., & Christensen, A. (1998). Acceptance
and change in couple therapy: A therapist’s guide to
transforming relationships. New York: Norton.
Papp, P., Scheinkman, M., & Malpas, J. (2013). Breaking
the mold: Sculpting impasses in couples’ therapy. Fam-
ily Process, 52, 33–45.
Polyamory
Geri D. Weitzman
Los Altos, CA, USA
Synonyms
Non-Monogamy, Consensual Non-Monogamy,
Open Relationships
Introduction
The term polyamory means “many loves.” It is a
relationship style in which partners offer one
another the freedom to pursue multiple romantic
connections, in addition to their own (Weitzman
2006). This differs from monogamy, in which
partners practice romantic exclusivity. This also
differs from infidelity, in which additional roman-
tic connections are secretly pursued.
Description
Polyamory can be practiced in numerous ways.
It often begins with a couple who opens up their
relationship to take other lovers, who in turn
often have existing relationships of their own.
The original couples often share typical rela-
tionship trappings such as cohabitation, com-
mon property, and child raising, whereas the
dates with lovers are often more occasional
and less centered around home and family. As
time passes, these distinctions can blur. Dating
partners often become more involved in one
another’s lives (Veaux and Rickert 2014) – con-
tributing to childcare, pitching in during crises,
and forming kinship networks in which bonds of
trust and friendship grow between partners of
2233
partners. Polyfamilies sometimes grow, with
multiple adults forming a household, sometimes
co-parenting one another’s children.
There are many benefits to polyamory. There is
the ability to have romantic and sexual depth with
multiple people, experiencing different flavors of
relationships simultaneously. Polyamorous part-
ners do not need to be all things to one another –
for example, Chitra’s introverted girlfriend
Marisol may meet her need for philosophical con-
versation, whereas her more extraverted boy-
friend Evangelos might go out with her to
parties. Through these two relationships, Chitra
is able to experience differentiation – she can
express multiple aspects of herself without need-
ing to circumscribe her interests according to
those of just one partner (Kassoff 1989).
Polyamory encourages greater levels of com-
munication, as partners negotiate their relation-
ship agreements. They also learn how to take
responsibility for their emotions, working through
feelings of jealousy and insecurity in ways that do
not restrict others’ self-expression (Easton 2010;
Kassoff 1989). Trust is enhanced by the absence
of infidelity, given the support to be open about
one’s other partnerships. Some partners even
experience compersion, which means feeling joy
when one’s partner shares happiness with another
person (Richards and Barker 2013).
Support is often offered between partners of P
partners (Veaux and Rickert 2014). For instance,
when a woman with five children was hospital-
ized, her husband’s other partners stepped in to
watch the children and cooked meals for the fam-
ily, so that he could be with her in the hospital.
In polyamorous families, resources such as
time, energy, money, and possessions are pooled.
If two parents work, a third can more easily stay
home with the kids. Children have a wider variety
of role models when they have multiple parents,
and they have the security that more people are
looking out for their interests (Weitzman 2006).
Relevant Research About Polyamory
Considerable research is focused on polyamory.
The prevalence of polyamory is higher than might
2234
be expected: approximately a quarter of lesbians
and a third of bisexuals are involved in polyamo-
rous relationships, as well as two thirds of gay
men (Blumstein and Schwartz 1983; Page 2004).
Among mainstream heteronormative couples,
approximately one fifth have “understandings”
in which non-monogamy is sometimes permitted.
Polyamorous relationships function as soundly
as do their monogamous counterparts (Rubin and
Adams 1986), with comparable scores on mea-
sures of relationship satisfaction and longevity;
this is true across sexual orientations. Polyamo-
rous people typically score within normal ranges
on psychological inventories. It is also found that
children who grow up in polyamorous families are
well adjusted (Sheff 2013).
Special Considerations for Couple
and Family Therapy
Psychotherapists can benefit from guidance on
how to address common polyamory themes that
can arise in session (Weitzman 2006). It is worth
noting that the modal polyamorous client is gen-
erally not seeking treatment for reasons having to
do with polyamory. They just happen to be poly-
amorous and are seeking therapy for the usual
reasons – depression, anger management, and
career change – but they want to feel free to
mention their second partner or their polyfamily.
The therapist’s goal here is to simply be an ally
and welcome the client’s diversity. But there are
also some polyamory-specific themes that can
arise in therapy.
When a client is first considering polyamory,
there is a coming-out process to self and others
(Veaux and Rickert 2014). There is a change in
identity and a sense of being different. The thera-
pist’s role is to help the client to process their
feelings, as well as validating polyamory as a
legitimate lifestyle. The therapist can also give
pointers to books and websites about polyamory,
as well as to polyamorous communities, where the
client can gain a sense of commonality and find
like-minded dating partners.
Relationship therapists sometimes encounter
couples who are seeking support in negotiating the
Polyamory
parameters of their newly open relationship
(Weitzman 2006). Partners might negotiate about
the pace at which they proceed – how often is it
acceptable to have dates with others, and how soon
is it okay to pursue various sexual acts? What pre-
ventive measures should be taken around pregnancy
and STDs, and how often should STD testing be
required? Is it ok to use the primary couple’s bed for
sex with another lover, or should the guest bedroom
be used or a hotel room booked?
Another point of negotiation that the therapist
can assist with is what type of relationship structure
the partners are open to. Do they wish a hierarchical
style of commitment, where their relationship
comes first, or would they prefer a style with fewer
inherent power dynamics (Veaux and Rickert
2014)? Are they open to eventually including other
partners in their bond, to form a polyfamily?
Polyamorous partners often discuss whether to
exchange “veto power” – the right to naysay each
other’s choice of lover. This should not be done
lightly, as the resentments that can build around a
suddenly vetoed connection can damage the pri-
mary relationship (Veaux and Rickert 2014).
Vetoing is generally reserved for situations in
which an outside lover acts with malice toward
the primary relationship. The therapist can help
the partners determine whether that is happening
and discuss how to handle it.
The therapist can help the partners to examine
and own their insecurities and jealousies and to
make respectful requests for support (Easton 2010;
Labriola 2013). Marisol may say to Chitra, “I know
it is good self-care for me to stay home tonight while
you and Evangelos go out, but I might feel lonely.
Could you send me a few texts?” Likewise, Chitra
might say to Evangelos, “You have every right to
play with Thuy at the party, but I am having feelings
‘cause I think that Thuy is more attractive than
I am. Could you reassure me that you still find me
attractive as well?”
These are optimal forms of communication.
Newly polyamorous partners can be encouraged
to make self-care plans for the first few times that
their partner is out on a date (Easton 2010;
Labriola 2013) – these can include a good book,
some meditation, or some social plans of
their own.
Polyamory
Sometimes, insecurities rise because one part-
ner is in fact giving more attention, affection, or
time to their newer lover. Requests can be made
for more conscious attention to be given to sched-
uling choices and romantic expression, in ways
that are respectful and not controlling or demand-
ing (Labriola 2013; Veaux and Rickert 2014). The
therapist can help the partners to communicate
around such concerns. The therapist can also
encourage the partners to assess how many rela-
tionships they truly have time for.
Another point of negotiation is around whether
to have rules and agreements at all. Some partners
set initial guidelines but may agree to revisit those
over time (Veaux and Rickert 2014), as the agree-
ments that help partners to feel safe initially can feel
confining later.
Partners may feel nervous when meeting each
other’s new lovers. The therapist can offer sug-
gestions such as having the meeting in a neutral
place, sharing a fun activity together, and agreeing
to limit public displays of affection. It can be
helpful for partners to get along with each other’s
sweeties, as this makes social events more com-
fortable. It also helps foster goodwill, coopera-
tion, and mutual support in times of crisis or at
times where compromises need to be made
(Weitzman 2006), for instance, around
rescheduling a date with one’s primary partner in
order to take care of one’s sick lover.
The counselor can help the partners to navigate
decisions about whether to come out to others.
Polyamorous people may encounter prejudice
from friends and family, and there are no legal
protections against discrimination based on poly-
amory (Veaux and Rickert 2014). Polyamorous
people can face job loss or challenges to their
child custody rights. In conservative settings,
there is often the choice not to be out. It can be
difficult to live one’s life in secret.
Therapists can help polyamorous families to
negotiate household issues (Weitzman 2006).
Will they buy a bed big enough for all to sleep
in together? Who sleeps next to whom? Will the
polyfamily be “polyfidelitous” (i.e., date only
each other) or also have outside relationships?
Will children be raised to call non-biological
parents “Mom” or “Dad?” Will finances be
2235
pooled? Do all partners pay equally for chil-
dren’s expenses? If a breakup occurs, will con-
tinued relationships between non-biological
parents and children be supported?
The therapist should be aware of gay-specific
trends around open relationships (Spears and
Lowen 2010). Gay male couples sometimes
have a “see each new lover once only” rule,
emphasizing their own romantic primacy.
Non-monogamous gay partners sometimes report
a sense of competitiveness if their partner has
more dates, or sexier dates, than they do; some
partners choose not to disclose many details about
their dates, to prevent a sense of boasting. Of
course, these trends do not apply to all gay
partners.
Sometimes a client may realize that they are
polyamorous while they are in a long-term monog-
amous relationship (Veaux and Rickert 2014). The
decision process about whether to come out to their
partner and request a relationship style change can
be difficult, as their monogamous spouse may be
angry about the request, or unwilling to consider
it. Cultural norms often equate monogamy with
commitment, so the monogamous partner may not
comprehend how their partner could hold love for
another while still remaining committed and in love
with them (Labriola 2013). The counselor can help
the partners to express their feelings and underlying
needs and to explore whether any points of compro- P
mise exist. They can also help the couple to recog-
nize that while monogamy is the cultural norm, this
does not confer moral superiority on it as a lifestyle.
This can help the couple to move away from the idea
that one lifestyle is inherently right while the other is
inherently perverse.
The therapist can suggest resources to help
the monogamous partner learn more about poly-
amory as a lifestyle, as well as an online support
group for monogamous people who are in rela-
tionships with polyamorous people (Weitzman
2006). This can help the monogamous partner to
better understand where their polyamorous part-
ner is coming from in desiring this style of
relationship and to validate their polyamorous
orientation as a legitimate one. The monoga-
mous partner can also learn about the variety
of options that exist for structuring a
2236
polyamorous relationship to see if any might
feel possible for them.
Sometimes the monogamous partner is unwill-
ing to make a change (Veaux and Rickert 2014),
and then there is a painful decision about whether
to stay together, with the polyamorous person
giving up the possibility of dating others, or
whether they will break up due to incompatibility.
The counselor can help the couple to share feel-
ings as they navigate this decision.
Sometimes the couple is willing to look for
compromises in order to preserve the relationship.
The monogamous partner may offer limited per-
missions to the polyamorous partner (Weitzman
2006). For instance, if the polyamorous partner is
into kink and the monogamous partner isn’t, then
the monogamous partner may offer the polyamo-
rous partner permission to go and explore their
kink interests at a local kink club or to find some-
one to play in kink-only ways with. Likewise,
sometimes the polyamorous partner is given per-
mission to explore play with someone who is of a
different gender from the monogamous partner.
Sometimes, the polyamorous partner is given per-
mission to have discreet liaisons but when away
on business trips. Permission might be given to
explore sensuality with others if both partners are
present – they might find a third person to play
with together or go together to swinging events
that emphasize sexual play over romantic connec-
tions. The therapist can help the couple to explore
these options to see if any present a workable
compromise.
Finally, the counselor should consider how to
make their practice welcoming to polyamorous
families (Richards and Barker 2013). There are
ways to signal this, such as advertising in poly-
amory therapy directories, keeping books about
polyamory on one’s bookshelf, and using
polyamory-inclusive language on intake forms.
A larger couch can support a polyfamily to sit all
together in the therapy room, and longer ses-
sions can help the partners to all have time to
feel heard. As with any family system, the ther-
apists should be aware of patterns in how the
partners relate.
Polyamory
Cross-References
▶ Bisexual Couples
▶ Gay Male Couples
▶ Gay Male Couples in Couple Therapy
▶ Lesbian Couples
▶ Lesbian Couples in Couple Therapy
▶ Transgender Couples and Families
▶ Transgender People in Couple and Family
Therapy
▶ Communication Training in Couple and Family
Therapy
▶ LGBT in Couple and Family Therapy
References
Blumstein, P., & Schwartz, P. (1983). American couples.
New York: Morrow.
Easton, D. (2010). Making friends with jealousy: Therapy
with polyamorous clients. In M. Barker &
D. Langdridge (Eds.), Understanding non-monogamies
(pp. 207–211). New York: Routledge.
Kassoff, E. (1989). Nonmonogamy in the lesbian commu-
nity. Women & Therapy, 8(1–2), 167–182.
Labriola, K. (2013). The jealousy workbook: Exercises and
insights for managing open relationships. Eugene:
Greenery Press.
Page, E. H. (2004). Mental health services experiences of
bisexual women and bisexual men: An empirical study.
The Journal of Bisexuality., 3(3/4), 137–160.
Richards, C., & Barker, M. (2013). Sexuality and gender for
mental health professionals: A practical guide. London:
Sage.
Rubin, A. M., & Adams, J. R. (1986). Outcomes of sexu-
ally open marriages. The Journal of Sex Research,
22(3), 311–319.
Sheff, E. (2013). The Polyamorists next door: inside
multiple-partner relationships and families. Lanham:
Rowman and Littlefield.
Spears, B., & Lowen, L. (2010). Beyond monogamy: Les-
sons from long-term male couples in non-monogamous
relationships. Electronic Journal of Human Sexuality,
13, 1. Retrieved from http://www.thecouplesstudy.com/
Veaux, F., & Rickert, E. (2014). More than two: A practical
guide to ethical polyamory. Portland: Thorntree Press,
LLC.
Weitzman, G. (2006). Therapy with clients who are bisex-
ual and polyamorous. Journal of Bisexuality, 6(1–2),
137–164. Retrieved from http://www.numenor.org/
~gdw/psychologist/bipolycounseling.html
Positioning in Couple and Family Therapy
Positioning in Couple and
Family Therapy
J. Gregory Briggs1 and Michelle A. Finley2
1
Department of Psychology, Counseling, and
Family Science, Lipscomb University, Nashville,
TN, USA
2
Antioch University Seattle, Seattle, WA, USA
Name of Intervention
Positioning
Introduction
Positioning is employed in the strategic family ther-
apy model and is one of the paradoxical interven-
tions that can be used with individuals, couples, or
families. Like all paradoxical interventions, such as
prescribing and restraining strategies, positioning is
rooted in the assumption that clients resist change
and are at times reluctant to adopt new ways of
communicating and interacting (Stanton 1981).
Positioning is an intervention founded on the expec-
tation that clients will rebel against therapists’
directives (Rohrbaugh et al. 1981). Therefore, ther-
apists employ positioning by accepting or exagger-
ating clients’ perspective on an issue. This
paradoxical intervention is used to get clients to
adopt a new and more helpful explanation of the
problem in response to the therapist’s embellished
perspective. Ultimately, the decision to use a para-
doxical intervention and how to apply it (to the
whole family or only part) lies in how seemingly
stable the family is in relation to the symptomatic
behavior, where any request for change would be
seen as a threat to the family’s stability (Haley 1976).
Theoretical Framework
Paradoxical interventions such as positioning are
designed to get clients to change by telling them
2237
to remain unchanged (Rohrbaugh et al. 1981). In
theory, paradoxical interventions are effective
because they require clients to accept responsibil-
ity for their problematic behavior; if clients com-
ply with paradoxical interventions, they prove that
their symptoms are something they have control
over, and if they rebel against a paradoxical inter-
vention, they must change symptomatic behavior
(Watzwalick et al. 1967).
Rationale for Intervention
The rationale for positioning, as with all paradox-
ical interventions, is to “prescribe the symptom”
in such a way that the client can no longer use the
symptom (Haley 1963). Therapists use position-
ing when a client’s perspective is understood to be
maintained and reinforced by other members of
the client system. As a defiance-based strategy,
the expectation is that clients will react against a
therapist’s positioning (Rohrbaugh et al. 1981).
When a therapist employs positioning by ampli-
fying the clients’ problematic position, the clients
have to make a helpful shift in perspective in order
to disagree with the therapist’s exaggeration. In
response to the therapist’s positioning, the clients
will reevaluate and modify their stance, moving
them out of the problematic position.
P
Description of the Intervention
Positioning is the process where a therapist attempts
to shift a problematic position held by the client by
accepting or exaggerating the position (Stanton
1981). The problematic position is usually enacted
and maintained by a client who receives an oppos-
ing or complementary response from others. For
example, a client may feel angry about a situation
in which his or her partner responds by pointing out
the positives and minimizing the severity in the
situation. Such an opposing response reinforces
and maintains the problematic position of the cli-
ent’s persistent anger at that situation. A therapist
would then position him- or herself by having more
2238
anger about the situation than the client, thus exag-
gerating and accepting the problematic position in
an attempt to shift the client out of the problematic
position of anger.
Case Example
John and Lisa entered couple therapy hoping to
improve their relationship after years of conflict
that included name-calling and periods where nei-
ther client would speak to the other for 1 or 2 days at
a time. In the first session, Lisa’s primary complaint
was that she had “a hard time making decisions” and
that instead of being patient with her, John would
make decisions that impacted them as a couple
without her consent. These decisions ranged from
John changing internet service providers to purchas-
ing a new car. When John heard this, he acknowl-
edged that he had indeed made some “big
decisions” without talking with Lisa, but added
that he had done so only because Lisa “always”
complained about being stressed and “never”
made a decision.
In response to the clients’ comments, the thera-
pist used positioning to exaggerate Lisa’s stance in
the hope that it would compel the couple to see
things differently. The therapist said the following:
Lisa, I hear you asking John to consult with you
before making any decision that may affect you
two, no matter how big or small, even if a
delay causes problems like failing to meet a critical
deadline or missing out on a once-in-a-lifetime
opportunity.
Upon hearing the therapist’s statement, both
clients altered their original position. Lisa said
that she understood that there may be times when
John needed to make a decision without consulting
her, but that she wanted John to be more patient and
check in with her more often. John seemed to
soften toward Lisa, admitting that he knew it was
important to “keep Lisa in the loop” and that there
are some decisions he should not make on his own.
Cross-References
▶ Haley, Jay
▶ Jackson, Donald
Positive and Negative Quality of Marriage Scale
▶ Paradox in Strategic Couple and Family Therapy
▶ Prescribing the Symptom in Couple and Family
Therapy
▶ Restraining in Couple and Family Therapy
▶ Stanton, M. Duncan
▶ Strategic Family Therapy
▶ Watzlawick, Paul
References
Haley, J. (1963). Strategies of psychotherapy. New York:
Grune & Stratton.
Haley, J. (1976). Problem solving therapy. San Francisco:
Jossey-Bass.
Rohrbaugh, M., Tennen, H., Press, S., & White, L. (1981).
Compliance, defiance, and the therapeutic paradox:
Guidelines for strategic use of paradoxical interven-
tions. American Journal of Orthopsychiatric, 51,
114–127.
Stanton, M. D. (1981). Strategic approaches to family
therapy. In A. S. Gurman & D. P. Kniskern (Eds.),
Handbook of family therapy (Vol. 1, pp. 361–402).
New York: Brunner/Mazel.
Watzwalick, P., Bavelas, J. B., & Jackson, D. D. (1967).
Pragmatics of human communication. New York:
W. W. Norton & Company.
Positive and Negative Quality
of Marriage Scale
Allison M. McKinnon, Richard E. Mattson and
Mathew D. Johnson
Department of Psychology, Binghamton
University, Binghamton, NY, USA
Name and Type of Measure
The Positive and Negative Quality in Marriage
Scale (PANQIMS; Fincham & Linfield, 1997) is
a self-report measure that elicits global evalua-
tions of a spouse’s positive and negative attitudes
about their spouse and their marriage.
Synonyms
PN-QIMS; PNQIMS
Positive and Negative Quality of Marriage Scale
Introduction
The factors that make an intimate relationship
happy are distinct from the factors that make a
relationship distressed. This can be observed
empirically, such as through factor analytic
findings that show separate positive and negative
dimensions underlie relationship function-
ing (Orden & Bradburn, 1968). Despite variability
in what determines these fluctuations in relation-
ship quality, how favorably an individual evalu-
ates his or her relationship is the ultimate criterion
by which relationship quality is measured. Some
researchers consider the satisfaction, adjustment,
health, and well-being of intimate relationships to
be the same construct.
Accordingly, there are several measures of
relationship quality available for both research
and clinical purposes. However, relationship
quality is typically measured as a one-
dimensional scale with opposing positive and
negative anchor points. Beginning with
Fincham and Linfield (1997), researchers
conducted several studies describing the limits
of a one-dimensional scale to differentiate eval-
uations toward the middle of the continuum,
which may reflect either indifference (i.e., nei-
ther positive nor negative evaluations) or
ambivalence (i.e., co-existing positive and neg-
ative evaluations). Consistent with the broader
literature on attitude assessment (e.g., Osgood
et al., 1957), Fincham and Linfield proposed
separate subscales to measure an individual’s
evaluation of the positive and negative charac-
teristics of the relationship, which together
comprised the Positive and Negative Quality in
Marriage Scale (PANQIMS).
Developers
The PANQIMS was developed in 1997 by
Frank Fincham of the University of Cardiff
(now at Florida State University) and Kenneth
Linfield of the University of Illinois at Urbana-
Champaign, supported by the Economic and
Social Science Research Council and a Fellow-
ship from the Nuffield Foundation.
2239
Description of Measure
The PANQIMS consists of six items, three for each
of the positive marital quality (PMQ) and negative
marital quality (NMQ) subscales. Respondents eval-
uate the degree of positivity of their spouse’s posi-
tive qualities, their positive feelings toward their
spouse, their good feelings about their marriage,
and then the inverse (degree of negativity of nega-
tive qualities and feelings). Items are rated from 0 to
10 (Not at all to Extremely), with higher scores
indicating more extreme evaluations, either in the
positive or negative direction. The sum of each set
of questions generates separate scores reflecting
positive and negative attitudes. Using median splits,
Fincham and Linfield (1997) categorized individ-
uals as either satisfied (i.e., high PMQ/low NMQ),
dissatisfied (i.e., low PMQ, high NMQ), indifferent
(i.e., low PMQ/low NMQ), or ambivalent (i.e., high
NMQ/high PMQ).
Psychometrics
Initial tests of this measure were conducted on a
sample of 123 couples. Findings demonstrated that
a two-factor model fit the data better than a unidi-
mensional model (Fincham & Linfield, 1997).
Additionally, the PANQIMS demonstrated unique
associations with known behavioral and attribu- P
tional correlates of relationship quality above and
beyond a traditional measure of marital quality
(Marital Adjustment Test; Locke & Wallace, 1959)
and a measure of positive and negative affective
tendencies. Moreover, ambivalent and indifferent
couples had different behavioral and attitudinal pro-
files relative to each other and both satisfied and
distressed couples, suggesting that these different
types of couples may present differently in terms
of relationship functioning.
In a subsequent study of 43 engaged couples,
Mattson et al. (2007) replicated the two-factor struc-
ture of the PANQIMS and further demonstrated that
the NMQ subscale, in particular, explained unique
variance in behavioral observations of the couple’s
emotional communication in social support interac-
tions, compared to another measure of relationship
satisfaction. A two-factor model was found to be a
2240
superior fit compared to a one-factor model
(Mattson et al., 2007). Other studies have found
that spouses’ ratings of PMQ and NMQ are also
linked to relationship maintenance behaviors in dis-
tinct ways (Malinen et al., 2012).
Example of Application in Couple and
Family Therapy
A multidimensional view of relationship satis-
faction provides a more nuanced view of an indi-
vidual’s evaluation of his or her relationship.
Specifically, differences in PMQ and NMQ scores
can highlight whether the relationship is lacking
in some positive ways (e.g., sexual frequency)
and/or struggling with negative process (e.g., hos-
tile conflict), and so provide a means to highlight
and track targets for intervention. Fincham and
Linfield (1997) point out that the particulars of a
couple’s trajectory (e.g., going from happy to
indifferent or distressed) may reflect fundamen-
tally different relationship processes, and thus
may be critical for understanding where the rela-
tionship has gone wrong and the likely prognosis.
Taken together, the PANQIMS provides a brief
measure to help both the couples and clinicians
conceptualize their relationship’s strengths and
weaknesses, as well as mark therapeutic progress,
in ways that cannot be gleaned from frequently
used one-dimensional metrics.
Cross-References
▶ Dyadic Adjustment Scale
▶ Locke-Wallace Marital Adjustment Test
▶ Marital Satisfaction Inventory: Revised
References
Fincham, F. D., & Linfield, K. J. (1997). A new look at
marital quality: Can spouses feel positive and negative
about their marriage? Journal of Family Psychology,
11(4), 489–502.
Locke, H. J., & Wallace, K. M. (1959). Short marital-
adjustment and prediction tests: Their reliability and
validity. Marriage and Family Living, 21(3), 251–255.
Positive Connotation in Couple and Family Therapy
Malinen, K., Tolvanen, A., & Ronka, A. (2012).
Accentuating the positive, eliminating the negative?
Relationship maintenance as a predictor of two-
dimensional relationship quality. Family Relations:
Interdisciplinary Journal of Applied Family Studies,
61(5), 784–797.
Mattson, R. E., Paldino, D., & Johnson, M. D. (2007).
The increased construct validity and utility of as-
sessing relationship quality using separate positive
and negative dimensions. Psychological Assessment,
19(1), 146–151.
Orden, S. R., & Bradburn, N. M. (1968). Dimensions
of marriage happiness. American Journal of Sociology,
73(6), 715–731.
Osgood, C. E., Suci, G. J., & Tannenbaum, P. H. (1957).
The measurement of meaning. Urbana: University of
Illinois Press.
Positive Connotation in
Couple and Family Therapy
Gary H. Bischof1, Karen B. Helmeke2 and
Crystal Duncan Lane2
1
Western Michigan University, Lee Honors
College, Kalamazoo, MI, USA
2
Western Michigan University, Kalamazoo,
MI, USA
Name of Concept
Positive Connotation
Synonyms
Noble ascriptions; Positive reframing
Introduction
A distinguishing characteristic of the early Milan
model of family therapy is the use of positive
connotation (Selvini Palazzoli et al. 1978), in
which therapists not only abstain from criticizing
anyone in the family but also point out the com-
mendable aspects of the symptomatic behavior of
both the identified patient and the other family
members (Selvini Palazzoli et al. 1989). The
Positive Connotation in Couple and Family Therapy
primary function of this *positive reframing tech-
nique allows the therapist to take a family systems
perspective of the family and the symptomatic
behaviors that have brought the family to therapy.
Positive connotation is often utilized as an ante-
cedent to the paradoxical prescription that the
family continues in its current functioning. It
should be noted that much of the early work of
the Milan team was with families dealing with
serious issues such as schizophrenia and anorexia
that had not responded to traditional treatments.
Theoretical Context for Concept
The Milan model is a branch of strategic family
therapy which contextualizes change via shifting
how family members make meaning of the pre-
senting problem and family interactions around
the problem. Therapists assume a stance of neu-
trality and utilize positive connotation as a way to
reduce blaming individuals or the family overall,
offering a novel way of viewing their challenges,
and ascribing positive intentions of family mem-
bers to maintain the balance or harmony of the
family system (Selvini Palazzoli et al. 1978). The
Milan approach draws from key principles of
general systems theory.
Description
Positive connotation is a specific form of
reframing the presenting problem. It is a positive
explanation of the current functioning within a
family system aimed at creatively circumventing
resistance and negating blame by approaching the
presenting problem from a position of circular
causality. Through this intervention, every family
member’s behavior is connoted as serving the
family system, which reconstructs behaviors as
good or even noble. A formulation is made by
identifying what family members hope to get for
the family or themselves by the way they interact
with the problem (Campbell et al. 1989).
For example, rather than seeing a child refus-
ing to go to school as evidence of low self-esteem
or oppositional defiance, therapists would
2241
positively connote a child’s refusal to go to school
as the child’s desire to provide companionship to
the depressed, unemployed father and to free up
the rest of the family from worrying about the
father being home alone and the father’s contin-
ued unemployment as an opportunity for him to
spend more time with his son. Positive connota-
tions then paved the way for the Milan team to
prescribe the symptom. For the Milan group, pos-
itive connotations were typically only offered
after two to three sessions of interacting with the
family, testing hypotheses, and team discussions,
so that when delivered, the positive connotation
was credible and fit well with the family’s
experiences.
Application of Concept in Couple and
Family Therapy
The Milan version of strategic family therapy along
with other strategic approaches emphasizes the
importance of viewing the symptomatic behavior
of the “patient” and family members as serving
some positive function or purpose in maintaining
the homeostasis of the family system. This positive
reframing or connotation allows the therapist to join
with the system, provides a different and typically
novel perspective of the interactions in the family
that moves away from blaming the “patient” and P
others in the system, and promotes cooperation of
the family with the therapist. Salvador Minuchin
notes, “Palazzoli has made contributions that have
endured and become part of the public domain of
the field [of family therapy]. Paradox, circular
questioning, and positive connotation – these are
no longer just her ideas. They are things that every-
body use” (Simon 1992, p. 146).
As the field of couple and family therapy has
evolved, some of the strategic interventions have
been criticized as manipulative. With a growing
interest in collaboration with clients and construc-
tivist approaches, imparting a positive connotation
as truth or suggesting paradoxical interventions with
limited explanation has given way to more tentative
presentations of such interventions. For example,
Williams and Auburn (2016) offer an approach to
positive connotation that integrates narrative therapy
2242
in which positive connotations are developed
together with the family. Others have suggested
ways to train therapists on the use of positive con-
notation (Constantine et al. 1984).
Clinical Example
The first author, GB, encountered this adolescent
and family while working in an adolescent group
home. “Tony,” age 15, was in the group home for
truancy, physical violence, and generally
uncooperative behavior. Tony lived with his
mother, and the negatively connoted story was
that the father was a violent alcoholic, had “aban-
doned the family,” and played little role in Tony’s
life, which was a source of considerable anger and
hurt. Tony and his mother were seen by the family
therapist on staff, and GB observed some family
sessions. Key aspects of the clinical work
included Tony trying to make sense of why his
father had abandoned the family, Tony’s resultant
low self-worth and angry outbursts, and his desire
for a relationship with his father.
On one occasion, building upon the therapeutic
relationship and details learned about the family
dynamics, GB suggested a positive connotation of
the father’s leaving that went like this: “Tony,
you’ve talked a lot about your father and how he
left your family and the anger you have about that.
I was thinking about your family the other day,
and I know you have told me about your father’s
drinking, violence, and use of guns. I know that
was a crazy and scary time in your family.
I wonder if at some level your father knew that if
this kind of behavior continued, someone was
likely to be seriously hurt or even killed, and
without seeing a way to change these behaviors,
he figured out that it might be best if he just wasn’t
around. So, he might have sacrificed his time with
you and seeing you grow up as a way to make sure
you and your mother stayed safe and alive.” The
impact of this positive connotation was immedi-
ately evident as Tony took this in. His face
dropped, tears formed in his eyes, and his typical
angry demeanor softened. He was moved by this
new perspective. Days later he mentioned this
new point of view in a family session.
Positive Connotation in Milan Systemic Therapy
Cross-References
▶ Cecchin, Gianfranco
▶ Milan Associates
▶ Milan Systemic Family Therapy
▶ Paradox in Strategic Couple and Family
Therapy
▶ Positive Connotation in Milan Systemic
Therapy
▶ Reframing in Couple and Family Therapy
▶ Selvini-Palazzoli, Mara
▶ Training Strategic Family Therapists
References
Campbell, D., Draper, R., & Huffington, C. (1989). Second
thoughts on the theory and practice of the Milan
approach to family therapy. New York: Karnac.
Constantine, J. A., Stone Fish, L., & Piercy, F. P. (1984).
A systematic procedure for teaching positive connotation.
Journal of Marital and Family Therapy, 10, 313–315.
https://doi.org/10.1111/j.1752-0606.1984.tb00022.x.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata,
G. (1978). Paradox and counterparadox: A new model
in the therapy of the family in schizophrenic transac-
tion. New York: Jason Aronson.
Selvini Palazzoli, M., Cirillo, S., Selvini, M., & Sorrentino,
A. (1989). Family games: General models of psychotic
processes in the family. New York: Norton.
Simon, R. (1992). One on one: Conversations with the
shapers of family therapy. Washington, DC/New York:
The Family Therapy Network/Guilford Press.
Williams, L., & Auburn, T. (2016). Accessible polyvocality
and paired talk: How family therapists talk positive con-
notation into being. Journal of Family Therapy, 38,
535–554. https://doi.org/10.1111/1467-6427.12096.
Positive Connotation in Milan
Systemic Therapy
Maru Torres-Gregory
The Family Institute at Northwestern University,
Evanston, IL, USA
Introduction
Positive connotation is a counterparadoxical
intervention conceived by Mara Selvini Palazzoli,
Positive Connotation in Milan Systemic Therapy
Luigi Boscolo, Giuliana Prata, and Gianfranco
Cecchin, members of the Milan Center for
the Study of the Family and creators of Milan
Systemic Family Therapy. It is based on the fun-
damental belief that symptoms – even psychotic
ones – arise out of a family system’s attempts at
maintaining homeostasis and cohesion instead
of from individual psychopathology. In its purest
form, a positive connotation is a therapist’s
expression of neutrality in regard to the family
system and the presenting problem; it is conceived
out of a process of hypothesizing; and it is
informed by data gathered through circularity of
inquiry. Successful positive connotation results in
“a restructuring of the therapist’s consciousness”
regarding presenting problems and the family sys-
tem (Boscolo et al. 1987, p. 7).
In their seminal work, Paradox and
Counterparadox (Selvini Palazzoli et al. 1978),
the authors explain that the primary function
of this intervention is for the therapist to be able
to access the family system as a whole by casting
all behaviors –not only those of the identified
patient–in a positive light and as beneficial to the
cohesion of the system. They also note the impor-
tance of not positively connoting some behaviors
while negatively connoting others, as this would
divide the family system and preclude the thera-
pist from accessing it.
Positive connotation should not be confused
with a positive reframe or with a mere prescrip-
tion of problematic behavior of the identified
patient.
Theoretical Framework
In their creation of the concept of positive con-
notation, the Milan Associates (before their split
in the early 1980s) was heavily influenced in
their thinking by the Palo Alto Group, particu-
larly by ideas depicted in the 1967 book Prag-
matics of Human Communication by Paul
Watzlawick, Don Jackson, and Janet Beavin,
as well as by the writings and ideas of Jay
Haley, John Weakland, and Gregory Bateson
(Boscolo et al. 1987). Of special relevance to
their processes, including their development of
2243
positive connotation, was their conceptualiza-
tion of problems within a cybernetic under-
standing of systems and of relational causality
(Boscolo et al. 1987), as well as the notion of
double-level communications in families with a
member diagnosed with schizophrenia
(Hoffman 1981). In their work with families
engaged in these double-level communications
or schizophrenic transactions, the Milan Asso-
ciates conceptualized Bateson’s therapeutic
double binds as family games that can only be
changed through the use of counterparadox such
as positive connotations and the prescription of
family rituals (Selvini Palazzoli et al. 1978).
Behavior and communication are synonymous,
and every behavior by a member of the family
communicates feedback creating a loop that
perpetuates the presenting problem (Selvini
Palazzoli et al. 1978).
Rationale for the Intervention
According to Boscolo et al. (1987), positive
connotation is an evolution from symptom pre-
scription, that is, asking clients to actively per-
form or continue their symptom rather than fight
it or fix it (Hoffman 1981; Watzlawick et al.
1974). Only doing this, Milan Associates
believed and runs several risks: exonerating P
the identified patient, making other members
of the family system feel blamed or at fault,
perpetuating symptomatology, and preventing
the therapist from regarding the family as a
systemic unit (Boscolo et al. 1987). Reframing
or changing the client’s entire experience,
meaning, or viewpoint of their difficulty by
placing it in a different frame that still fits its
facts (Watzlawick et al. 1974) was not consid-
ered a sufficient intervention either by the Milan
Associates, as it is merely ascribing good
motives to negative behaviors (Boscolo et al.
1987). In addition, Selvini (1988) explains that
positive connotation conveys the necessary
stance of therapist neutrality by preventing two
major problems from arising: alliances between
therapists and clients and assignment of blame
in the family.
2244
Description of the Intervention
Positive connotation, as applied in the interven-
tion phase of the five-part model of therapy
developed by the Milan Associates before their
split in 1980, consists of accepting all behaviors
of all members of the family system –not just
those of the identified patient– as having benev-
olent motives and being helpful to the family
system’s cohesion and homeostasis (Boscolo
et al. 1987; Selvini Palazzoli et al. 1988). It is
an implicit declaration of the therapist’s alliance
with the family in preserving its homeostasis,
which garners the therapist influence over the
family system in its efforts to change. Though
considered a counterparadoxical intervention, it
is crucial to remember that positively connoting
a problem is not to be done as a strategic or
paradoxical maneuver to trick a family system
into changing (Selvini Palazzoli et al. 1988), as
this would imply that the therapist has not truly
undergone the process of consciousness
restructuring previously mentioned. How the
paradoxical nature of the intervention works is
by placing the family in the paradox of having to
question the need of a patient or pathological
behavior for the sake of its cohesion – beneficial
for the family – which should then propel it into
changing (Selvini Palazzoli et al. 1978).
Case Example
A family, consisting of separated heterosexual
parents and two siblings, a college-aged boy, and
a high school-aged daughter, requests therapy
with their teenaged daughter as the identified
patient. In a joint intake call, the parents describe
the daughter as engaging in self-harming behav-
iors every time they try to schedule a family
meeting. Mother explains that whenever she
attempts to talk to the daughter about the separa-
tion, the impending divorce, and potentially hav-
ing to choose in court which home to make
her main home, the daughter “looses it, locks
herself in her room, and self-harms with scissors.”
Mother further explains that daughter will not
come out of the room until father drives over
Positive Connotation in Milan Systemic Therapy
and talks to her through her bedroom door.
Both parents describe the son as disengaged
from the family drama, excelling academically
and enjoying his college experience. Father
explains that they have tried having the daughter
talk to the social worker at school, which she
refuses to do.
At the therapist’s request, all four family mem-
bers present for therapy. While talking to the
daughter in session, the therapist learns that she
feels extremely alone, missing her brother terribly
since he left for college and only talking to him
when mother calls him and asks him to console
his sister after an episode. She explains not want-
ing to self-harm and hating the scars she’s getting,
but finding it helps her deal with the horrible
feeling she gets when she knows “the talk from
mom is coming.” She tells the therapist that she
still doesn’t understand why the parents are get-
ting divorced when they get along so well, never
fight, and always agree with each other.
Mother and father both explain not wanting
to finalize their divorce without having a grown-
up conversation with their daughter about it,
but slowly coming to think that it is not possible
to do so until she learns how to handle her
emotions and stops self-harming. They inform
the therapist that they have put their divorce
on hold.
After reflecting on the family’s story, the
therapist turns to the clients and congratulates
them on having such a close-knit, thoughtful,
and caring family. She explains that she is
impressed by how they each think of the other
before thinking of themselves, particularly how
they are willing to sacrifice their personal goals
and put their plans on hold to keep their family
together. She turns to the son and thanks him for
making himself available to his sister when she
needs him. The therapist then addresses the
daughter by telling her she feels for her but
understands her loyalty to her nuclear family
before herself, even her own body, something
rare for kids her age. And to the parents, she
says that their commitment to their kids is admi-
rable and understands their decision to put the
divorce on hold until it becomes clear that the
divorce is absolutely necessary. The daughter
Positive Feedback in Family Systems Theory
denies self-harming for her parents’ or the
family’s sake; the son shrugs his shoulders;
and mother and father share their disbelief that
the therapist would not categorically declare the
daughter’s behavior as unacceptable. Mother
turns to father and recriminates him for never
wanting to fight in front of the children
and having moved out so abruptly. The therapist
schedules a session a month later.
Mother and father return as scheduled but on
their own. They inform the therapist having
decided to go ahead with the divorce after the
daughter announced that she was not putting the
family first. She started meeting with the school
social worker, has started using skills to regulate
her emotions, and is self-harming less fre-
quently. They also inform the therapist that the
son has been calling his sister once a week. They
request meeting with the therapist without the
children to work on their communication diffi-
culties and co-parenting during and after the
divorce.
Cross-References
▶ Bateson, Gregory
▶ Cecchin, Gianfranco
▶ Circular Questioning in Milan Systemic
Therapy
▶ Double Bind Theory of Family System
▶ Family Rituals
▶ Feedback in Family Systems Theory
▶ Haley, Jay
▶ Homeostasis in Family Systems Theory
▶ Identified Patient in Family Systems Theory
▶ Jackson, Donald
▶ Milan Associates
▶ Neutrality of Therapist in Couple and Family
Therapy
▶ Palo Alto Group, The
▶ Positive Connotation in Milan Systemic
Therapy
▶ Prata, Giuliana
▶ Reframing in Couple and Family Therapy
▶ Selvini-Palazzoli, Mara
▶ Weakland, John
2245
References
Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987).
Milan systemic family therapy: Conversations in theory
and practice. New York: Basic Books.
Hoffman, L. (1981). Foundations of family therapy.
New York: Basic Books.
Selvini, M. (1988). Positive connotation and the problem
of guilt. In M. Selvini (Ed.), The work of Mara Selvini
Palazzoli (pp. 135–136). New York: Aronson.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G.
(1978). Paradox and counterparadox. New York:
Aronson.
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G.
(1988). The treatment of children through brief
therapy of their parents. In M. Selvini (Ed.), The work
of Mara Selvini Palazzoli (pp. 121–144). New York:
Aronson.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change:
Principles of problem formation and problem resolu-
tion. New York: Norton.
Positive Feedback in Family
Systems Theory
Miranda Smith and Eli Karam
University of Louisville, Louisville, KY, USA
Name of Concept
P
Positive Feedback in Family Systems Theory
Synonyms
Morphogenesis; Positive feedback loops
Introduction
Positive feedback occurs in a family system when
members respond to the introduction of new infor-
mation in such a way that destabilizes the unit.
The feedback is labeled “positive” not because of
intended valence, inherent health, or value to the
system but rather to indicate the presence of an
active shift away from the standing rules, roles,
and norms of the system.
2246
Theoretical Context for Concept
Positive feedback was extended to the realm of
family systems theory after anthropologist Greg-
ory Bateson’s participation in the Macy Confer-
ences on Cybernetics in 1946. At the conferences,
Bateson worked alongside Norbert Wiener, a
mathematician who studied how machines and
their control processes become self-regulating
via the automated application of output data as
new input data (Stagoll 2006). Bateson applied
the notion that systems teach themselves to react
to their own behaviors to families, society, and life
in general. Hence positive feedback sits in the
intersection of family systems and cybernetics
theories.
Description
Positive feedback occurs when a behavior or
communication by one family member triggers
a response that accelerates the system away from
its previous state of stability, or homeostasis.
Specifically, positive feedback follows when
one member’s behavior either amplifies or
diminishes the usual reactions of others, thus
pulling the entire family system away from its
homeostatic state. The homeostatic state is the
familiar place where the family is able to resist
changes to rules and norms that might upset its
sense of balance. Thus positive feedback ulti-
mately results in some modification to the struc-
ture that determines the family’s status quo. It
should be noted that positive feedback could be
either beneficial or detrimental to family func-
tioning. The descriptor “positive” here refers
only to the presence of the said amplification or
diminution of reactions away from homeostasis.
Hence it is not significant whether the original
behavior or communication or the ensuing
behavioral shifts are objectively healthy or
unhealthy for the system. Positive feedback
occurs so long as the interaction in question
moves the family system away from its most
stable structure, which can be either good or
bad for family members. Positive feedback is
the counterpart of negative feedback, a parallel
Positive Feedback in Family Systems Theory
phenomenon wherein members of the system
actively adjust to others’ behaviors in a fashion
that offsets change and thereby maintains overall
homeostasis.
Application of Concept in Couple and
Family Therapy
Therapeutic assessment of communication pat-
terns and a presenting problem will uncover a
complex system of feedback loops. A positive
feedback loop is completed in therapy when devi-
ation from a family system’s normal functioning
is amplified (by either therapist or family member)
rather than reduced and more variation in the
system occurs. Families dominated by negative
feedback loops are characteristically stable and
homeostatic. On the other hand, families highly
regulated by positive feedback may “run away”
with new ideas or behaviors introduced as inputs.
Such systems, dominated by positive feedback,
show more variability and, if unchecked, may
become unstable.
The therapist might note that the family’s pre-
senting problem is the product of an unchecked
positive feedback loop that has escalated away
from homeostasis and toward a state the family
perceives as chaotic. On the other hand, if the
initial homeostatic state upon which the system
enters therapy is not healthy for the family, the
therapist might observe how a positive feedback
loop could unbalance the system in beneficial
ways. Whether positive feedback is a part of the
problem, the solution, or both, it is vital that the
therapist recognizes when members of a client
system are reacting to new information in a way
that is destabilizing.
When a therapist prescribes any behavioral
change for a member of a couple or family, either
a positive or a negative feedback loop will ensue.
Positive feedback is sometimes signaled by an
escalation of conflict. In other instances, positive
feedback takes the form of a constructive conver-
sation or interaction that effectively changes fam-
ily rules and norms. For better or for worse,
positive feedback delivers a couple or a family
away from its baseline of functioning.
Positive Reinforcement in Couples and Families
Clinical Example
Clark and his girlfriend, Pamela, bring Clark’s
adopted 13-year-old daughter, Christina, to begin
working with Megan, a family therapist. Clark
and his ex-wife, Lynn, adopted Christina from
foster care when she was 6 years old. Prior to
being adopted by Clark and Lynn, Christina had
lived with nine different foster families. After
years of marital strain, Clark and Lynn divorced
when Christina was 10 years old. Lynn moved to a
different state and lost most contact with Chris-
tina. Clark began dating Pamela 1 year later when
Christina was 11 years old.
Clark and Pamela report that Christina acts out
when Pamela is in Clark’s home. Two months
ago, she stole Pamela’s cell phone and lied repeat-
edly to cover it up. She even went so far as to write
an emotional letter to Pamela promising that she
would “stop at no end” to find out who did this to
her. Last week, one of Pamela’s bracelets went
missing from the home. Christina resists disci-
pline when Pamela is in the home by lying and
throwing emotional screaming fits. Pamela admits
to Megan that she can hardly stand to look at
Christina because she is so sneaky and manipula-
tive. Clark reports that the tension in the home
when both Christina and Pamela are present is
unbearable.
After observing their interactional cycle,
Megan learns that Clark blames Christina for his
divorce from Lynn. It soon becomes clear to
Megan that when Clark is frustrated with Chris-
tina for developmentally normal offenses such as
talking back to him, he shames her by telling her
he can’t believe she is “going to cost him another
relationship.” In fact, Christina tells Megan during
the first session that her main motivation to suc-
ceed in therapy is to improve behavior so as to not
“ruin another relationship for dad.”
Megan meets with Clark individually to explore
and process these messages of blame and respon-
sibility being directed toward Christina. Megan
explains that the messages are likely placing
undue and unmanageable pressure on Christina,
which might in turn be contributing to her pattern
of acting out around and toward Pamela even
more intensely. Megan acknowledges that when
2247
Christina talks back to or screams at Clark or
Pamela, Clark probably expects the comments
about her ruining his relationships to incentivize
and lead to better behavior. If this approach were
working, the family would have enacted a self-
regulating negative feedback loop. In reality, how-
ever, the messages of blame heighten Christina’s
defenses and thereby increase and intensify
Christina’s poor behavior. Thus Clark, Pamela,
and Christina are caught in a positive feedback
loop that is escalating out of control.
References
Stagoll, B. (2006). Gregory Bateson at 100. Australian and
New Zealand Journal of Family Therapy, 27(3),
121–134.
Positive Reinforcement in
Couples and Families
Jennifer M. Lorenzo1, Rupsha Singh1 and Robin
A. Barry2
1
Department of Psychology, University of
Maryland, Baltimore Country, Baltimore, MD,
USA
2
Department of Psychology, University of
Wyoming, Laramie, WY, USA P
Name of Concept
Positive reinforcement in couple and family
therapy
Synonyms
Reward
Introduction
A reinforcement is any consequence or experi-
ence that follows a behavior and increases the
likelihood of the behavior occurring in the future.
2248
A positive reinforcement is a consequence of
behavior that is added to the individual’s environ-
ment rather than removed. For example, receiving
verbal appreciation from one’s mother following
helpful behavior is positive reinforcement to the
extent that it promotes helpful behavior in the
future. Positive reinforcement in couple and fam-
ily therapy describes therapeutic techniques that
aim to increase the desired behaviors of couple
and family members to promote therapeutic goals.
Theoretical Framework for Concept
Positive reinforcement in couple and family ther-
apy is derived from operant behavior theory (e.g.,
Skinner 1953). Operant theory explains a way in
which behavior is learned. The theory purports
that the consequences of, or experiences that fol-
low, a specific behavior will increase or decrease
the likelihood of the behavior occurring in the
future. There has been some controversy regard-
ing what constitutes “behavior” according to dif-
ferent behavioral theorists. Early behavior
theorists, such as Watson, limited their definition
of behavior to action that was observable by
others. Later theorists, particularly those inter-
ested in human behavior, expanded their defini-
tion of behavior to include anything that people
“do” including observable actions, emotions, and
cognitions.
Behavioral principles are at the core of many
approaches to assessment, conceptualization of
presenting problems, and treatment of couples
and families, for issues ranging from child con-
duct disorders, relationship conflict, and mood
and anxiety disorders. Problems in family and
couple relationships, and individuals in these rela-
tionships, are often viewed as a function of indi-
viduals’ reinforcement histories. Hence, in this
theoretical framework, positive reinforcement is
used to increase the frequency of specific desired
behaviors within the family system. Reducing
family and couple members’ tendency to posi-
tively reinforce problematic behaviors is also a
critical focus of behaviorally oriented family and
couple therapies (see review in Martin and Pear
2016).
Positive Reinforcement in Couples and Families
Rationale
Within family therapy, positive reinforcement is
used to modify individual behaviors and family
relationships (Martin and Pear 2016). Therapists
work with families to identify specific desirable
behaviors (e.g., child obedience to parental
requests and use of effective coping skills when
anxious). Defining the desirable behaviors helps
to promote reliable detection of the desired behav-
iors and increases the likelihood that the reinforce-
ment program will be applied consistently. In
addition to identifying desirable behaviors and
suitable positive reinforcements, the therapist
works with the family to develop appropriate
behavioral contingencies (i.e., behaviors that
must occur before the positive reinforcement
will be presented). This is especially critical
because parents often unintentionally reinforce
problem behaviors thereby sustaining the behav-
iors. For instance, if parents are busy and primar-
ily give children attention to scold them when they
are “misbehaving,” then the parents’ attention
likely functions as positive reinforcement for
“misbehavior.” Parents may intend their scolding
to punish their child’s misbehavior. However,
parental attention is strong positive reinforcement.
When the child is behaving properly, parental
attention is not required and busy parents can
direct their attention to other activities. As a result,
the child may seek out the parents’ attention by
engaging in misbehavior or may engage in mis-
behavior for other reasons only to have this behav-
ior positively reinforced by parents’ attention.
Utilizing positive reinforcement in therapy is
also a useful approach for couples with relationship
distress because distress is often conceptualized as
an unbalanced exchange of social reinforcers
(Patterson and Reid 1970), failure in mutual rein-
forcement (Stuart 1969), or aversive partner behav-
iors attempting to control the other partner’s
behaviors (Patterson and Hops 1972). Instead of
using positive reinforcement to shape their part-
ner’s behaviors and the relationship, couple-mem-
ber may come to rely on negative reinforcement
and punishment. Inappropriate use of punishment
and unintentional reinforcement of problem behav-
iors are frequent pitfalls of families who are
Positive Reinforcement in Couples and Families
seeking treatment (Martin and Pear 2016). Inten-
tionally, introducing positive reinforcement
changes the pattern of couple interactions. This
can be useful with all couples, including less dis-
tressed couples, because behavioral principles are
universal. Using positive reinforcement can help to
strengthen positive interactions that a couple or
family is already exhibiting.
Description
Before using positive reinforcement in couple and
family therapy, a functional behavior analysis is
conducted to assess what stimuli are sustaining the
problem behaviors in what specific situations
(McLeod et al. 2013). During this process, the cli-
nician learns about the specific problem behaviors,
the positive and negative aspects of the behaviors,
the parent or partner’s response, and the positive and
negative aspects of the response behavior. After the
functional behavior analysis, the clinician can work
with the couple or family to identify desired behav-
iors and undesired behaviors, reduce couple or fam-
ily members’ tendency to positively reinforce
undesired behaviors, and increase positive rein-
forcement for desired behaviors.
In child or family therapy, the use of behavioral
techniques is common for a wide range of pre-
senting problems (e.g., conduct issues, anxiety,
depression, sleep disorders, and feeding disor-
ders). The goal is often to make positive reinforce-
ment contingent on the desired behavior. There
are five categories of positive reinforcement to
consider when attempting to modify behavior:
consumable (i.e., food), activity (e.g., screen
time), manipulative (e.g., extra credit), posses-
sional (e.g., toy), and social (e.g., praise; Martin
and Pear 2016). Positive reinforcements can also
be combined, such as in token economies. In
token economies, the child earns small positive
reinforcements (i.e., tokens, such as poker chips,
tickets, or stickers) that can be exchanged for
larger rewards* (e.g., candy or toys) after they
have earned a specific number of small rein-
forcers. In addition to identifying and providing
positive reinforcements for the child, for desirable
behaviors, parents and families are often taught to
2249
ignore non-dangerous problem behaviors (i.e.,
selective inattention). Ignoring undesirable
behaviors is a way of removing positive reinforce-
ment (i.e., parental attention) that was helping to
sustain undesirable behaviors. Pairing selective
inattention with increased attention to desirable
behaviors helps improve relationships and rein-
forcement patterns.
Couple therapies that emphasize behavioral
principles incorporate positive reinforcement by
helping couple-members make the relationship
positively reinforcing for one another instead of
punishing. That is, therapists attempt to increase
couple members’ tendency to positively reinforce
one another’s attempts to constructively commu-
nicate with one another and to engage in relation-
ship behaviors that each couple member would
find desirable. One way in which this change can
be accomplished is by teaching couples effective
communication skills (e.g., active listening, effec-
tive emotional expression, and assertive commu-
nication). When couples replace insults, character
assassinations, and blaming with effective com-
munication skills, partners should increase their
tendency to engage in communication with one
another and increase attempts at problem-solving
because positive reinforcement is experienced
during these altered communication contexts.
Couple and family therapies that are founded
in behavioral techniques utilize homework as a P
major component of therapy. Homework serves as
an opportunity to practice behavioral changes and
experience positive reinforcement outside of ther-
apy. Additionally, review of the homework in
therapy is a time for the clinician to provide feed-
back and to model some of the techniques or
principles. For instance, clinicians may praise
couple or family members for homework comple-
tion, which not only models the desired behavior
(i.e., praise) but also reinforces the clients’ home-
work completion.
Clinical Example
Devon and Casey entered couple therapy follow-
ing a recent argument in which Casey threatened
to leave the marriage if Devon would not engage
2250
in couple therapy. They had been married for
6 years and had a 4-year-old son (Toby), and
were in the process of adopting their second
child. The couple’s relationship was characterized
by a history of frequent, heated arguments. How-
ever, the couple reported this was the first time
that either partner had made a “serious” threat to
end the marriage. Both Devon and Casey reported
high commitment to the relationship.
In the intake, the couple described their typical
pattern of conflict and communication. Casey
reported feeling alone in much of the parenting
and household responsibilities. Casey described
that talking with Devon about “taking a more active
role” felt like “talking to a brick wall.” Devon
described feeling “attacked”. Devon’s efforts help
were “never good enough.” Typically, as the con-
flict ensue, Casey would become more angry and
communicate concerns and dissatisfaction more
intensely (e.g., shouting, attacking) and Devon
would withdraw by shuting down, or leaving the
room or house. Upon entering therapy, one of
their frequent topics of conflict was bedtime
issues with Toby. At 4 years of age, both parents
expected that Toby would consistently sleep in his
own bed. Nearly every night, Toby would “put up
a fight” about going to bed (e.g., plead for a later
bedtime, cry when his parents left his room, and
leave his room to sleep with his parents). Casey
wanted Devon to take the lead on this issue but
reported feeling Devon was “too harsh” when
dealing with Toby for leaving his bed (e.g.,
shouting and withholding screen time the next
day). Casey often intervened in Devon’s efforts
to get Toby to go to bed which left Devon feeling
undermined. Both of them wanted the issue
resolved but felt somewhat helpless about chang-
ing Toby’s behavior.
The clinician began therapy by asking questions
about Toby and their interactions with him during
daytime and nighttime. Through this interview, the
clinician developed several hypotheses about what
behaviors were reinforcing Toby’s nighttime behav-
iors and explained the following to them. Because of
their busy schedules, it seemed that Devon and
Casey spent little time interacting with Toby during
the daytime. Reading a bedtime story and putting
him to bed was the most time they spent with him
Positive Reinforcement in Couples and Families
without any other distractions. When Toby
complained or asked for more stories, they often
“gave in” and provided additional attention. This
extra attention positively reinforced Toby’s
complaining and other problematic nighttime
behaviors because it meant he would receive addi-
tional attention from them. Additionally, the incon-
sistency in adhering to punishments threatened by
his parents meant that the more Toby fought bed-
time, the more likely he would get what he wanted.
Devon and Casey were inadvertently reinforcing
worse tantrums.
In addition to identifying behaviors that were
reinforcing Toby’s nighttime problems, the clinician
observed Devon and Casey’s interactions to learn
what was sustaining their conflicts. The clinician
described the pursue-withdraw conflict pattern to
the couple, and the couple agreed their typical argu-
ments reflected this pattern. Additionally, the clini-
cian proposed that there were punishing and
reinforcing aspects that maintained these conflict
interactions. For Casey, shouting at Devon was pos-
itively reinforcing because shouting was a way
Casey could feel heard.” However, the shouting
was aversive to Devon, and withdrawing from the
conflict by leaving the home was negatively
reinforced because Devon no longer had to hear
Casey’s shouting or insults. The therapist also
explained other ways that lack of positive reinforce-
ment had changed the couple’s interactions with one
another making the relationship and co-parenting
less satisfying for both of them. The couple and
therapist agreed that a primary goal of therapy was
to increase positively reinforcing aspects of their
relationship with one another and with Toby.
The clinician introduced a communication skills
intervention and a nighttime behavior intervention.
To improve their communication and break their
cycle of conflict, the couple was taught active lis-
tening skills (e.g., reflections and validation) and
assertive communication skills (e.g., “I”-statements
and requests). The first homework assignments
emphasized validating the partner’s concerns and
avoiding blaming or insulting their partner. This
change in communication would foster a less aver-
sive exchange and receiving validation for their
concerns and efforts would serve as positive rein-
forcement of positive communication behaviors.
Post-Divorce Families in Couple and Family Therapy
The clinician assigned homework each week.
Receiving feedback from the clinician positively
reinforced the couple’s homework completion and
use of the techniques learned in therapy.
The nighttime intervention incorporated posi-
tive reinforcement of desired behaviors (e.g.,
Toby staying in his bed throughout the night).
The clinician worked with the couple to decide
on bedtime and instructed the couple to clearly tell
Toby what time they expect him to go to bed. The
clinician recommended drawing a picture of a
clock with the bedtime, as a reminder. Being
specific and consistent would be critical to the
success of the intervention. Part of the consistency
involved creating a bedtime routine that would
start about 1 hour before bedtime and involved
calming activities, such as cuddling or reading a
bedtime story together. Because both Devon and
Casey were busy, giving Toby special attention at
bedtime would help Toby see bedtime in a
positive way.
To positively reinforce sleeping in his own bed,
the clinician recommended Devon and Casey
make an agreement with their child that they
would check on him 5–10 min after putting him
in bed. If he was in bed at this checkpoint, he
would earn a sticker, and if he slept in his bed
the whole night, he would earn a second sticker.
At the end of the week, if Toby earned eight
stickers, he earned the opportunity to choose that
weekend’s family activity. Through this interven-
tion, the stickers and choice of activities were
positive reinforcements for positive bedtime
behaviors. To stop reinforcing problem behaviors,
the clinician recommended Devon and Casey
ignore Toby’s protests to prolong bedtime. They
would say “it is bedtime” and return him to bed
without additional conversation.
After about 2 weeks, Devon and Casey
reported less frustration with Toby’s bedtime. As
a result of reduced distress, they reported fewer
arguments. The couple began using active listen-
ing skills and practicing the skills in session with
the clinician. Although they continued to have
difficulty validating their partner consistently,
each member of the couple used fewer critical
statements. Over the next month, they continued
improving their communication skills and
2251
increased Toby’s goal to 12 stickers per week.
Over the following 3 months, the couple faded
out Toby’s sticker chart but continued weekly
family activities as an opportunity to provide
him positive attention.
Cross-References
▶ Token Economy in Couple and Family Therapy
References
Martin, G., & Pear, J. (2016). Behavior modification: What
it is and how to do it (10th ed.). London: Routledge.
McLeod, B. D., Jenson-Doss, A., & Ollendick, T. H.,
(2013). Overview of diagnostic and behavioral assess-
ment. In B. D. McLeod, A. Jenson-Doss & T. H.
Ollendick (Eds.), Children and adolescents: a clinical
guide (pp 3–33). New York, NY: Guilford Press.
Patterson, G. R., & Hops, H. (1972). Coercion, a game for
two: Intervention techniques for marital conflict. In
R. E. Ulrich & P. Mountjoy (Eds.), The experimental
analysis of social behavior. pp 151–179. New York:
Appleton-Century-Crofts.
Patterson, G. R., & Reid, J. R. (1970). Reciprocity and
coercion: Two facets of social systems. In C. Neuringer
& J. L. Michael (Eds.), Behavior modification in clin-
ical psychology (pp. 133–177). New York: Appleton-
Century-Crofts.
Skinner, B. F. (1953). Science and human behavior.
New York: Macmillan. P
Stuart, R. B. (1969). Operant-interpersonal treatment of
marital discord. Journal of Consulting and Clinical
Psychology, 33, 675–682.
Post-Divorce Families in
Couple and Family Therapy
Rachel D. Miller and Kristina S. Brown
Couple and Family Therapy Department, Adler
University, Chicago, IL, USA
Name of Family Form
Post-Divorce Families in Couple and Family
Therapy.
2252
Synonyms
Binuclear families
Introduction
Given that 40–50% of marriages end in divorce
(American Psychological Association 2017), it is
imperative, from a therapeutic standpoint, to con-
template the changes, challenges, and opportuni-
ties families face post-divorce. These issues might
range from grieving the losses of the relationship,
extended family, and plans for the future, to
co-parenting challenges, behavioral issues in chil-
dren, returns to family court to update custodial or
financial arrangements, to the addition of steppar-
ents, stepsiblings, and half-siblings. A couple can
dissolve their relationship, and separate their
household, but if there are children involved,
post-divorce families, both nuclear and extended,
often remain intrinsically intertwined. Regardless
of age, or time passed, children of divorce carry
the impact of parental separation. The legacy with
which that leaves them will vary widely,
depending on how families rearrange themselves
and learn to function post-divorce. Therapists, to
best help families navigate the ever-changing
landscape that is post-divorce life, should have a
basic understanding of the research around the
potentially negative impacts of divorce, and the
interventions and approaches that have shown to
be helpful in mitigating these impacts long term.
Additionally, therapists are encouraged to under-
stand both the general and shared experiences of
families who have separated, regardless of legal
marital status, or configuration, as well as the
unique circumstances that each system brings to
their configuration as a post-divorce family.
Description
Divorce dissolves a marriage; it does not dissolve
a family. Dr. Constance Ahrons, in her book, The
Good Divorce, offers the term binuclear family to
describe post-divorce families, attempting to nor-
malize this now common family form. Binuclear
Post-Divorce Families in Couple and Family Therapy
family, according to Ahrons (1994), acknowl-
edges the existence of the original nuclear family
while simultaneously recognizing they now reside
in more than one household. Post-divorce families
may consist of single-parent, or multigenerational
homes, homes with a parent in various configura-
tions of remarriage or cohabitation, or more
recently an arrangement called nesting. Nesting
allows the children to remain in their familial
home, while the parents rotate in and out based
on a predetermined schedule. Children of divorce
appear to be less impacted by the living arrange-
ment parents choose than they are by the quality
of their relationship with their parents, and their
parents’ relationship with each other (Ahrons
2007). Ahrons (1994) considers a “good divorce”
one where “both the adults and children emerge at
least as emotionally well off as they were before
the divorce” (p. 2). Having a good divorce, and
maintaining positive relationships between
divorced parents, while posited as the ideal, is
not always possible, and can be challenging to
accomplish. Co-parenting may need to be
replaced with low- or no-contact parallel parent-
ing at times to ensure all parties remain emotion-
ally well off. This approach has been shown to be
beneficial for those post-divorce families that
remain high-conflict, or where domestic violence
is known or suspected to exist (Jaffe et al. 2008).
Relevant Research about Post-Divorce
Family Life
Post-divorce families will continue to navigate
major lifespan phases and come to therapy for
them, just like their nondivorced counterparts.
Children of divorce will continue to experience
the same developmental milestones and struggles
as their peers and be brought to therapy for them
by well-meaning, concerned parents. While much
of the research shows that children of divorce will
struggle with academic, behavioral, relational,
and psychological problems throughout their
lives, a newer study suggests that these difficulties
are not preordained, can be mitigated through
positive parental relationships, and will have
varying degrees of long-term impact (Amato
Post-Divorce Families in Couple and Family Therapy
et al. 2011). Additionally, while the dominant
narrative around what it means to be a child of
divorce, and its negative impact, can provide a
baseline for shared experiences, not all children
find their parents’ divorce the defining moment of
their lives (Bernstein 2007). If parents buy into the
dispositive narrative of divorce being catastrophic
for children, it becomes easy to blame every dif-
ficulty a child experiences on the divorce, when it
may simply be age-appropriate behavior or devel-
opment (Ahrons 1994; Bernstein 2007). Post-
divorce families whose parents can maintain pos-
itive co-parenting relationships seem to have chil-
dren with fewer behavioral problems, but children
from single-parent and parallel parenting homes
fare similarly to their co-parented counterparts in
the areas of self-esteem, liking school, and life
satisfaction (Amato et al. 2011). That said, a
25-year-longitudinal study on the legacy of
divorce concluded that children will reprocess
their divorce experience at each developmental
stage (Wallerstein et al. 2000) which may exacer-
bate typical transitions, such as launching, getting
married, and becoming a parent. Wallerstein et al.
(2000) found adult children of divorce indicated
that their parents’ divorce impacted their ability to
trust, and their expectations about relationships
noting possible future struggles in the develop-
ment of their own intimate relationships. Coping
with change was also highlighted as being prob-
lematic for children of divorce (Wallerstein
et al. 2000).
Most post-divorce families will experience
remarriage, or parental cohabitation, at some
point (Ahrons 2007). This addition of people to
the binuclear family can prove both challenging
and confusing for the children and adults (Ahrons
1994). These relationships with stepparents,
stepsiblings, and half-siblings, along with
extended family, will vary depending on the
child’s relationship with their biological parent,
time spent with new family members, and person-
ality matches (Ahrons 2007). To complicate the
situation further, many parents believe their chil-
dren will be happy for them and their new-found
love, and that blending families together will be a
simple task, underestimating the care needed.
When this is not the case, as it often proves to
2253
be, all family members tend to feel disappoint-
ment and experience distress. Parents who can
positively co-parent are more likely to have chil-
dren who maintain healthy relationships with both
parents, and develop more positive relationships
with their stepfamilies and extended kin (Ahrons
2007).
Research also shows that in post-divorce fam-
ilies there is increased potential for fathers to
disengage from their children (Ahrons 1994,
2007; Wallerstein et al. 2000). This impacts not
only the children’s relationship with their father,
but also with the father’s extended family (Ahrons
1994, 2007). While courts have become more
proactive in providing parenting time to fathers,
court mandated time does not ensure good rela-
tionships between fathers and their children.
Fathers disengage for any multitude of reasons
ranging from grief, feeling rejected by their chil-
dren, to conflict with the children’s mother, to
uncertainty in their new role, to the introduction
of a new partner, or any combination of these and
other reasons (Ahrons 1994; Wallerstein et al.
2000). Early interventions with both fathers and
mothers stressing the importance of consistent
father involvement helps minimize this occur-
rence, regardless of the reason for disengagement.
Special Considerations for Couple and P
Family Therapists
When working with post-divorce families, thera-
pists should be aware that the foundational
research on this family form was conducted on
American, mostly white, middle-class, heterosex-
ual couples before same-sex marriages were legal
(Ahrons 1994, 2007; Wallerstein et al. 2000). This
limits what is known about post-divorce families
with varying cultural backgrounds, families with
same-sex parents, or polyamorous family forms.
Therapists maintaining a collaborative, not-
knowing stance can provide these post-divorce
families the opportunity to share their experiences
and make meaning of them moving to a healthy
structure as mutually defined.
Post-divorce families in the therapy room can
present in a myriad of ways for countless reasons.
2254
A child struggling in school, or a child suddenly
having behavioral issues, can result in panicked,
guilt-ridden parents running their children to ther-
apy because they are sure the divorce, or the other
parent, is the reason for the problem. When work-
ing with post-divorce families, it is important
therapists have at least a basic understanding of
the family court system and how it intersects with
work done in therapy. Divorce decrees and child
custody arrangements, or modifications to either,
typically have stipulations around who is allowed
to participate in therapy, who is to bring the iden-
tified client to therapy, or whose approval needs to
be obtained before therapy can begin. Therapy
may also be court mandated due to high conflict,
or other matters that have been unresolvable
through the courts, for example, parenting agree-
ments, domestic violence, or life transitions like
remarriage or college. Protective orders may be in
place that must be honored, or other legal deci-
sions may impact how therapy can be conducted.
Insight into the family court system and knowl-
edge of custody agreements are essential in ensur-
ing Couple and Family Therapists practice legally,
ethically, and within their scope. In addition, this
knowledge and insight can aid in determining
which treatment modality or therapeutic approach
might best serve the family.
A cooperative, positive co-parenting unit is
known to be best for a post-divorce family
(Ahrons 1994, 2007). Long-term, the children
who have this type of parental unit fare best
throughout their lives. Couple and Family Thera-
pists can help post-divorce families expand their
ideas of what it means to be a family. A far-
reaching, relational lens can shift how post-
divorce families see themselves and their connec-
tions to each other, even though the parental union
has dissolved. The timing of such interventions
can prove challenging. One must consider how
new the divorce is, the reason the marriage
dissolved, the current crisis that brought the fam-
ily to therapy, the history of violence in the family,
and the willingness of the different parties to
participate in therapy. This does not mean it is
impossible, only that it may be a delicate, and
potentially lengthy, process. Time can often aid
in developing positive co-parents, as wounds heal,
Post-Divorce Families in Couple and Family Therapy
communication is improved, and the well-being
of the children regains priority.
Not all post-divorce families will include chil-
dren. Therapists may see individuals who are
struggling to move past their divorce, or who
will need to process their feelings, thoughts, and
beliefs about their divorces before they are able to
move forward into new relationships. The reason
the marriage dissolved may be key to determining
the direction of therapy with post-divorce individ-
uals. For example, a divorce that involved infidel-
ity requires a different approach for healing than a
divorce that was amicable, though both will likely
involve some amount of work around grief and
loss. In addition, a new relationship, or
remarriage, has the potential to trigger past hurts
or anxieties, which may require therapists to delve
into a client’s divorce in couple’s therapy. Divorce
leaves a legacy even for those who are able to
walk away without forever being tied to an
ex-partner through mutual children that will likely
need to be worked through in therapy.
Working with post-divorce families has the
potential to trigger many self-of-the-therapist
issues. Whether a therapist is a child of divorce,
a divorced parent, going through a divorce, an
individual for whom divorce goes against their
religious beliefs, or is simply someone who has
strong beliefs about how post-divorce families
should function, there are plenty of areas where
personal triggers can impact the therapist’s work
with the family. Examining one’s beliefs around
divorce and post-divorce families can aid in dis-
covering possible triggers. Working through one’s
own experiences with divorce and post-divorce
families can increase awareness around triggers,
as well as increase empathy for clients and their
situations.
Cross-References
▶ Ahrons, Constance
▶ Divorce in Couple and Family Therapy
▶ Divorced Families
▶ Family
▶ Single Parent Families
▶ Stepfamilies in Couple and Family Therapy
Postmodern Approaches in the Use of Genograms
References
Ahrons, C. R. (2007). Family ties after divorce: Long-term
implications for children. Family Process, 46(1), 53–65.
https://doi.org/10.1111/j.1545-5300.2006.00191.x
Ahrons, C. (1994). The good divorce. New York:
HarperCollins.
Amato, P., Kane, J., & James, S. (2011). Reconsidering the
“good divorce”. Family Relations, 60(5), 511–524.
https://doi.org/10.1111/j.1741-3729.2011.00666.x
American Psychological Association. (2017). Marriage
and divorce. Retrieved from http://www.apa.org/
topics/divorce/
Bernstein, A. C. (2007). Re-visioning, restructuring, and
reconciliation: Clinical practice with complex post-
divorce families. Family Process, 46(1), 67–78.
https://doi.org/10.1111/j.1545-5300.2006.00192.x
Jaffe, P. G., Johnston, J. R., Crooks, C. V., & Bala, N.
(2008). Custody disputes involving allegations of
domestic violence: Toward a differentiated approach to
parenting plans. Family Court Review, 46(3), 500–522.
https://doi.org/10.1111/j.1744-1617.2008.00216.x
Wallerstein, J. S., Lewis, J. M., & Blakeslee, S. (2000). The
unexpected legacy of divorce: A 25 year landmark
study. New York: Hyperion.
Postmodern Approaches in
the Use of Genograms
Jacob Mosgaard1 and Monica Sesma-Vazquez2
1
Kongens Lyngby, Denmark
2
University of Calgary, Calgary, AB, Canada
Introduction
In the field of couples and family therapy,
genograms are widely known and used as graphic
tools for gathering general or detailed information
about family structure and interpersonal relation-
ships, including relevant data regarding family
demographics and key aspects of the past and
present. Systemic family therapist Monica
McGoldrick is not only a pioneer in developing,
popularizing, and describing how to depict differ-
ent family structures, and establishing codes and
symbols, but she also proposes diverse modalities
to utilize genograms as therapeutic instruments
for assessments and interventions (McGoldrick
et al. 2008).
2255
A genogram is designed to help understand
family composition, dynamics, and patterns
across generations. Genograms in a sense are ver-
sions of family trees. Some people define them as
graphic representations for mapping psychologi-
cal factors and transgenerational relationship
punctuations that influence individuals’ behav-
iors, emotions, and performances.
Traditional genograms include symbols to por-
tray the so-called index person (also called “iden-
tified patient”), gender, age, marital status, and
deaths, among other factors (see Fig. 1 for exem-
plification). The classic genogram is used by ther-
apists to elaborate hypotheses, formulate the
clinical case, and include other potential explana-
tions concerning causes or factors that preserve
couple and family problems. These explanations
are attempts at understanding the role of “symp-
toms” within the family. Traditional genograms
moreover have the goal of determining the most
affected member in the family, inform therapeutic
goals, orient therapists’ decisions, and assist in
designing therapeutic interventions. Traditionally,
genograms have specific guidelines on how to
create and intervene on them.
Different fields of practice (such as sociology,
psychiatry, social work, etc.) and therapeutic
schools (psychoanalytic, cognitive-behavioral,
among others) have adopted the use of
genograms. Though emerging in the 1970s, P
unlike many other systemic tools genograms are
still widely used. They are still seen as practical
devices for gathering information as well as com-
plex gateways to connecting with family mem-
bers. Besides being tools for information and
intervention, they can help generate rich conver-
sations, whether approached traditionally or from
a postmodern perspective.
From Systemic to Postmodern
Approaches to Genograms
The change from modernist systemic practice to
postmodernist practice is essentially a shift in
epistemology, from systemic thinking to social
constructionism. Following this shift is the devel-
opment of new methods and the continuation of
2256 Postmodern Approaches in the Use of Genograms

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Construction School Teacher Darren
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Student
Matthew Sarah Natalie

Postmodern Approaches in the Use of Genograms, Fig. 1 Traditional genogram

already existing ones, but with altered theoretical
underpinnings. The same questions may be asked
(for instance “circular questions”) and the same
tools may be used (for instance “genograms”), but
their implications may differ.
It is a change from language as a depiction of
reality as it is (e.g., family systems) to language as
creating reality. This shift may seem subtle at first
since both the systemic and the social construction-
ist stances stress a focus on relationships. But the
differences become clearer when looking at specific
applications, such as the uses of genograms. The
differences reside in the center of attention of the
professional practice. Systemic genogram practice
places the individuals as the core elements of these
relationships (e.g., “Who is closer to whom?,”
“What is he doing, when she is doing that?,” etc.),
whereas postmodern genogram practices position
relationships as the basis, even of “individuals”
(e.g., “What are we together making possible and
impossible?,” “Which cultural ideas are these rela-
tionships enforcing?,” etc.).
The shift in epistemology is not merely a
peaceful refocusing exercise. It entails some sub-
stantial criticism, some of which is of importance
to the shifts in the uses of genograms as well.
Systemic thinking has been criticized for over-
looking social or power issues such as class, gen-
der, and race (see Paré 1995). As for the
professional positioning, it has been criticized
for being too functionalist, being too fixated on
hierarchies, or subject-subject relationships
(hence risking becoming individualist). This
leads to a traditional construction of the profes-
sional as the master analyst and the goal of the
genogram as assessment.
The aspirations of postmodern genogram use are
more anthropological, more concerned with explor-
ing than uncovering. They are aspirations of trying
to not focus on “the family as a known entity,” but
on a family as a complex and always unique set of
ideas, values, preferred identities, and relational
practices (see Iversen et al. 2005). The postmodern
genogram is not functionalist, and therefore not
seeking final or authoritative answers, but may be
used as a scaffold for dialogue Table 1.
Genograms as Entry Points for Dialogue
When leaving a structuralist application behind,
genograms become not static snapshots, but
Postmodern Approaches in the Use of Genograms
Postmodern Approaches in the Use of Genograms, Table 1 Comparison of modern and postmodern uses of
genograms
Traditional
Created by the therapist
Oriented toward symptoms (index person)
Symbols are important (predetermined, consensual, and
specific). Therapist could follow institutional genograms
or software
Focus on family structure and relational patterns
Focus on behaviors of individuals and families
An objective portrayal of the family
Truths about the family
An invitation to formulate systemic hypotheses
Emphasis on content
Static
Therapist perspective and interpretation
Helps the therapist (orienting questions and strategies)
No playfulness. Stays in the room and within the client’s
life
dynamic vantage points for dialogue and for
relational reflections. Postmodern practitioners
consider the genogram a starting point for conver-
sations about relationships, and the purpose is a
creative deconstruction and reconstruction of the
complex meaning ascribed to these relationships.
In other words, postmodern therapeutic approaches
to genograms tend to become workshops of crea-
tivity, stepping from the evaluation of traditional
family structures into unknown territories.
A Not-Knowing Approach to Genograms
The focus on dialogue highlights an important
shift in the use of genograms – the changing of
professional positioning. The postmodern prac-
titioner is less interested in seeking the truth
behind the genogram, recording information,
and generating interventions, than in pragmati-
cally collaborating in a process of exploration of
the meaning and possible or preferable paths
ahead for the clients coconstructing the geno-
gram. When no longer utilizing the genogram
for seeking answers to questions of “the world
out there,” the professional ceases to act as an
expert and starts working as a collaborator. It is a
2257
Postmodern
Cocreated with the client
Oriented toward dialogue and conversation
Symbols are cocreated, flexible. Symbols are creative and
organic. Graphics are created by people involved in the
process and make sense within local dialogue
Focus on clients’ stories, narratives, remembering, among
others
Focus on rhizomes and social complexities
A generative visualization tool
Family stories
An invitation for genuine curiosity
Emphasis on process
Fluid
Client/therapist perspective, multiple voices
Helps both therapist and client (creating new meaning)
Clients can invite others to their therapeutic conversations
by sharing their genograms and bringing their voices
step from knowing better and knowing enough to
knowing differently. The new position is one of
thinking with the client instead of thinking (and
talking) about the client (Shotter 2006). It strives
to include the clients’ voices with as much soli-
darity as possible. It implies a shift from being
helpful (a heroic savior of sorts) to being useful
(in the service of the client’s wishes and truths)
(Cecchin et al. 1992).
Postmodern approaches to genograms build on a P
not-knowing stance (Anderson 1997). The profes-
sional does not know where the dialogue is sup-
posed to end or which steps will be the correct ones.
The client does not know either. It is a shared
process of discovery. This points to a noticeable
difference in traditional systemic and postmodern
or social constructionist use of genograms – the
assigned expertise. In a dialogical use of genograms,
the role of interpreter lies not so much with the
professional as with the client, and even more pref-
erably in a collaborative effort by the professional
and the client. Thus, there are no “correct” ways of
interpreting the meaning or the important areas of
the genogram. Since it is not understood as a “truth-
ful” depiction, but rather as one visual image of a
possible many, what should be stressed or reflected
upon is not set in stone. This shifts the use of the
genogram from a tool for “unmasking” to an aid in a
2258
hopefully useful dialogue around issues of impor-
tance for the client.
Genograms as any other form of visualization
tool functions as a sort of common third, a shared
project to explore. This process is sometimes
called loitering (a term from narrative practice)
since it is in no hurry to get anywhere
specific. Genograms can thus be used as starting
points for a mutual exploration of the hitherto
unknown. When neither professional nor client
has fixed answers to questions arising from the
genograms, this exploration may evolve into dis-
covering or even creating new relational realities.
This approach to genograms demands a basic
curiosity on the behalf of the professional, a tol-
erance of uncertainty (see Seikkula and Arnkil
2014), and what might be termed an “anthropo-
logical gaze” (Mosgaard in press). For the rela-
tional links that may appear or that may be part of
a dialogue of anticipation will often be new, and
even surprising.
Genograms Within Therapeutic Contexts
Postmodern uses of genograms in therapy can be
the traditional practice of static depiction with the
purpose of getting an overview of relationships of
importance to clients. From this starting point,
conversations may venture into subjects such as
attachment experiences, relational identities, pre-
ferred stories, and/or highlighting significant rela-
tionships (e.g., in a narrative remembering
conversation). They may be introduced as a visu-
alization of crucial relationships and as a way of
discovering the strong or weak links with other
people: “Who is closer or distant to me, and do
I prefer it this way?”
Traditionally, a genogram is a depiction of the
family as it is. The focus lies primarily on the family
and the microrelations between its individuals.
A postmodern approach removes the focus from
the singular focus on the microcosm of the family,
and – if of interest to client and therapist – broadens
the scope to include other networks of importance
(Sesma-Vazquez 2011). A genogram thus can
include community, institutions, multiple families,
friends, kin, significant others, and the weak or
Postmodern Approaches in the Use of Genograms
strong links between the multiple agents; and it
may include other information, dreams, or values
of the clients. It may even include externalized
concepts of importance to bring into the dialogue
the relationship between the human agents and the
externalized concepts (see White 2007).
As with traditional genograms, they can be used
in individual, couples, and family therapy. With
more than one client present, it is possible to do
both a shared genogram with their current family
unit as the center of attention and do two or more
genograms (especially of interest to adults) of their
respective families of origin and expanded net-
works. This may lead to reflections on overlapping
qualities or special difficulties or tensions noticed
or clarified when comparing the genograms.
Genograms Within Clinical Supervision
and Training Contexts
Supervision of psychotherapy and other relational
practices, such as social work or family counsel-
ing, is a practice of metareflection. This reflecting
process may benefit from using genograms of
significant relationships, of the clients in focus of
the professional work, or placing the professional
relationship in the genogram as well. It may even
be illuminating to include the supervisory rela-
tionship itself, as a visualization of the complex-
ities of relational and metarelational connections.
In contexts of training (e.g., couple and family
therapy or social work), genograms can be helpful
as a way of training the practitioner’s positioning
skills, practicing seeing “reality” from different
relational vantage points. Creating genograms of
families, maybe of the student’s own, can be an
invaluable training in taking a relational
(as opposed to a primarily individual) perspective
in working with people. The visualizing itself also
introduces the possibility for, on a metalevel,
working creatively with families.
Other Creative Applications
As postmodern uses of genograms are not
attached to any fixed procedure or intervention,
Postmodern Approaches in the Use of Genograms 2259

being a tool for dialogue rather than intervention,
the applications can be manifold. Some ways of
using genograms apart from traditional ones are
suggested here:
(a) Dream Genogram, which can be compared to
the “realistic” one and help ground problem-
solving or decisions not only in “reality,” but
within the frame of clients’ preferred values
and stories.
(b) Change-Focused Genogram, which can help
highlight which relationships clients wish to
strengthen, weaken, or look more into, and
which experiences or relationships they are
missing and would like to enrich or bring back.
(c) Storying Genogram, which opens space for
exploring family members’ experiences, life
transitions, histories/stories of mental health
or illness and helps locate the problems in
larger societal or gender contexts.
In summary, there can be innumerable applica-
tions and uses of genograms. Creativity is the central
component. Couple and family thera5pist may com-
bine genograms with other relational maps, use maps
for meaning making, integrate genograms with mind
maps, linguagrams, ecomaps, or other visualized
externalizations (Fig. 2).

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School
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School Teacher Darren
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Matthew Sarah Natalie It isn’t
what we say
or think
that defines us.
but what
we do.
ANXIETY

ANTIDOTES FOR ANXIETY

Creativity love: |luv| - n.

1. an intense affection for another
person based on personal or familial
Making magic ties 2. the deep tenderness, affection,
and concern felt for a person with
whom one has a relationship.
Love and accountability

Sports, football soccer

Writing and journaling Strong independent women, brave, self-confident

Postmodern Approaches in the Use of Genograms, Fig. 2 An example of a postmodern genogram

2260
Case Example
A married couple came to therapy seeking help in
changing what they described as exhausting con-
flicts, with much shouting and mutual belittling.
They did express love for each other, but too often
misunderstandings led to protracted discussions and
yelling, but not resolution. They agreed on one
thing: Their difficulties somehow derived from
their different upbringings and different family
norms and traditions.
This led to the therapist suggesting the genogram
as a way of talking about family history. They each
drew one of their family of origin and added some
other important relationships of their childhoods.
This, in turn, led to dialogues about relational
bonds and of values belonging to different relation-
ships. They then compared the two and had a talk
about differences and similarities, and about their
experiences of listening to the other person talk
about subjects of personal significance.
On a subsequent session, they drew a genogram
together of their current shared family, brought out
the family of origin genograms and drew lines and
circles around important connections and significant
meanings. This lead to talks about future relation-
ships, shared dreams, and ways of dealing with
those dreams that were not shared.
The role of the therapist, in this case, was not
that of an interventionist, but rather of a curious
facilitator of the couples’ own reflections and their
own conclusions. The couple, as well as the ther-
apist, expressed an experience of ending up some-
where none of the three had anticipated.
Cross-References
▶ Creativity in Couple and Family Therapy
▶ Dialogical Practice in Couple and Family
Therapy
▶ Externalizing in Narrative Therapy with Cou-
ples and Families
▶ Family
▶ Genogram in Couple and Family Therapy
▶ McGoldrick, Monica
▶ Postmodernism in Couple and Family Therapy
▶ Social Construction and Therapeutic Practices
Postmodernism in Couple and Family Therapy
▶ Social Constructionism in Couple and Family
Therapy
▶ Therapist Position in Couple and Family
Therapy
References
Anderson, H. (1997). Conversation, language, and possi-
bilities: A postmodern approach to therapy. New York:
Basic Books.
Cecchin, G., Lane, G., & Ray, W. A. (1992). Irreverence:
A strategy for therapists’survival. London: Karnac Books.
Iversen, R. R., Gergen, K. J., & Fairbanks, R. P., II. (2005).
Assessment and social construction: Conflict or
co-creation? British Journal of Social Work, 35(5),
689–708. https://doi.org/10.1093/bjsw/bch200.
McGoldrick, M., Gerson, R., & Petry, S. (2008).
Genograms: Assessment and intervention (3rd ed.).
New York: W.W. Norton.
Mosgaard, J. (in press). Therapy as anthropology. In
S. Schliewe, N. Chaudhary, & P. Marsico (Eds.), Cul-
tural psychology of intervention in the globalized
world. Charlotte: Information Age Publishing.
Paré, D. A. (1995). Of families and other cultures: The shifting
paradigm of family therapy. Family Process, 34(1), 1–19.
https://doi.org/10.1111/j.1545-5300.1995.00001.x.
Seikkula, J., & Arnkil, T. E. (2014). Open dialogues and
anticipations: Respecting otherness in the present
moment. Helsinki: THL, Finnish National Institute for
Health and Welfare.
Sesma-Vazquez, M. (2011). Pathways to dialogue: The
work of collaborative therapists with couples. Interna-
tional Journal of Collaborative Practices, 2(1), 48–66.
Shotter, J. (2006). Understanding process from within: An
argument for withness’-thinking. Organization Studies,
27(4), 585–604. https://doi.org/10.1177/01708406060
62105.
White, M. (2007). Maps of narrative practice. New York:
Norton.
Postmodernism in Couple and
Family Therapy
Olga Smoliak1 and Tom Strong2
1
University of Guelph, Guelph, Canada
2
University of Calgary, Calgary, Canada
Name of Theory
Postmodernism
Postmodernism in Couple and Family Therapy
Synonyms
Poststructuralism
Introduction
The “postmodern turn” in social sciences has not
bypassed couple and family therapy. Lyotard
defined postmodern as “incredulity toward meta-
narratives” (p. xxiv). Postmodernism entered fam-
ily therapy in 1980s (e.g., Anderson and
Goolishian 1988; Hoffman 1990; White and
Epston 1990). It brought along a radical
reconceptualization of family therapy practice
and concerns and experiences families bring to
therapy. Postmodern therapies – also referred to
as relational, dialogical, discursive, conversa-
tional, open-dialogue, poststructuralist, and
constructionist – share in common an interest in
meaning-making, language, and stories. Postmod-
ern influences originate in the work of construc-
tivist and social constructionist scholars (e.g.,
Maturana, Varela, von Foerster, von Glasersfeld,
Watzlawick, Dell, Gergen, Berger, Luckmann).
Most commonly cited postmodern approaches
include narrative therapy, collaborative therapy,
and solution-focused therapy. Family therapy is
becoming increasingly familiar with and
accepting of postmodern ideas and practices.
This is evident in journals publishing more post-
modern work and dedicating special issues to
postmodern practice (e.g., Family Process in
2016; Journal of Marital and Family Therapy in
1996; Journal of Systemic Therapies in 2006),
publication of books and textbooks centered on
postmodern ideas (e.g., Friedman 1993;
McNamee and Gergen 1992), and postmodern
therapies increasingly featuring in family therapy
textbooks.
Informed by postmodern ideas, many family
therapists redirected their attention from
detecting and addressing some objectively iden-
tifiable pathological structure to the role of lan-
guage and culture in constituting clients’
“problems” and experiences. Rather than
envisioning therapy as a movement from sys-
temic pathology to systemic wellness,
2261
postmodernists propose a dialogical, discursive
(i.e., focused on language and social interac-
tion) conception of clients’ concerns and
change, according to which problems, solu-
tions, experience, and identity are discursively
“done” or produced jointly by people in specific
sociocultural and dialogical contexts (Anderson
1997; Friedman 1993; McNamee and Gergen
1992; White and Epston 1990). This shift to
language and meaning-making has also
involved a political critique of knowledge gen-
erated in therapy (Anderson and Goolishian
1988; Hare-Mustin 1994; Paré 1995) and a cer-
tain way of participating in therapy (Anderson
1997).
Prominent Associated Figures
Tom Andersen, Harlene Anderson, Harry
Goolishian, Steve De Shazer, Lynn Hoffman,
Insoo Kim Berg, David Epston, Karl Tomm,
Michael White, Peggy Penn, Jaakko Seikkula,
Kaethe Weingarten, and others.
Description
Although the initial use of the term “postmod-
ernism” can be traced back to the 1870s, it is only P
in the later part of the twentieth century it found
its cultural and intellectual prominence (Dickens
and Fontana 1994). Alvesson (2002) noted that
the term postmodern has been used to denote
both an orientation or style in the arts and social
sciences and a historical period. A particular
rationality was imported from engineering
whereby social science knowledge was seen as
applicable to engineering solutions to human
concerns (Gergen 1994; Toulmin 1990). Starting
in 1940s, in Western arts and architecture, the
term marked an amalgamation of different
traditions – both the extension of modernism
and its critique and passing. In the 1980s, post-
modernism entered social sciences, mainly
through the work of French and Anglo-Saxon
scholars, representing a wide range of critiques
of conventional ideas and ways of examining
2262
social phenomena (Dickens and Fontana 1994).
Postmodernity, or postmodernism as a historical
period, brought along changes at the economic,
political, cultural, and organizational levels of
Western and other societies (Susen 2015). Polit-
ically, the postmodern era signifies the move-
ment beyond ideologies (e.g., conservatism,
socialism, liberalism, communism) or loss of
their legitimacy and credibility. Some have
argued, however, that postmodernity is “pseudo-
post-ideological,” as it preserves and spreads the
influence of the liberal-capitalist system, which
no longer needs to compete with alternative ide-
ologies, such as communism (Susen 2015, p. 30).
Key postmodern thinkers around the globe
include Jean-François Lyotard, Frederich Nietz-
sche, Martin Heidegger, later Ludwig Wittgen-
stein, Michel Foucault, Jacques Derrida, Jean
Baudrillard, Richard Rorty, Gilles Deleuze,
Judith Butler, Karen Barad, and others.
Critique of clarity and certainty are among
the most commonly cited attributes of postmod-
ernism. Accordingly, it is difficult, if not impos-
sible, to offer a concise, exhaustive, and clear
definition of postmodernism without violating
its key premises and characteristics. Defini-
tional challenges also stem from heterogeneity
in how postmodern ideas have been understood
and applied across disciplines and spheres of
life (Susen 2015). Postmodernism encompasses
a wide range of traditions spanning various dis-
ciplines, including poststructuralist perspec-
tives that critique the structuralist paradigm
according to which social phenomena are com-
prised of some innate universal “structures”
(e.g., families as inherently organized in terms
of social roles, hierarchies, or boundaries) (for
the discussion of the relationship between post-
modernism and poststructuralism see Alvesson
2002).
Postmodernism can be best described as a
reaction to or a critique of prior intellectual
and cultural movements rather than as yet
another theory or perspective. It is a philosoph-
ical and political movement that challenges
modernism’s assumptions of certainty, univer-
sality, and objective truths and emphasizes the
partiality of truth, local or contextual
Postmodernism in Couple and Family Therapy
knowledge, and communal and constructed
nature of knowledge. Postmodernists challenge
the modernist urge to use the scientific method
as the way to understand and solve societal
problems (Gergen 1994). In critiquing modern-
ist ideas and practices, postmodernism builds on
or exploits these ideas rather than seeks
to replace them. In family therapy, the thera-
pist’s nonexpert, “not-knowing” stance
(Anderson 2012), advocated by some postmod-
ern practitioners, relies on the audience’s under-
standing of what “knowing something” or
“being an expert” mean and, as such, arguably
reifies and reinstates these modernist concepts
while undermining them.
Although postmodernism resists clear-cut
definitions, it is nonetheless possible to distin-
guish some general ideas characterizing post-
modern discourse. Postmodernists reject a
representational conception of language,
according to which there is the world “out
there” that can be accurately captured using
language. They propose that language used by
scientists and other individuals constitutes the
world rather than neutrally describes or repre-
sents it (Barad 2003). For them, all knowledge is
historically and culturally mediated and there
are no absolute criteria to determine what counts
as the ultimate truth. Multiple explanations and
descriptions of reality are favored over singular,
universal accounts, and the focus shifts from
accuracy of an account to its usefulness as deter-
mined by participants in a specific context. Post-
modernists question the authority of universal
explanations of society. They envision knowl-
edge and language as relational and communal,
rather than individual and autonomous, activi-
ties. Furthermore, postmodern scholars chal-
lenge individualist and essentialist conceptions
of identity, according to which family members
possess a unified and stable self “within,” in
favor of relational, socially constituted under-
standings of identity. They also call into ques-
tion the modernity’s premise that people are
increasingly liberated economically and politi-
cally, highlighting how seemingly emancipa-
tory movements can comprise forms of
oppression and domination.
Postmodernism in Couple and Family Therapy
Relevance of Postmodern Ideas to
Couple and Family Therapy
Postmodernism has not merely introduced yet
another set of approaches to family therapy but
has been a catalyst of paradigmatic changes in the
field. The very nature and meaning of family
therapy practice has been reconfigured in light of
postmodern critiques. Postmodernists proposed
the metaphor of narrative, conversation, and dia-
logue in place of the conventional cybernetic-
biological metaphor for understanding families
and therapy (Anderson 2012; Anderson and
Goolishian 1988; Hoffman 1990).
Focus on Multiplicity of Perspectives
Whereas the earlier first-order systemic work was
focused on the observed systems (family), the
second-order, postmodern cybernetics directed the
focus to the observer of systems (therapist). The
second-order cybernetic practice was a reaction to
instrumentalism and objectivism in earlier family
therapy practice, specifically the notion that the
therapist is external to the family and can objectively
determine the reality of the family and bring about
change (Hoffman 1990). Postmodernists saw them-
selves as a part of the system they observed and
understood descriptions of family dynamics featur-
ing in therapy not as objectively mirroring some
stable, underlying reality but as one possible way
to depict and understand human experience and
relationships (Hoffman 1990). Accordingly, the
concern of postmodern therapists shifted from the
world as objectively existent to their understanding
and description of it. From a postmodern perspec-
tive, there is no reality beyond people’s interpreta-
tions of it. There was thus a shift from control and
influencing to meaning-making. The therapist con-
tributes to the “production” of a certain version or
understanding of the family, and it is impossible to
arrive at a description of the family that is ultimately
true or representative of reality. Postmodern thera-
pies represent a distinct philosophy or way of under-
standing therapy (Anderson 2012) and not merely a
set of practices or concepts. Postmodernism is a
“lens about lenses” (Hoffman 1990, p. 3) or an
examination of all theories, ideas, and practices: it
turns its gaze onto itself and other perspectives and
2263
examines them in terms of their assumptions, impli-
cations, and conditions for their emergence and
advancement.
Attention to Sociocultural Context and
Discourse
In critiquing master-narratives or universal truths,
postmodernists attend to discourse, or broader
cultural systems of meaning and people’s situated
uptake of them (Hare-Mustin 1994). They exam-
ine how all meaning-making and knowledge are
shaped by and reflect socio-historic conditions
and dynamics, specifically how some meanings
become culturally privileged or are socially con-
stituted as the truth or “how things are,” margin-
alizing other possible ways to understand the
world and experience (Combs and Freedman
2012; Weingarten 2016; White and Epston
1990). For instance, postmodernists identify and
discuss gendered discourses, such as the sexist
notion that men and women inherently possess
different caregiving and breadwinning predispo-
sitions and capacities. They explore how people’s
uptake and reproduction of gendered discourses
reinforces gender hierarchies by tying women to
the domestic sphere of life and freeing men from
domestic responsibilities and affording them
greater access to socioeconomic resources and
opportunities (Hare-Mustin 1994).
P
Dialogic Interactions
Skepticism regarding a possibility and desirability
of generating singular, objective explanations
meant a shift from clients seeking expert profes-
sional knowledge to all perspectives, regardless of
who introduces them, being equally legitimate.
The therapist’s story is not given primacy or
seen as a better representation of truth than clients’
own story (Paré 1995). Clients may have their
own preferred ideas or theories, so can therapists.
Not only multiple but also divergent and even
contradictory perspectives may feature in thera-
peutic interaction. Meanings in therapy are not
only jointly developed or co-constructed but also
negotiated, with speakers formulating and
advancing their “preferred” meanings while
orienting to and addressing (e.g., building on,
expanding, undermining) alternative accounts.
2264
Therapists and clients also coordinate their talking
and relating. Coordination concerns not developing
a unified, shared perspective but creating space for
different perspectives to coexist in the same interac-
tion and be heard. As McNamee remarked, “this
bridging or coordinating of incommensurable per-
spectives is the process of co-construction. It does
not yield my truth over yours but ours” (McNamee
2004, p. 253). The goal is to understand others’
perspectives from their viewpoint, not one’s own
(Anderson 2012). In this dialogic, polyphonic inter-
action new possibilities for action and understand-
ing (and hence therapy change) emerge. Monologue
is not an opposite of dialogue but is an aspect of it
(Seikkula et al. 1995), with monologic and dialogic
forces being in tension in any interaction (Shotter
1993).
Reflexive Practice and Local Knowledge
When therapists rely on general (professional)
knowledges and normative cultural prescriptions
concerning how people are or should be, they may
inadvertently overlook and disqualify “insider
knowledge” or clients’ ideas concerning their
own experience that may not fit dominant cultural
discourses. Mindful of this concern, postmodern-
ists attempt to explore clients’ preferred ways of
understanding and relating and marginalized and
subjugated knowledges as a way to disturb and
unsettle the primacy and universal applicability of
dominant discourses (White and Epston 1990).
Postmodern therapists strive to engage in reflex-
ive practice of therapy and continuously ask ques-
tions about implications of relying on certain
grand narratives, such as “what institutions and
ways of being are supported by the discourse?”
(Hare-Mustin 1994, p. 2). It is impossible for
clients and therapists to transcend cultural dis-
courses and for clients to tell stories “authenti-
cally” or in ways that are not constrained or
informed by normative cultural understandings
(Weingarten 2016). This does not mean that
reflexivity is a pointless initiative and should be
abandoned. Recognizing any description as ideo-
logical, postmodern therapists bring a reflexive
sensitivity to introducing and advancing under-
standings and ways of being to clients - given
Postmodernism in Couple and Family Therapy
the sociopolitical and other implications of such
interactions. Reflexivity, from a postmodern/post-
structural perspective, is less about the therapist’s
cognitive, autonomous activity and more about
how therapists and clients jointly participate in
their relationship and interaction: how they repro-
duce and reenact dominant cultural meanings and
ways of being and/or challenge and transform
them (e.g., constitute alternatives meanings).
Reflexivity is particularly important in therapy
participants’ use of professional discourses.
Uncritical uses of conventional family therapy
concepts and practices, developed mainly by rep-
resentatives of privileged social groups (men,
white, middle/upper-class, heterosexual, able-
bodied, etc.), can sustain the cultural invisibility
and marginality of alternative ways of being and
relating. There has been an extensive postmodern
critique of the oppressive effects of diagnostic and
other professional discourses and practices
(Marecek and Hare-Mustin 2009). From a post-
modern perspective, diagnostic language is used
not to represent some underlying pathological
structure or dynamic, as presumed within the
medical model, but a way to categorize and hier-
archize people or a tool of social control (Marecek
and Hare-Mustin 2009). It is used to legitimize the
medical establishment as the authority and arbiter
of truth. Individuals who do not conform to the
norm are constituted as “ill” or “abnormal” and
socially stigmatized and disenfranchised. Post-
modernists are interested in how people’s routine
reliance on medical and other professional dis-
courses produces or constitutes certain identities
or people of a certain kind (Combs and Freedman
2012). Overall, postmodernists challenge the nor-
mative conception of wellness (Paré 1995) and
highlight that without critically examining norma-
tive assumptions and practices (i.e., how they are
advanced through therapeutic interactions,
including therapists’ contributions to therapy dis-
course), therapy may reinforce unjust and oppres-
sive societal conditions.
Collaborative, Relationally Responsive Stance
Postmodernists challenge the notion that they are
experts on clients’ lives and experiences and
Postmodernism in Couple and Family Therapy
emphasize relational or dialogic type of expertise.
While clients are viewed as experts on their lives,
therapists bring in relational or dialogical exper-
tise and are viewed as experts on creating a space
for collaborative relationships and dialogic con-
versations (Anderson 1997). They adopt a not-
knowing stance and avoid positioning themselves
as having privileged access to knowledge. Thera-
pists invite clients to join an interaction in which
all perspectives can be heard and understood and
are careful to contribute ideas in ways that do not
imply that they are privileged or more accurate or
morally superior. This involves introducing
knowledge as one possible way to understand
clients’ situation or experience and not persisting
if clients display or indicate disinterest (Anderson
2012). Therapists engage in “radical listening” in
interaction with clients, which involves not only
attending and following how clients make sense
of experience and situation but also critically
examining or deconstructing cultural constraints
implicit in clients’ formulations of their concerns
and experiences (Weingarten 2016). Postmodern
therapists strive to maintain curiosity in
interacting with clients and make public or share
with clients their inner conversations or reflec-
tions. They further avoid precontemplated prac-
tices and strategies and prefer to develop jointly
with clients a map for moving forward in interac-
tion. Overall, they strive to develop collaborative
therapeutic relationships, foster dialogue and mul-
tiple perspectives, and co-construct understand-
ings that “fit” clients (Anderson 2012).
Clinical Example of Application
McDonough and Koch (2007) described apply-
ing postmodern and social constructionist ideas,
specifically collaborative therapy (Anderson
1997), in working with Paul, an 11-year-old
boy and his mother Heidi. A brief and selective
summary of this work is presented here. Heidi
checked herself out of a psychiatric hospital and
was urged by the psychiatric staff to access ther-
apeutic services in the community. She contacted
the therapist’s (Pat Koch) and shared a story of
2265
her life characterized by numerous painful and
abusive experiences. Already in the first meeting,
Pat was struck by Heidi’s determination to thrive
despite hardship she has experienced. Heidi and
Pat often discussed Heidi’s desire to be a good
mother. Concerns with diagnosis and pathology
were set aside in favor of respectful and attentive
listening to Heidi’s descriptions of her dilemmas
and concerns. Instead of conversations being
guided by a genetic professional theory of
trauma and sexual abuse, meanings of Heidi’s
experience were cocreated “from within” con-
versations. Pat’s responses were not influenced
by some theory but by join co-construction of
meaning, wherein Pat would introduce ideas in
ways responsive to Heidi’s understandings and
preferences in and for their interaction. Heidi
missed some sessions. Pat assumed a nonexpert,
not-knowing stance when she called to inquire
about how Heidy was feeling, setting aside any
assumptions about Heidi’s absence. Pat also did
not know who would join future sessions. During
their meetings, Pat and Heidi talked about vari-
ous experiences and events in Heidi’s life,
including seemingly trivial but also more com-
plex dilemmas and concerns. Over time, Pat
observed Heidi experiencing a greater sense of
personal agency as she talked to others in her life,
including Pat, about her concerns and experi-
ences. As Heidi experienced herself making P
“preferred choices” in her relationships with
others in her life, she began to experience herself
as a person (mother, wife, daughter) she wanted
to be. Others in Heidi’s life were referred to as a
“team.” Pat saw herself not as an expert offering
the perspective on Heidy’s situation but as one
member of Heidi’s team. Diversity of viewpoints
and new possibility for action and meaning was a
byproduct of collaborative relationship and dia-
logic conversation Pat and Heidi developed.
Cross-References
▶ Second-Order Cybernetics in Family Systems
Theory
2266
References
Alvesson, M. (2002). Postmodernism and social research.
Philadelphia: Open University Press.
Anderson, H. (1997). Conversation, language and possi-
bilities: A postmodern approach to therapy. New York:
Basic Books.
Anderson, H. (2012). Collaborative relationships and dia-
logic conversations: Ideas for a relationally responsive
practice. Family Process, 51(1), 8–24. https://doi.org/
10.1111/j.1545-5300.2012.01385.x.
Anderson, H., & Goolishian, H. (1988). Human systems as
linguistic systems: Preliminary and evolving ideas
about the implications for clinical theory. Family Pro-
cess, 27, 157–163. https://doi.org/10.1111/j.1545-
5300.1988.00371.x
Barad, K. (2003). Posthumanist performativity: Toward an
understanding of how matter comes to matter. Signs:
Journal of Women in Culture and Society, 28(3),
801–831. https://doi.org/10.1086/345321.
Combs, G., & Freedman, J. (2012). Narrative, post-
structuralism, and social justice: Current practices in
narrative therapy. The Counseling Psychologist, 40(7),
1033–1060. https://doi.org/10.1177/0011000012460
662.
Dickens, D. R., & Fontana, A. (1994). Postmodernism in
the social sciences. In D. R. Dickens & A. Fontana
(Eds.), Postmodernism and social inquiry (pp. 1–22).
New York: Guilford.
Friedman, S. (Ed.). (1993). The new language of change:
Constructive collaboration in psychotherapy.
New York: Guilford.
Gergen, K. J. (1994). Toward transformation in social
knowledge (2nd ed.). London: Sage.
Hare-Mustin, R. (1994). Discourses in the mirrored room:
A postmodern analysis of therapy. Family Process,
33(1), 19–35. https://doi.org/10.1111/j.1545-5300.
1994.00019.x.
Hoffman, L. (1990). Constructing realities: An art of
lenses. Family Process, 19, 1–12. https://doi.org/
10.1111/j.1545-5300.1990.00001.x.
Marecek, J., & Hare-Mustin, R. T. (2009). Clinical psy-
chology: The politics of madness. In D. Fox,
I. Prilleltensky, & S. Austin (Eds.), Critical psychol-
ogy: An introduction (2nd ed., pp. 75–92). London:
Sage.
McDonough, M., & Koch, P. (2007). Collaborating with
parents and children in private practice: Shifting and
Overlapping conversations. In H. Anderson &
D. Gehart (Eds.), Collaborative therapy: Relationships
and conversations and make a difference
(pp. 168–181). New York: Routledge.
McNamee, S. (2004). Therapy as social construction: Back
to basics and forward toward challenging issues. In
T. Strong & D. A. Paré (Eds.), Furthering talk:
Advances in the discursive therapies (pp. 253–270).
New York: Kluwer Academic/Plenum.
McNamee, S., & Gergen, K. (Eds.). (1992). Therapy as
social construction. Thousand Oaks: Sage.
Poststructuralism in Couple and Family Therapy
Paré, D. (1995). Of families and other cultures: The
shifting paradigm of family therapy. Family Process,
34(2), 1–19. https://doi.org/10.1111/j.1545-5300.1995.
00001.x.
Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K.,
Keränen, J., & Sutela, M. (1995). Treating psychosis by
means of open dialogue. In S. Friedman (Ed.), The
reflecting team in action: Collaborative practice in
family therapy (pp. 62–80). New York: Guilford.
Shotter, J. (1993). Conversational realities. London: Sage.
Susen, S. (2015). The ‘postmodern turn’ in the social
sciences. New York: Palgrave MacMillan.
Toulmin, S. (1990). Cosmpolis: The hidden agenda of
modernity. Chicago: University of Chicago Press.
Weingarten, K. (2016). The art of reflection: Turning the
strange into the familiar. Family Process, 55, 195–210.
https://doi.org/10.1111/famp.12158.
White, M., & Epston, D. (1990). Narrative means to ther-
apeutic ends. New York: Norton.
Poststructuralism in Couple
and Family Therapy
Stephen Madigan1 and David Nylund2,3
1
Vancouver School for Narrative Therapy,
Vancouver, BC, Canada
2
California State University, Sacramento, Fair
Oaks, CA, USA
3
Gender Health Centre, Sacramento, CA, USA
The article outlines a new practice of narrative
therapy informed Relational Interviewing
(RI) with conflicted couple relationships. We
begin by locating Relational Interviewing within
post-structural ideas and offer a critique (We are
using our interpretation of Michel Foucault’s
understanding of the word critique, where a cri-
tique does not consist in saying that things aren’t
good the way they are. A critique consists in
seeing on just what type of assumptions, of famil-
iar notions, of established and unexamined ways
of thinking the accepted practices are based. To do
criticism is to make harder those acts that are now
too easy.) as to why Relational Interviewing steps
away from popular modern day relationship ther-
apies informed by humanism and individualism.
Relational Interviewing practice methods
such as ethical remembering conversations,
Poststructuralism in Couple and Family Therapy
re-moralizing actions, rites of passage, ethical
documents, therapeutic questions, and writing
therapeutic letters to the couple relationship are
highlighted through a therapeutic RI example.
A Few Theoretical Underpinnings of
Relational Interviewing Practices
There are contemporary understandings of psy-
chological pain and emotional distress as an out-
come of couple conflict and relationship
separation that appear to obscure many cultural
complexities and particularities that shape the
couple’s experience of relationship life and of
their expressions of this experience.
Narrative therapy informed Relational
Interviewing (RI) is the Vancouver School for
Narrative Therapy’s response to fill in the gaps
found in these contemporary practices of couple
therapy that seem to be somewhat relationally and
conceptually disembodied from culture, context,
and normative discourse.
Therapeutic conversations informed by con-
temporary understandings contribute to the con-
struction of a significantly fragile, deficit, or
vulnerable sense of self and relationship and
leave people with a keen sense that: (a) members
of the intimate relationship come to a psycholo-
gized view of themselves and the other as deficit
persons and lacking the abilities for what is
viewed as necessary for a healthy relationship
life, (b) the present conflict experience of the
relationship is/was the only expression of the rela-
tionship, (c) the experience of the relationship
future will be dictated by and be expressed
through a continued relational conflict.
We find a problem-focused and psychologized
understanding of relationship life closes down
options for people to take action in regard to
their predicaments in their relationship life and
diminishes their general sense of knowing how
to assist the relationship to proceed going forward
in life.
Relational Interviewing brings to our attention
an ethical responsibility that therapists have in the
shaping of therapeutic conversations with couple
2267
relationships that may contribute to the construc-
tion of a more “robust” sense of self/relationship,
rather than a “frail” sense of self/relationship.
The intention of Relational Interviewing is the
consideration and development of a sense of rela-
tionship for:
(a) Couples to re-remember and appreciate the
foundational ethics and values shaping of
their relational lives
(b) Opening up possibilities for relationships to
take action in regard to their dilemmas in life
(c) Enriching the couple’s general sense of know-
ing how to proceed in relationship life
(d) Re-collecting counter-practices based in their
relational ethics and values to reduce rela-
tional conflict
The practice of Relational Interviewing is in
concert with narrative therapies ideological move
away from 150 years of psychological, psychiat-
ric, family therapy, and other mental health prac-
tice beliefs informed by vocabularies of
individualism, humanism, and structuralism.
A narrative therapy informed Relational
Interviewing practice represents an interpretive
turn towards understanding the couple’s relation-
ship identity as discursively, culturally, and rela-
tionally created. P
Relational Interviewing is informed by post-
structural theories (Brinkmann 2016; Butler 1997;
Deleuze 1968; Foucault 1979, 1980, 1989; Illouz
2007; May 2006, 2012; Nylund 2007; White
1991; Winslade 2009) supporting a relational/
contextual/discursive/non-individualist therapeu-
tic view of lives and relationships. Relational
Interviewing practice demonstrates a therapeutic
practice that is coherent with a post-humanist,
decentered, and relational views of identity.
These theoretical/practical/political positions set
out to unsettle any essentialist psychological
notion of the stable autonomous person, the orig-
inal author (of problem conversations or other-
wise), or a given reality of what constitutes
the self.
Relational Interviewing questions and cri-
tiques the popular humanist ideas of “self”
2268
determination, “self” realization, and “personal
growth” (through an independent transcendence
of the “self”) that seems central to most couple
therapy practices. French philosopher, Michel
Foucault (1979) suggests the construct of a self-
realized identity would be difficult to achieve
since all our actions, from eating to dressing to
working are tied to and indelibly influenced
through a prevailing normative cultural discourse.
Couple therapy practices which support the
humanist idea of self-realization seem to suggest
that a practice of self-realization can only be com-
pleted by identifying the complication in the story
of: “what prevents the relationship from being
happy, connected, properly attached, successful?”
Psychologies project appears to make sense of this
question through a focus on individually “working
through” a historical event that is viewed as
privatized within the individuals body and experi-
ence (often viewed as trauma). Contemporary
understandings of psychological pain and emotional
distress as an outcome of trauma often obscure
many of the complexities and particularities of peo-
ple’s experiences of trauma, and their experience of
this experience. Therapeutic conversations informed
by some of these contemporary understandings may
according to White 1997 and others, contribute to
the construction of a significantly fragile or vulner-
able sense of self – as some of these understandings
draw a ‘natural’ and linear link between trauma and
psychological pain/emotional distress – leading to a
thin grasp of the consequences of therapeutic con-
versations. Modern therapeutic practices often close
down options for people to take action in regard to
their predicaments in life, and is often diminishing
of their general sense of knowing how to proceed in
life.)) from ones individual past.
As the self-realization/trauma tautology guides
these couple therapy practices, the mandate is to
structurally help with an understanding of one’s
relationship life as a generalized dysfunction to
overcome (Nylund 2002). The therapeutic belief
then is that a true and successful identified “self”
is only uncovered and expressed in the experience
of the “suffering narrative” and within a clear
understanding of “underlying” emotions gained
through telling the therapist the intimate particu-
larities of the deficit story.
Poststructuralism in Couple and Family Therapy
The narrative of the self-realized, individualist
couple therapy practice is fundamentally one of
memory and – more specifically – a memory of
suffering. That is, that one exercises one’s mem-
ory of suffering in order to free oneself of it and to
then achieve – what is culturally considered –
a successful relationship life (Relational
Interviewing is cautious of couple therapy
instructing the couple towards set standards of
normativity, and the hegemonic public demand
for the performance of this suffering through
discursive avenues like therapy, talk shows,
legal courtrooms, intimate relationships etc.,
(Illouz 2007).
Relational Interviewing favors the idea that our
identities, and our remembrances of our identities,
are profoundly political – both in their origins and in
their implications (Madigan 1996, 1999, 2011).
“Identity,” says feminist writer Jill Johnston
(1974), is “what you can say you are, according to
what they say you can be.” The identity she is
referring to is not a freely created product of intro-
spection or the unproblematic reflection of a private
inner self. To be clear, a practice of RI perceives the
dominant western psychological understanding of
identity, being based in great measure on a neolib-
eral (The politics of neoliberalism partially explains
how the field of couple therapy continues to support
the predominant narrative of individualism and self-
realization within normative couple therapy, and
hence – our therapeutic couple cultures privileging
of the performance of surface/depth explanations of
trauma and suffering and the subsequent focus on
the individuals experience to explain the trouble in
relationships.) individualist framework (Sugarman
2015), is maintained and shaped through various
institutions, discourse, and archives of science and
economics (Madigan and Law 1992).
In a parallel critique of individualism and ther-
apy, narrative therapist and co-founder Michael
White (For extensive interviews with Michael
White and to view his commentaries on the limi-
tations of modern psychology please visit TCTV.
live) considers the essentialism underlying
humanist conceptions of the identified “self” in
therapeutic culture to be “quite limiting.” White
states that he does not believe the practice of
narrative therapy is “a recycled structuralist/
Poststructuralism in Couple and Family Therapy
humanist psychological practice” that involves
“discourses of psychological emancipation.”
He proposes that narrative therapy is also not
a liberatory approach to therapy designed to assist
persons to challenge and overturn the forces
of repression so they can become free to be
“who they really are” – and then identify their
“authenticity” and give true expression to this
(White 1997, p 217).
To further orientate yourselves within post-
structuralism, let’s presume the narrative therapy
informed Relational Interviewing therapist does
not therapeutically concern themselves with “sur-
face and depth” metaphors (or any other formal
beliefs situated within internal state psychology).
Nor does narrative therapy utilize any practice
constructs concerning ideas about “cause or
cure” (Madigan 1999, 2011). A post-structural
informed therapy designs the couple therapy ses-
sion on the practice belief that relationships are
relational (Sampson 1993).
The intention of the Relational Interviewing
practice is to make allowances for a critically
reflexive and creative reengagement with the rela-
tionships’ ethical and moral principles once
important to relational life. The therapist initiates
remembering (The remembering metaphor origi-
nates from the work of Barbara (1982, 1986).
Remembering conversations describe preferred
accounts of identity, couple practices within rela-
tional of life, cherished values and abilities. These
accounts of relational identity and these knowl-
edges and abilities are richly explored in their
particularities (discoveries, realizations, conclu-
sions, learning, problem-solving practices, etc.))
questions in the first session to assist with a rela-
tional reconstruction of ethics before any decon-
structive discussion of the prevailing conflict (It is
important to note that entering a dialogue of crit-
ical reflexivity with the conflicted couple through
relational remembering conversations is not
designed to reinvigorate a memory of dysfunction
or suffering in relationship life.).
Relational Interviewing is intrigued with a
question posed by Queer scholar Judith Butler
(1997) when they ask: What is the value of our
values? Leading RI to concentrate on what made
up the “moral character” of the relationship
2269
previously preferred/lived through – prior to the
onset of conflict. Following Butler’s question,
Relational Interviewing acts to circumvent
demoralizing practices of the conflict (shame,
blame, accusation, anger) that seem to hold the
relationship frozen within this conflict by begin-
ning the session with “re- moralizing” dialogues
once important to the relationships values and
ethical story.
Remembering the memory of the relationships
moral character stimulates a “companion”
storyline (personal conversation with sociologist
Arthur Frank, Therapeutic Conversations 13 con-
ference, Vancouver, Canada, 2016) to accompany
the dominant story of conflict. Questions are
posed to make available a possibility to reimagine
(the now restrained) preferred intentions of what
the relationship once were (love, respect, laughter,
acceptance, trust, etc.). By expanding and explor-
ing the plot of the companion story, remembering
questions act to disrupt the finalized story of the
conflicted past and destabilizes it.
The dialogic process of remembering is not
simply the return of the “old.” Rather it is the
old story of the preferred ethical relationship
returning in new ways. The relationship can
begin to remember what the story of the conflict
has helped the relationship to forget. This conver-
sation affords the relationship a dialogic opportu-
nity to consider what it has already experienced P
and known in the realm of ethics – differently.
Relational Interviewing is therefore not about
“discovery” or a simple remembering of the past.
Nor is it about a passive recollection. Rather, RI
moves therapeutically towards rigorous
reengagements with significant ethical practices
of the relationships history.
Relational Interviewing finds itself in concert
with Gilles Deleuze ideas on relational
difference – and the creativity and possible new
identity an experience of difference brings forth
(Deleuze 1968). The difference landscape is not
populated or colonized by the relationship identity
but can construct what they might already know –
differently. For the relationship, this represents a
potential rich space yet to be articulated (Todd
May and John Winslade, Therapeuticcon-
versations.tv (Therapeuticconversations.tv is an
2270
online narrative therapy interactive teaching plat-
form involving hundreds of video and audio
recording curated by the Vancouver School for
Narrative Therapy.)). Relational Interviewing pro-
vides the relationship an entry point to these pre-
existing possibilities that are (already) discur-
sively and experientially available.
Deleuze uses the term “virtual” to refer to an
aspect of reality that is ideal, but nonetheless real.
The virtual is the kind of imagined potentiality that
can be fulfilled in the actual – the practice of the
construct or idea. It is still not material, but it is real
(Deleuze 1968). What can emerge through rela-
tional interviewing is the re-collection of how ver-
sions of the ethical relationship the couple once
served and created relationally might somehow
become re-imagined, transformed, and transported
towards a preferred relationship future (either a
newly formed separated or intimate relationship –
or some other kind of relationship frame possibility).
Narrative Therapy Informed Relational
Interviewing
Phillip and Carol arrived for their first couple
therapy session in separate vehicles. They pre-
sented themselves as a white, middle class, het-
erosexual couple, married for 13 years, and
coparents of 11 year old daughter Jade. They
immediately situated their relationship by letting
us know that since their separation (aproximately
1 year before) they had not sat in the same room
without some form of legally appointed counsel
present (mediator, judge, lawyer, or testing/
assessment psychologist). During this time
period, the couple had only communicated
through short text messages (regarding their
daughter Jade), and long legal documents
constructed by their family lawyers.
We responded by asking why they had come to
therapy without legal counsel in attendance at this
particular time? Carol answered by saying “we
feel there has to be a better way to separate.”
Phillip stated that “our friends told us you had
been helpful in their hostile separation.” Carol
and Phillip filled us in on how “exhausted” they
had become through the legal process, how “too
Poststructuralism in Couple and Family Therapy
much family money had been spent on the legal
battle” (approximately $40,000 CDN each), how
the structures supporting the legal narrative had
acted to “increase the conflict in their relation-
ship,” and how they were worried that their ongo-
ing unresolved relational conflict was “negatively
affecting” their 11-year-old daughter Jade.
Prior to us inventing what is now called “Rela-
tional Interviewing,” we would always begin the
first couple session with a standard narrative ther-
apy inquiry using what narrative therapists call
“relative influence questions” (Relative influence
questions are those that help define the context of
the problem: simply stated – what are the influ-
ences of the problem on the couple and – what are
the influences the couple may have on the prob-
lem.) (Madigan 1992; White and Epston 1990;
White 1988). However, after interrogating our
narrative work with highly conflicted couples
(by transcribing session texts and watching videos
of our taped work for hours and hours on end), we
eventually found the experience of organizing the
session’s starting point around the problem of
relational conflict less helpful than if we began
the session with an account of the relationships
story of ethics, values, and moral principles the
couple’s relationship started out with.
Relationally Remembering Ethics:
Critical Reflexivity
After the couple had given us a brief orientation of
why they had sought me out for counseling, We
began the first RI session by asking Carol and
Phillip if we might begin our meeting by getting
to know their relationship a little bit. Through the
course of the next 2 h we explored simple rela-
tional remembering questions to purposefully
direct the couple’s experience away from the con-
fines of conflict and open up the potential for a
different experiential and relational
understanding:
– Carol and Phillip, could you catch me up on
where and how you first met?
– How did you prepare the relationship to move
from a friendship to an intimate relationship?
Poststructuralism in Couple and Family Therapy
– Were there any particular relational ethics and
values you decided to build your relationship
on? (For Carol and Phillip these were they
mentioned, “trust, kindness, loyalty, respect
and love”).
– Can you recall any stories of the particular
ways you served the relationship with trust,
kindness, loyalty, respect, and love?
– Why did you feel these particular ethical prac-
tices were vitally important to the building up
of the relationship?
– Could you tell me a specific story that you
remember when you experienced your rela-
tionship experiencing kindness?
– If I was to interview your relationship, what do
you feel the relationship would tell me about
how it was feeling back then – that may be
different from now?
– Philip, were there any values you shared in
common with Carol that helped encourage
your desire to have a child together?
– Who in your community of supporting others
were most supportive of your relationship?
Safety in Common Ground
Through the above remembering questions/con-
versations, Carol and Phillip’s relationship
entered a dialogic space for creating an experien-
tial common ground. The common ground
established allowed for the “proximal distance”
of past stories (Lorraine Hedtke 2015, Therapeu-
ticconversations.tv) to transport the relationship
beyond the distant past and towards a present
experience and future imagination. Remembering
conversations allowed their relationship to
develop a creative refashioning/reconfiguring of
a relationship counter-story. The relational com-
mon ground of the counter-story began to slowly
un-freeze/un-suffer the relationships experiential
discursive conflicted problem orientation frame.
Through relational remembering questions, we
witnessed Carol and Phillip begin to recount their
nine (pre- conflict/pre-problem) adventurous
years together: their first date; the first night of
intimacy; the stories they told others about their
relationship; job transfers; favorite activities; as
2271
well as numerous relational rites of passage
including stories about: how they described the
other person to their friends/family; how they
grieved the death of Phillips parents; how they
decided to move into together; how they decided
what neighborhood to settle in; how they decided
to become co-parents, etc.
We hovered (We invented/use the word
‘hover’ in a narrative therapy conversation and it
means to richly explore the intimate particularites
of a particular counter-story before moving on to
another topic. In Carol and Phillips case, hovering
helped support and more thoroughly remember
the relationships forgotten counter-stories of
“trust, love, loyalty, respect, kindness” and the
practices that helped these values endure through
time.) with close up relational questions to solicit
rich relational descriptions – leading to more and
more animated remembered stories of ethics and
values. There were times throughout the interview
the couple helped each other “fill in the gaps” of
the story and assist each other with the intimate
ethical “plotlines” that made up their relationship
tale. The couple found themselves collaborating,
remembering, and becoming enchanted with a
re-collection of their prior relationship life – in
the experiential present. Carol and Phillip also
began to share a few looks at one another and
(to their stated surprise) – even laughed a little
bit. After a year of hardened bitterness and conflict P
they had begun to experience a felt sense of relief.
Reconstruction Before Deconstruction
How the relationship “anticipates” the possibility
of a conflict free future has direct meaning on the
relationships present dialogue and practice
(Madigan 2008). When the relationship remem-
bers the particulars of the multiple stories that
make up the relationships ethical past – the story
of the relationship expands beyond the confines/
restraints of the conflicts immobilized landscape.
The RI first session began with a reconstruc-
tion of the Carol and Phillips relationship before
any act of deconstruction of the problem
was considered. The couple’s recollections pro-
vided a substitute ethical and value driven
2272
dialogue – beyond the dominant discourse of
individualized suffering, blame, and personal fail-
ure. The conversation afforded the relationship
“emotional relief” from the year of bifurcated
dialogic hostility alongside mediation, family
law, and psychological testing discourses.
At the end of the first session, we asked what
they might possibly take away from our conver-
sation. Carol laughed and stated, “It was nice to
recall our past and remember it wasn’t all bad.”
Phillip said, “I’ve never considered our relation-
ship as something we both have to take care of!”
They turned to look at one another and began
tearing up. Carol passed Phillip the tissue box.
Session Two
The preferred relationship Carol and Phillip had
once desired was outlined through the couple’s
recollected stories in the first session. The first
session’s critical reflexivity afforded space for
the couple to emotionally prepare – “just
enough” – to experience an intimate dialogue
about loss and grief.
Loss and Grief
We began the second session by slowly reading
the notes taken back to Carol and Philip from our
first session. The performance of “re-telling” their
words took about 15 min. We then asked them if
the session notes needed any revisions or
additions.
Carol and Phillip’s response to the re-telling of
the prior session was to begin addressing their
story of the relationships loss (Hedtke and
Winslade 2016). With the experience of their rela-
tionships counter-stories, ethical past recalled
through the many re-collected tales they told, the
weight of what they had collaboratively lost was
experienced as (in Phillips words) “quite pro-
found.” There were stretches of time throughout
this conversation that fell respectfully silent as
Philip and Carol collectively wept.
Many couples experience the relationship
loss as a loss in their lives that they have never
Poststructuralism in Couple and Family Therapy
before encountered. The majority of conflicted
couples we see explain that prior to the session’s
discussion of relational loss, and by witnessing
the grief of the other, allows them to reconcile
the nagging question of: did the intimate rela-
tionship mean anything to the other person? For
the relationship to experience this loss in the
presence of the other is often the turning point
away from relational conflict, anger, and indi-
vidualized blame. The grief they had believed
was an individual experience was now being
mutually recognized and relationally experi-
enced. The relationships experience of the
ethics and values lost, and the relational harm
the conflict had created, allowed Carol and
Philip to realize they might have an alternative
counter-conflict map to take them forward
(Although it is never the intention of RI to
bring separated couple relationships back
together, there are occassions when the recol-
lection of grief and loss initiate some couples
deciding on attempts to reunite.).
We asked Carol and Phillip the following
questions:
– What is it that stands out about the ethics of this
relationship the conflict has helped you turn
away from?
– How do you imagine your relationship felt
when its cherished values were replaced by
blame, silence, and court appearances?
– Does the relationship in any way feel a sense of
relief now that it knows you are both grieving
what it once was together?
– Are there any values that were hijacked by
conflict that may need to be re-found if your
relational and ethical orientation of the rela-
tionship was to make a comeback?
– Are there any ways your future separated rela-
tionship might benefit – if you were to imagine
taking these ethics and values forward?
– How might your relationships relationship
with your daughter Jade change if these values
were to be re-instated?
– What is it that you would most want your
daughter Jade to notice if your relational values
and ethics re-found themselves at the center of
your relationship?
Poststructuralism in Couple and Family Therapy
Individualized Personal Failure
Crucial to the RI sessions was to co-research the
relational contexts Carol and Philips relationship
was having with other relationships (the relation-
ships relationship with work, children, school,
finances, siblings, parents, friends, fitness, health,
etc.). The idea is to broaden the view of the indi-
vidualized relationship to include all the many
contextual and culturally inspired relationships
their relationship is (necessarily) involved with –
and pressured to maintain in culturally
specified ways.
In a social world currently dominated by a
neoliberal politic, the message is clear: it is the
individual who is fully responsible for whatever
happens in their own individual life (John
Winslade 2016, therapeuticconversations.tv). As
a result, the couples I see in therapy experience the
failure of the relationship as purely a failure of the
individual self and/or the other individual
involved. This sense of individualized personal
failure (obviously) denies any contextual or cul-
tural influence. For example, many couples com-
plain about “not having enough time for one
another.” The couple attributes this lack of time
as a sign they do not care for one another. When
I inquire about the effect other relationships have
on their intimate relationship – most relationships
come to realize that their intimate relationship
often ends up as a low priority.
After asking a few questions about other rela-
tionships their relationship was involved with, we
asked:
– By you both fulfilling our societies definition
of what represents what a good worker, parent,
son/daughter, and overall citizen is, did these
cultural achievements in anyway negatively
affect your intimate relationship?
– When the other relationships exhausted you,
how did you explain this exhaustion to your
intimate relationship?
– Were there ever times when you placed your
intimate relationship above the demands of the
other relationships? Or was your intimate rela-
tionship instructed to wait until all the other
relationships had been served?
2273
– With so many relationships taking you away
from your intimate relationship, why were you
prone to blame your separation only on your-
selves and view this as a personal failure?
– Do you think it is fair the way our culture helps
intimate relationships to feel rejected – and
then blames it on the couple?
– Did anyone ever inform you that the other
relationships don’t really care about your inti-
mate relationship? (Often this question draws a
good laugh from the couple)
Session Three
After the second session, we wrote a letter
addressed to Carol and Phillips relationship
(written from the perspective of the relationship
by each person – to the couple). We wrote this
letter to their relationship to evoke a new posi-
tion for the relationship to stand in (a meta-
position) to draw upon the relationships ethical
“wisdom.”
Writing Therapeutic Letters to the
Couple’s Relationship
Dear Carol and Phillips relationship; P
As you know we met with Carol and Phillips for
their second 2-h therapy session today. You also
recognize the sessions are the first time they had
spoken together in the same room without a medi-
ator, psychological tester, Judge, or legal counsel of
any kind in over a year. Carol and Phillip talked
about you – their relationship – quite a bit. In fact
they took me through the history of building you up,
their dreams of the kind of relationship they desired
to build, and the values and ethics they wished to
build the foundations of you the relationship
on. They also showed me what a profound sense
of loss and grief they both feel having moved you
away from their best intentions and unfortunately
filled you up with conflict. However, you may be
happy to know they are now beginning to feel
concerned for your well-being in the future.
As Carol and Phillips relationship therapist, we are
writing to ask if you would write them a letter from
your point of view. Would you consider writing
them to offer your version of what you as their
relationship needs to grow forward? Perhaps say a
bit about what you value, share any experienced
2274
wisdom you have collected over the past 13 years,
and perhaps offer a “tree top” view of what you
would like to see the future separated relationship
evolving into. We know this may seem like a large
assignment so – please keep each letter to a maxi-
mum of 150 words or so.
Many thanks.
Stephen Madigan & David Nylund.
Ps – if its ok with you we’d like to keep you updated
on our future sessions together.
Carol and Phillip were asked not to show the other
the letter written by the relationship to the couple
before arriving at the third session (There are
numerous examples of wiritng letters to the cou-
ples relationship and their reading of these letters
in the couple sessions you can view on therapeu-
ticconversations.tv) (Bjoroy et al. 2016). The
structure of this session when relational letters
are involved is as follows: Phillip read his letter.
We then interviewed Phillip about the experience
of writing the letter from the relationships per-
spective. I then turned to Carol and interviewed
her about her experience of receiving and listen-
ing to Phillips letter to them from the relationship.
Carol then read aloud her relationship letter and
we repeated the process of: reading, experiencing,
re-telling, and responding.
Carol and Phillips letters written from the rela-
tionships point of view followed along a similar
path to most couples involved in the practice of
RI. In both letters, the relationship thanked them
for making attempts to end the conflict by coming
to therapy. Each letter outlined the relational
ethics and values that were once important to
their relationship, and what the relationship felt
it needed to create a more harmonious separated
relationship future. Each letter suggested the
importance of restoring the relational ethics to
improve their daughter’s relational and emotional
life with their relationship.
At the end of the session we asked if Carol and
Philip would be willing to bring two members of
their community of concern (Madigan and Epston
1995) to the next session. The intent was to
increase the circulation and support of the rela-
tionships newly emerging ethical story. They
agreed and – we sent off another letter addressed
to their relationship to report how the session
had gone.
Poststructuralism in Couple and Family Therapy
Session Four: Creating a Community of
Concern
Carol and Philip both brought a friend and a sister
to our session. The members of the community of
concern, who Carol and Phillip had once
described as “very close” prior to the separation,
described being isolated off from one another due
to the ongoing relational conflict. We began our
fourth session by reading aloud the notes taken in
the first session on their critically reflexive rela-
tional remembering. Then we asked Carol and
Phillip to read aloud their letters written to them
from the relationship from the third session. After
each reading, we paused to ask the community
members to respond. The therapy room filled up
with conversations of respect, compassion, relief,
and tears.
The dialogue between the eight of us pro-
ceeded to wonder: within the envisioned rela-
tional ethics of the relationship, as well as what
the relationship stated it needed to go forward –
how might we somehow transport and support the
ethics from the past and present time – into a
newly creative experience of the future (The trans-
port of ethics is not seen as discovery of the old
but more of an act of newly born relational
creativity.).
We speculated that if this relational rite of
passage was possible, what the emerging story
of the relationships relational ethics might mean
to all aspects of the relationships future. We won-
dered on:
– What practices supporting the ethics of the
relationship could be resurrected
– What the community of concern might name
this newly formed relationship
– What the first steps might be if the community
were to help step the relationship towards this
transitional journey
– In what ways could the community of concern
help circulate the newly forming relationship
story and best support these efforts
After this fourth session we wrote a letter to the
relationship about the session and sent a copy out
to everyone who had attended the session.
Poststructuralism in Couple and Family Therapy
Rites of Passage
The majority of couples we see in relationship ther-
apy seem to have forgotten to remember the numer-
ous rites of passage (White and Epston 1990) the
relationship has successfully traversed through the
course of their relational life (deciding to live
together, dealing with loss and grief of important
people, new living locations, etc.) These rites of
passage bring forth a description and ethic of rela-
tionally collaborative decision-making. When the
relationship is realized to have developed through
several life changing rites of passage, it highlights
the relationships abilities and trust to change and
grow forward into something new (including a
newly separated relationship).
Many conflicted couple relationships have no
definition of what the separated relationships rite
of passage map might be. Often not knowing how
they might shift from an intimate relationship to a
separated relationship. Our cultures discursive
practice regarding this crucial rite of passage is
also quite limited in answering how we might
more fully support and create harmonious and
collaborative versions of separated relationships
(The cultures focus (supported through legal and
psychological narratives) is for the separating
couple to sign the spearation agreement signed
with less emphasis on emotionally supporting
how the newly separated couple/family identity
will survive.).
Without a creative alternative map for separa-
tion, the separated relationship is left with no
definition or character (except as a conflicted rela-
tionship). Within these limitations, the relation-
ship can often “freeze” within its conflicted
identity (Defining the newly separated relation-
ship identity is especially important to the chil-
dren of the separated relationship.).
Session Five
The fifth session involved the couple, their daugh-
ter Jade, and discussions on how to move towards
their possible future relationship as a separated –
but newly reunited – family. We then booked a
follow up session with the couple relationship,
2275
daughter, and community of concern in 4 weeks
time. The couple stated that it was “in the best
interests of the relationship not to contact the
lawyers until after our next session.” We asked
Carol and Phillip:
– What would happen if their lawyers made
attempts to recruit them back into adversarial
relational practices?
– Were there ways that re-remembering the
ethics of the relationship might resist the temp-
tations of entering back towards adversarial
legal practices presented through the therapeu-
tic courtroom?
Two months after we first met, the couple
completely dropped their legal battle.
Questions to consider:
Can you imagine any advantages of not beginning
your therapeutic discussions with conflicted
couples with the story of the conflict?
In your experience, why might it be important
for relationship therapists to help emotionally
prepare conflicted couples – before entering
into mediation, separation, and separation
agreements?
What assistance/perspective does the RI practice
of writing therapeutic letters directly to the
relationship offer the couple? P
Cross-References
▶ Foucault, Michel
▶ Narrative Couple Therapy
▶ Narrative Family Therapy
References
Bjoroy, A., Madigan, S., & Nylund, D. (2016). The prac-
tice of therapeutic letter writing in narrative therapy. In
B. Douglas, R. Woolfe, S. Strawbridge, E. Kasket, &
V. Galbraith (Eds.), The handbook of counselling psy-
chology (4th ed.). London: Sage Publications.
Brinkmann, S. (2016). Diagnostic cultures: A cultural
approach to the pathologization of modern life.
London: Routledge Publications.
Butler, J (1997). Excitable speech: A politics of the perfor-
mative. Routledge Publications. New York.
2276 Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy
Deleuze, G (1968) Difference and repetition. English
translation (1994). Patton, P. New York: Columbia
University Press.
Epston, D. (1988). Collected papers. Adelaide, South
Australia: Dulwich Centre Publications.
Foucault, M. (1979). Discipline and punish: The birth of
the prison. Middlesex: Peregrine Books.
Foucault, M. (1980). Power/knowledge: Selected inter-
views and writings. New York: Pantheon Books.
Foucault, M. (1989). In S. Lotringer (Ed.), Foucault live:
Collected interviews, 1961–1984. New York:
Semiotext(e).
Hedtke, L., & Winslade, J. (2005). The use of the subjunctive
in re-membering conversations with those who are griev-
ing. OMEGA, 50(3), 197–215, 2004–2005. New York.
Hedtke, L., & Winslade, J. (2016). The crafting of grief:
Constructing aesthetic responses to loss. Routlege
Publications. New York, UK.
Illouz, E. (2007). Cold Intimacies: The making of emo-
tional capitalism. Polity Press. Cambridge, UK.
Johnston, J. (1974). Lesbian nation: The feminist solution.
New York: Routledge.
Madigan, S. (1992). The application of Michel Foucault’s
philosophy in the problem externalizing discourse of
Michael White. British Journal of Family Therapy,
14, 265–279.
Madigan, S. (1996). The politics of identity: Considering the
socio-political and cultural context in the externalizing of
internalized problem conversations. Special edition on
narrative ideas. Journal of Systemic Therapies, 15, 47–63.
Madigan, S. (1999). Destabilizing chronic identities of
depression and retirement. In I. Parker (Ed.),
Deconstructing Psychotherapy (pp. 150–163).
Thousand Oaks: Sage.
Madigan, S. (2003). Injurious speech: Counter-viewing
eight conversational habits of highly effective prob-
lems. International Journal of Narrative Therapy and
Community Work, 2, 12–19.
Madigan, S. (2008). Anticipating hope within conversa-
tional domains of despair. In I. McCarthy & J. Sheehan
(Eds.), Hope and despair (pp. 104–112). London:
Bruner Mazel.
Madigan, S. (2011). Narrative therapy – Theory and prac-
tice (p. 211). New York: American Psychological
Association Publications.
Madigan, S., & Epston, D. (1995). From “spy-chiatric
gaze” to communities of concern: From professional
monologue to dialogue. In S. Friedman (Ed.), The
reflecting team in action: Innovations in clinical prac-
tice (pp. 257–276). New York: Guilford Press.
Madigan, S., & Law, I. (1992). Discourse not language:
The shift from a modernist view of language to the
post-modern analysis of discourse in family therapy
(Cheryl White, Ed.). International Journal of Narrative
Therapy and Community Work, 1.
Madigan, S., & Law, I. (1998). PRAXIS: Situating dis-
course, feminism, and politics in narrative therapies.
Vancouver, British Columbia, Canada: Yaletown Fam-
ily Therapy Press.
May, T. (2006). The philosophy of Michel Foucault.
Chesam: Acumen Publishing Limited.
May, T. (2012). Friendship in the age of economics:
Resisting the forces of neo-liberalism. Maryland:
Lexington Books.
Myerhoff, B. (1982). Life history among the elderly: Per-
formance, visibility and re-membering. In J. Ruby
(Ed.), A crack in the mirror: Reflexive perspectives in
anthropology. Philadelphia: University of
Pennsylvania Press.
Myerhoff, B. (1986). Life not death in Venice: Its second
life. In V. Turner & E. Bruner (Eds.), 1986: The anthro-
pology of experience. Chicago: University of Illinios
Press.
Nylund, D. (2002). Poetic means to anti-anorexic ends.
Journal of Systemic Therapies, 21(4), 18–34.
Nylund, D. (2007). Reading Harry Potter: Popular culture,
queer theory and the fashioning of youth identity.
Journal of Systemic Therapies, 26(2), 13–24.
Sampson, E. (1993). Celebrating the other: A dialogic
account of human nature. San Francisco: Westview
Press.
Sugarman, J. (2015). Neoliberalism and psychological
ethics. Journal of Theoretical and Philosophical
Psychology., 35, 103–116.
White, M. (1988/1989). The externalizing of the problem
and the re-authoring of lives and relationships. Dulwich
Centre Newsletter [Special issue], Summer, pp. 3–20.
White, M. (1991). Deconstruction and therapy. In
D. Epston & M. White (Eds.), Experience, contradic-
tion, narrative, and imagination: Selected papers of
David Epston and Michael White, 1989–1991.
Adelaide: Dulwich Centre Publications.
White, M. (1997). Narratives of therapists’ lives.
Adelaide: Dulwich Centre Publications.
White, M., & Epston, D. (1990). Narrative means to ther-
apeutic ends. New York: Norton Publications.
Winslade, J. (2009). Tracing lines of flight: Implications of
the work of Gilles Deleuze for narrative practice.
Family Process, 48, 332–346.
Posttraumatic Stress Disorder
(PTSD) in Couple and Family
Therapy
Candice M. Monson1, Naomi Ennis1 and Steffany
J. Fredman2
1
Ryerson University, Toronto, ON, Canada
2
The Pennsylvania State University, University
Park, PA, USA
Name of Concept
Posttraumatic Stress Disorder in Couple and Fam-
ily Therapy
Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy
Introduction
Posttraumatic stress disorder (PTSD) is a preva-
lent and pernicious disorder characterized by
intrusion symptoms (e.g., flashbacks); persistent
avoidance of stimuli, emotions, and thoughts
associated with the traumatic event; negative
alterations in cognitions and moods (e.g., persis-
tent negative emotional state); and alterations in
arousal and reactivity (e.g., sleep disturbances;
American Psychiatric Association 2013). PTSD
is strongly associated with intimate relationship
and family relationship problems. In addition,
PTSD in one intimate partner is associated with
psychological problems and caregiver burden in
the other partner. In consideration of these associ-
ations, and of the potent role of social support in
trauma recovery (e.g., Ozer et al. 2003), efforts
have been made to develop couple- and family-
based interventions for the treatment of PTSD.
Couple- and family-based interventions for
PTSD can take a number of formats including
partner-assisted interventions, generic couple
therapy, and education and family-facilitated
engagement. In this entry, we describe cognitive-
behavioral conjoint therapy for PTSD (CBCT for
PTSD; Monson and Fredman 2012), a disorder-
specific therapy with the most evidence to date for
the amelioration of PTSD symptoms, enhance-
ments in relationship functioning, and improve-
ments in intimate partner mental health
(Macdonald et al. 2015; Monson et al. 2012).
The term “conjoint” is used rather than “couple,”
because the therapy need not be applied exclu-
sively to intimate dyads, because many issues
relevant to couples are also pertinent to non-
intimate dyads (e.g., siblings, parent-adult child).
Theoretical Context for Concept
The rationale for CBCT for PTSD stems from
Monson and colleagues’ cognitive-behavioral
interpersonal theory of PTSD (C-BIT; Monson
et al. 2010). This theory accounts for the associa-
tions between PTSD and intimate relationship
problems. Central to C-BIT is the distinction
between “natural” and “impeded” recovery after
trauma. Compared with other mental disorders
2277
that develop over time, PTSD is considered a
disorder of “impeded recovery.” Following
trauma exposure, most individuals experience dis-
tress that abates over time without intervention,
and these individuals are not diagnosed with
PTSD. This is considered “natural recovery”
(e.g., Rothbaum et al. 1992). A minority of indi-
viduals will not experience natural recovery and
will be diagnosed with PTSD. According to
C-BIT, there are interpersonal and intrapersonal
factors that impede or facilitate natural recovery.
Specifically, behavioral, cognitive, and emotional
variables are thought to interact within each indi-
vidual and between individuals in the dyad. These
interacting variables, in turn, influence the rela-
tionship milieu shared by the dyad, and the well-
being of each individual, either facilitating or
hindering trauma recovery.
The theory holds that behavioral avoidance is
central to the maintenance of PTSD symptoms and
intimate relationship problems. For the trauma-
exposed individual, certain stimuli associated with
the traumatic event are classically conditioned to
provoke distress following trauma. This distress is
maintained through the negative reinforcement of
avoidance of these stimuli. In response to the
trauma-exposed individual’s distress, and to avoid
or reduce conflict related to PTSD symptoms, sig-
nificant others often modify their behavior, a phe-
nomenon referred to as “accommodation” to PTSD P
symptoms (Fredman et al. 2014). Examples of
accommodation include limiting emotional discus-
sions in order to avoid upsetting the client, taking
over daily activities or tasks (e.g., driving the client
everywhere or accompanying them to places remi-
niscent of the trauma), and managing the client’s
interactions with others. Accommodation serves to
promote or maintain the client’s avoidant behaviors
and contributes to relationship problems and dissat-
isfaction through decreased engagement in shared
pleasurable activities (e.g., going to movies), reduc-
tion in affective expression, and limited self-
disclosure, including trauma-related disclosure.
In C-BIT, trauma-related cognitions are pos-
ited to impede trauma recovery and contribute to
relationship distress. Individuals within a dyad
may make problematic appraisals about the
cause of the trauma (e.g., “If I/she would not
have drank that night, I/she would not have been
2278 Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy
raped”) or draw conclusions from the trauma that
interfere with trauma processing and successful
relationships (e.g., “It is dangerous to get close to
others”). Disturbances in cognitive processes such
as attention/concentration deficits and selective
attention to negativity and threat are also common
after trauma and can contribute to relationship
distress. For example, selective attention to threat
can extend to perceptions of a partner’s behavior,
such as suspicion that a partner’s intentions are
malevolent.
In terms of emotional factors in trauma recov-
ery and intimate relationship problems, C-BIT
holds that individuals who experience and express
a range of emotions associated with trauma (e.g.,
fear, anger, guilt, grief, shame) are more likely to
have natural recovery. By experiencing and
expressing emotions, individuals gain a sense of
mastery and better emotion regulation. Expres-
sion of emotions can also facilitate intimacy and
interpersonal closeness. Conversely, avoidance of
emotional experience and expression can result in
communication deficits within the dyad and rela-
tionship impairments.
With C-BIT as a guiding framework, CBCT for
PTSD concurrently ameliorates PTSD symptoms
and enhances relationship functioning by reducing
behavioral and emotional avoidance and modifying
trauma-related cognitions through cognitive and
behavioral dyadic interventions.
Description
CBCT for PTSD is a manualized stand-alone
treatment for PTSD that is delivered in a conjoint
format. It is comprised of 3 phases that include
15 sessions (Monson and Fredman 2012). The
goals of the first phase are to provide the rationale
for conjoint treatment and educate the dyad about
PTSD and associated relationship problems. The
goals of the second treatment phase are to enhance
relationship satisfaction and undermine avoidant
behaviors that maintain PTSD symptoms and
reduce relationship satisfaction. This is achieved
through activities to build the dyad’s communica-
tion skills and couple-based in vivo approach
assignments to reduce avoidance and increase
the dyad’s participation in mutually enjoyable
activities. The overall goals of the third phase
are to make meaning of the traumatic event
(s) and to reach the end of therapy (but not the
end of using the skills). In this phase, a dyadic
cognitive intervention is used to target problem-
atic appraisals and beliefs that emanate from the
traumatic event that maintain PTSD symptoms
and contribute to relationship distress. Each ses-
sion is 75 min in length, and dyads are assigned
within-session and out-of-session practice
assignments.
Application of Concept in Couple and
Family Therapy
Given the nature and goals of CBCT for PTSD,
several issues should be considered in its clinical
application. First, CBCT is not an adjunctive couple/
family therapy to individual therapy for PTSD.
Rather, it is a stand-alone, disorder-specific couple/
family therapy to address PTSD and enhance rela-
tionships. Moreover, it is not designed only for
relationally distressed dyads (Shnaider et al. 2015).
Although most of our research has focused on cou-
ples in which one person has PTSD, dual PTSD
couples have also been treated with the intervention.
Partners’ mental health problems can also improve
with the treatment.
Therapists do not conduct individual sessions
with dyad members, except during the assess-
ment process. Once treatment begins, meeting
with one partner when the other partner is absent
can undermine the conjoint frame. The therapy
has not been tested with more than a dyad in
therapy sessions. However, participants are
encouraged to apply the skills learned in the
treatment to their relationships with close others
outside of the dyad (e.g., children, coworkers). In
addition, the treatment can be applied to non-
romantic dyads and delivered in almost the
same manner as with romantic dyads with only
minor changes in session content (e.g., content
on the role of sexuality or sensuality is shifted to
focus on physical closeness, comfort in being in
physical proximity to others, and physical affec-
tion with family members and friends).
Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy
In CBCT for PTSD, “good termination” is
defined by a reduction in PTSD symptom severity
and improvements in relationship functioning (e.g.,
increases in relationship satisfaction). These out-
comes should be monitored throughout the 15 ses-
sions of therapy with at least self-report measures.
Clinical Example
Sarah and Tom self-referred for couple therapy at
an outpatient mental health clinic to address
Sarah’s PTSD symptoms secondary to sexual
abuse by her coach as a child and their relation-
ship difficulties. Sarah and Tom were in their late
20s, had been intimately involved for 4 years, and
were cohabiting. They were experiencing clinical
levels of relationship distress and described a
“black cloud” hanging over their relationship
stemming from Sarah’s tendency to become easily
emotionally dysregulated, cry, and yell with little
provocation. Tom attempted to support Sarah by
preemptively removing any sources of potential
stress (e.g., he would come home immediately
after work rather than stay late to finish tasks so
that she would not feel lonely, do a majority of
household chores, and stay home with her on
weekends, so that she did not feel anxious about
being out in public). The couple had not been
sexually active in almost 2 years because sexual
activity and physical intimacy (e.g., holding
hands, kissing, snuggling) served as trauma-
related triggers for Sarah.
Phase 1 of treatment (sessions 1–2) focused on
psychoeducation about the association between
the cycle of PTSD symptoms and relationship
problems. Tom and Sarah developed PTSD-
related relationship goals (e.g., increased sexual
intimacy and physical affection, increased fre-
quency of outings in public places, more sharing
of control, increased emotional expression). The
couple was asked to “catch each other doing
something nice” (i.e., to monitor and reinforce
positive relationship behaviors in each other) as
out-of-session work to build more positivity in
their relationship. They were also taught skills to
negotiate “time-outs” in conflicts characterized by
high emotionality.
2279
Phase 2 of treatment (sessions 3–7) focused on
improving the couple’s communication skills and
helping the partners use communication to miti-
gate behavioral avoidance and emotional numb-
ing. The couple was taught communication skills,
in particular paraphrasing. Sarah was encouraged
to speak with Tom about her PTSD symptoms,
and Tom was coached to use paraphrasing skills to
ensure that Sarah felt understood and to increase
her tolerance for experiencing negative emotions
and opening up about her trauma-related
responses.
In phase 2, the therapist also helped the couple
generate a list of feared people, places, and things,
and feelings, in order to address couple-level
avoidance. The couple participated in in vivo
approach activities in which they systematically
engaged in activities on the list, such as visiting
the park once for an hour on a Wednesday morn-
ing working their way up to spending an entire
Saturday afternoon there while it was crowded. To
target Tom’s accommodation to Sarah’s PTSD
symptoms, Tom was encouraged to express his
emotions even if he thought they would create
conflict with Sarah. The couple began gradually
engaging in activities that involved physical inti-
macy that were not necessarily sexual, such as
holding hands, hugging and kissing, and cud-
dling. The couple was taught problem-solving
skills to solve issues around behavioral avoidance P
and redistribution of household chores. In this
phase, the couple was also taught a cognitive
intervention process to challenge maladaptive
thoughts and appraisals (e.g., Sarah’s thought:
“If I have a male boss at work, he will sexually
assault me.”)
In phase 3, the therapy focused on helping the
couple address appraisals of the trauma and
unhelpful ways of thinking in the domains of
trust, control, emotional closeness, and physical
closeness. By the end of treatment (session 15),
Sarah’s symptoms had diminished and no longer
met diagnostic criteria for PTSD, and both part-
ners’ relationship satisfaction increased into the
satisfied range. The couple engaged in physical
affection daily and some sexually intimate touch-
ing once or twice per week but still had not
engaged in sexual intercourse since beginning
2280
treatment. They were engaging in a range of activ-
ities together and apart that Sarah had previously
avoided. At a follow-up session 3 months after the
therapy terminated, Sarah reported that her PTSD
symptoms continued to decrease, and the couple
reported they had continued to increase their sex-
ually intimate behavior.
Cross-References
▶ Adult Survivors of Sexual Abuse in Couple and
Family Therapy
▶ Behavioral Couple Therapy
▶ Cognition in Couple and Family Therapy
▶ Cognitive Behavioral Couple Therapy
▶ Communication Training in Couple and Family
Therapy
▶ Monson, Candice
▶ Socratic Questioning in Couple and Family
Therapy
▶ Speaker-listener Technique in Couple and Fam-
ily Therapy
▶ Time Outs in Couple and Family Therapy
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arling-
ton: American Psychiatric Association.
Fredman, S. J., Vorstenbosch, V., Wagner, A. C., Macdon-
ald, A., & Monson, C. M. (2014). Partner accommoda-
tion in posttraumatic stress disorder: Initial testing of
the Significant Others’ Response to Trauma Scale
(SORTS). Journal of Anxiety Disorders, 28, 372–381.
Macdonald, A., Pukay-Martin, N. D., Wagner, A. C.,
Fredman, S. J., & Monson, C. M. (2015).
Cognitive–behavioral conjoint therapy for PTSD
improves various PTSD symptoms and trauma-related
cognitions: Results from a randomized controlled Trial.
Journal of Family Psychology, 30, 157–162.
Monson, C. M., & Fredman, S. J. (2012). Cognitive-
behavioral conjoint therapy for PTSD: Harnessing
the healing power of relationships. New York: Guilford
Press.
Monson, C. M., Fredman, S. J., & Dekel, R. (2010). Post-
traumatic stress disorder in an interpersonal context. In
J. G. Beck (Ed.), Interpersonal processes in the anxiety
disorders: Implications for understanding psychopa-
thology and treatment (pp. 179–208). Washington,
DC: American Psychological Association.
Power in Family Systems Theory
Monson, C. M., Fredman, S. J., Macdonald, A., Pukay-
Martin, N. D., Resick, P. A., & Schnurr, P. P. (2012).
Effects of a cognitive-behavioral couple therapy for
PTSD: A randomized controlled trial. Journal of the
American Medical Association, 308, 700–709.
Ozer, E. J., Best, S. R., Lipsey, T. L., Tami, L., & Weiss,
D. S. (2003). Predictors of posttraumatic stress disorder
and symptoms in adults: A meta-analysis. Psychologi-
cal Bulletin, 129, 52–73.
Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., &
Walsh, W. (1992). A prospective examination of post-
traumatic stress disorder in rape victims. Journal of
Traumatic Stress, 5, 455–475.
Shnaider, P., Pukay-Martin, N. D., Sharma, S., Jenzer, T.,
Fredman, S. J., Macdonald, A., & Monson, C. M.
(2015). A preliminary examination of the effects of
pre-treatment relationship satisfaction on treatment out-
comes in cognitive-behavioral conjoint therapy for
PTSD. Couple and Family Psychology: Research and
Practice, 4, 229–238.
Power in Family Systems
Theory
Markie L. C. Twist1 and Megan J. Murphy2
1
University of Wisconsin-Stout, Menomonie, WI,
USA
2
Purdue University Northwest, Hammond, IN,
USA
Name of Concept
Power in Family Systems Theory.
Synonyms
Decision-Making; Dominance; Empower; Hierar-
chy; Influence
Introduction
Individuals exercise a certain degree of power to
have control of their lives, as well as to have influ-
ence and a share in the decision-making within their
relational systems. Power is a multifaceted concept
which can refer to qualities an individual may have,
features of a relationship, or larger sociocultural
Power in Family Systems Theory
concepts that impact groups in society. Most defini-
tions are concerned with the degree of influence one
has over another through the use of resources and/or
the ability to get someone to do or believe some-
thing that they would not have necessarily done or
believed on their own (French and Raven 1959;
Johnson 1976). These definitions typically empha-
size situations in which one person dominates over
another through demonstrations of influence, or the
ability of the person to make decisions for each of
the individuals involved in a relationship. Through
such definitions, power is conceptualized as power
over others (Blumer et al. 2007; Goodrich 1991). In
more recent years, definitions of power have
expanded to include more positive aspects of
power, such as power to help others, or use of status
resources in which each person in an interaction is
enhanced by the interaction with another (Goodrich
1991). From this perspective, power is seen as
something to be shared, not as a mechanism to
dominate or control another person (Blumer et al.
2007; Goodrich 1991).
Theoretical Context for Concept
Bateson (1972) considered power to be an error in
the understanding of the true interactions between
people. For many years, this view of power pre-
vailed, as power as a concept was not included in
family systems theories. In fact, some wrote about
the “myth” of power, or that power was seen as a
dangerous and/or an irrelevant idea that should be
abandoned. The only time power was considered
in traditional systemic thinking – in the form of
hierarchy – was via age and generation, and not in
terms of gender, race, or sexual orientation (Hare-
Mustin and Marecek 1990). Thus, power differ-
entials have typically been thought to be hierar-
chical between parent and child, with parents
having more power than children, but with no
difference in power between the parents. Yet cur-
rent research suggests that instead of a “myth” of
power, there may be a “myth of equality” in that
couples believe they are in egalitarian relation-
ships, when in reality they are not sharing tasks
and decisions in an equitable manner (Knudson-
Martin and Mahoney 2009).
2281
It is important to keep in mind that systems
theory is rooted in a larger dominant discourse that
reflects the cultural ideation that barricades society
as a whole from recognizing and acknowledging
power in relational systems. For instance, a domi-
nant discourse regarding gender and power between
couples in United States society is the “marriage-
between-equals-discourse” or the belief that unions
between adult partners do not involve power differ-
entials (Hare-Mustin 1994). Certain aspects of this
discourse reinforce traditional heterosexual, cis-
gender gender roles like those around household
tasks, where it is believed that the husband needs
time after work to recover, making him unable to
help with chores, and the wife has a need to do the
chores because she is obsessive about keeping up
the appearance of the home (Hare-Mustin 1994).
Through this discourse, behaviors that reflect
power differentials are reinterpreted in a way that
rationalizes role behaviors without reference to
power differences between genders. This societal-
based discourse is able to continue to conceal male
domination and female subordination as long as
both men and women continue to participate
in cooperating with reframing these power differen-
tials in household tasks as gender differences and
not only as gender differences, but as equality
between the genders, thus allowing marriage to
conceal the extent of male domination and female
subordination (Hare-Mustin 1994). In relation to P
this type of discourse, as well as in response to
the ignoring of power in traditional systems theory,
feminist critics have focused on the benefit
of considering the role of power in relational sys-
tems (DeMaria et al. 2017; Hare-Mustin
and Marecek 1990; James and McIntyre 1983;
Lyness and Lyness 2007; Prouty and Twist 2015;
Viers and Prouty 2002).
Description
The way power is handled in relational systems
affects discussions, arguments, and decision-
making, and is often established through hierar-
chies (Galvin et al. 2012). Such processes are
attempts to control others through influence, per-
suasion, and assertiveness. Power processes are
2282
measured through empirical observation of com-
munication exchanges between members of a
relational system. Through research, four primary
types of power processes in cisgender, heterosex-
ual, partnered dyads have emerged – (1) egalitar-
ian, (2) female-dominant, (3) male-dominant, and
(4) anarchic or autonomic (McDonald 1981).
Couples characterized by egalitarian or anarchic/
autonomic power processes are those in which
power can be conceptualized as balanced, but in
the former type, the balance of power encourages
shared decision-making and empowerment, and
in the latter type, the power leads to a stalemate in
the decision-making (Gray-Little et al. 1996). In
anarchic/autonomic exchanges this stalemate
often occurs because there appears to be no real
way for members of the dyad to figure out how to
make a decision as both parties are caught in an
internecine struggle where each partner attempts
to control the other while simultaneously resisting
the other’s influence (Gray-Little et al. 1996).
Differently than these two configurations, in
female- and male-dominant dyads, power pro-
cesses are characterized by one person wielding
more power and authority than the other, and
therefore they are the one who makes the deci-
sions (Gray-Little et al. 1996).
Empirically and practically speaking, certain
power processes lead to certain outcomes in rela-
tional systems. For instance, in cisgender, hetero-
sexual dyads the highest levels of satisfaction are
associated with egalitarian power processes,
followed by male-dominant, anarchic/autonomic,
and lastly female-dominant (Galvin et al. 2012;
Gray-Little et al. 1996). In addition, in observa-
tional research of couples in therapy, egalitarian
couples show the smallest number of negative
behavioral exchanges, followed by hierarchical
couples and then anarchic/autonomic couples,
who show the highest number of negative behav-
iors (Gray-Little et al. 1996).
Application of Concept in Couple and
Family Therapy
Despite therapists’ and researchers’ recommenda-
tions for what is considered best practice in the
Power in Family Systems Theory
family therapy field (Lyness and Lyness 2007;
Murphy et al. 2006; Murphy and Wright 2005;
Prouty and Twist 2015; Werner-Wilson et al.
1997; Zimmerman et al. 2001) issues relating to
power are often ignored. Yet, attending to power
in the relationships of one’s clients is essential in
the therapeutic context, particularly with a focus
on fostering egalitarian power processes in dyads,
as this power process promotes higher levels of
relational satisfaction, more sustained intimacy,
increases in positive regard, empathy, and affir-
mation, as well as higher levels of marital adjust-
ment (Gray-Little et al. 1996; Zimmerman et al.
2001). In addition, attending to power in relational
systems in one’s clinical practice can foster
improved work-family balance in the system,
and decreases in interpersonal systemic violence
(Lyness and Lyness 2007).
Despite the research demonstrating the benefits
in addressing power in family therapy, doing so
continues to be met with resistance in that some
consider it inappropriate or even unethical to
address and try to influence traditional power
patterns in therapy, particularly if a relational sys-
tem does not see their power differential as
problematic. Moreover, some in the family ther-
apy field continue to contend that even believing
in the “myth of power” in the therapeutic context
leads to “mental pathology,” or may be considered
ethically misguided and antitherapeutic (Bateson
1972; Deissler 1988; DeShazer 1988; Larner
1995). This resistance is not only countered by
the research but also by clinicians in the field that
encourage empowerment and egalitarianism in
relational systems, particularly feminist family
therapists (Prouty and Lyness 2011; Prouty and
Twist 2015; Tamasese 2003).
Haddock et al. (2000) proposed the “Power
and Equity Guide” to help family therapists rec-
ognize the role of power in the lives of clients,
but also in the context of clinical relationships.
Using this guide, family therapists are encour-
aged to recognize and attend to power differen-
tials between supervisors and supervisees, as
well as therapists and clients (Haddock et al.
2000; Prouty and Twist 2015). This is essential
because not only does power play out in the lives
of clients it plays out in the lives of clinical and
Power in Family Systems Theory
supervisory coparticipants. Indeed, qualitative
findings from a reviewing of master family ther-
apists’ work have indicated that even advanced
family therapists use their role as therapists to
exert power and communicational control in
therapy, regardless of their stance on power
(Murphy et al. 2006). Such communicational
power exchanges may be through a one-up or
expert position, or a one-down position, or via
confirming or disconfirming communication
exchanges (Galvin et al. 2012).
Via the guide, family therapists are also
encouraged to focus on the goal of empowering
clients to honor and integrate all aspects of
themselves, especially those aspects not
supported by dominant culture (Haddock et al.
2000). One way to do this is for family thera-
pists to practice appropriate use of self-
disclosure and role modeling for clients
(Blumer and Barbachano 2008; Cheon and
Murphy 2007; Green and Dekkers 2010;
Mowbray et al. 1984), particularly of one’s non-
dominant identities and cultural realties.
Another way is through the cocreation of a col-
laborative space for clients to recognize them-
selves as the experts on their own lives and
the encouragement of their use of this expertise
(Blumer and Barbachano 2008; Blumer et al. 2010;
Brown 2006).
Lastly, through the “Power and Equity Guide,”
it is suggested that family therapists’ work
towards the reduction or elimination of power
inequities between clients who are partners in
relational systems (Haddock et al. 2000). Family
therapy supervisors/trainers can help developing
therapists with this therapeutic task by first getting
them to notice power, and then to intervene in the
power exchanges with clients in real time. The
noticing of power dynamics and how power inter-
sects with identity variables can occur through
mechanisms like live supervision, review of dig-
ital video footage of clinical work, and movie
reviews (Blumer 2010; Prouty and Twist 2015).
The intervening in power dynamics in real time in
a clinical context can occur through the learning,
adoption, and implementation of feminist and
social justice lenses to systemic family therapy
(Prouty and Twist 2015).
2283
Clinical Example
Cyd and Terry are a couple, living together for
8 months, who entered therapy due to communi-
cation issues. Cyd works at a warehouse as a
forklift operator, and Terry is a nurse at a local
hospital. Terry makes over twice as much as a
nurse than Cyd makes as a forklift operator. Fur-
ther, Terry has an associate’s degree, whereas Cyd
did not complete high school.
Cyd complains that Terry has friends over “all
the time,” and that Cyd finds many of Terry’s
friends to be disrespectful, treating Cyd as a ser-
vant, and making rude comments about the clean-
liness of the house, as well as Cyd’s appearance.
Cyd has tried to talk with Terry about these con-
cerns, but feels that Terry is dismissive by not
seeing that there is a problem. Terry points out
that nursing is a very stressful job, and that having
friends over is important to Terry as a way to
unwind after work. The situation came to a head
when one of Terry’s friends broke their large-
screen television after becoming drunk one
night. Terry feels bad about the incident, but
refuses to stop having friends over after work.
By their definition, this couple presented with
communication issues, not with issues in power
dynamics. Yet, power dynamics are clearly
impacting this couple. Terry has not accepted
Cyd’s attempts to discuss and resolve the prob- P
lem, which is a form of power in that Terry has not
accepted Cyd’s influence. The therapist may be
curious to know more about the financial arrange-
ments that the couple has made. Because Cyd
makes considerably less money than Terry, Cyd
may have fewer options to leave the relationship,
particularly if there is financial dependence on the
relationship. Further, Cyd’s level of education
may make it difficult to find another job given
the current state of the economy. The therapist
may also note that there is a power imbalance in
terms of expectation of who will clean the house,
given visitors’ comments to Cyd about cleanliness
of the house.
A therapist working with this couple would
want to talk with the couple about shared
decision-making as it relates to leisure time,
finances, and housework. Given the unbalanced
2284
power dynamics in this couple’s relationship, the
therapist may empower Cyd by encouraging
Cyd’s use of voice, and assisting Terry to hear
Cyd’s concerns as valid. The therapist may be
mindful of power processes in the therapy room,
by attending to who dominates the talk time, who
interrupts who, and work to disrupt imbalanced
patterns in therapy. Finally, depending on the gen-
der, race, and/or sexual orientation of the mem-
bers of this couple, the therapist may explore how
dominant discourses around what it means to be a
man/woman impacts each person’s expectations
of their partner, themselves, and the relationship.
References
Bateson, G. (1972). Steps to an ecology of mind.
New York: Ballantine.
Blumer, M. L. C. (2010). “And action!” Teaching and
learning through film. Journal of Feminist Family
Therapy, 22(3), 225–235. https://doi.org/10.1080/
08952833.2010.499703.
Blumer, M. L. C., & Barbachano, J. M. (2008). Valuing the
gender-variant therapist: Therapeutic experiences, tools,
and implications of a female-to-male trans-variant clini-
cian. Journal of Feminist Family Therapy, 20(1), 46–65.
https://doi.org/10.1080/0895280801907135.
Blumer, M. L. C., Green, M. S., Murphy, M. J., &
Palmanteer, D. (2007). Creating a collaborative
research team: Feminist reflections. Journal of
Feminist Family Therapy, 19(1), 41–55. https://doi.
org/10.1300/J086v19n01_03.
Blumer, M. L. C., Green, M. S., Compton, D., &
Barrera, A. M. (2010). Reflections on becoming
feminist therapists: Honoring our feminist mentors.
Journal of Feminist Family Therapy, 22(1), 57–87.
https://doi.org/10.1080/08952831003652319.
Brown, L. S. (2006). Still subversive after all these years:
The relevance of feminist therapy in the age of
evidence-based practice. Psychology of Women
Quarterly, 30, 15–24. https://doi.org/10.1111/j.1471-
6402.2006.00258.x.
Cheon, H. S., & Murphy, M. J. (2007). The self-of-the-
therapist awakened: Postmodern approaches to the use
of self in marriage and family therapy. Journal of
Feminist Family Therapy, 19(1), 1–16. https://doi.org/
10.1300/J086v19n01_01.
Deissler, K. G. (1988). Do we need the power metaphor to
construct our interpersonal reality? Contemporary
Family Therapy, 10(2), 114–117. https://doi.org/
10.1007/BF00896590.
DeMaria, R., Weeks, G., & Twist, M. L. C. (2017).
Focused Genograms: Intergenerational Assessment of
Individuals, Couples, and Families (2nd ed.).
New York, NY: Routledge.
Power in Family Systems Theory
DeShazer, S. (1988). A requiem for power. Contemporary
Family Therapy, 10(2), 69–76. https://doi.org/10.1007/
BF00896586.
French, J. R. P., & Raven, B. H. (1959). The bases of social
power. In D. Cartwright (Ed.), Studies in social power
(pp. 150–167). Ann Arbor: University of Michigan
Press.
Galvin, K. M., Bylund, C. L., & Brommel, B. J. (2012).
Family communication: Cohesion and change
(8th ed.). Boston: Allyn & Bacon, Pearson Education.
Goodrich, T. J. (1991). Women, power, and family therapy:
What’s wrong with this picture? In T. J. Goodrich (Ed.),
Women and power: Perspectives for family therapy
(pp. 3–35). New York: Norton.
Gray-Little, B., Baucom, D. H., & Hamby, S. L. (1996).
Marital power, marital adjustment, and therapy out-
come. Journal of Family Psychology, 10(3), 292–303.
https://doi.org/10.1037/0893-3200.10.3.292.
Green, M. S., & Dekkers, T. D. (2010). Attending to power
and diversity in supervision: An exploration of super-
visee learning outcomes and satisfaction with supervi-
sion. Journal of Feminist Family Therapy, 22(4),
293–312. https://doi.org/10.1080/08952833.2010.528
703.
Haddock, S. A., Zimmerman, T. S., & McPhee, D. (2000).
The power equity guide: Attending to gender in family
therapy. Journal of Marital and Family Therapy, 26(2),
153–170. https://doi.org/10.1111/j.1752-0606.2000.
tb00286.x.
Hare-Mustin, R. T. (1994). Discourses in the mirrored
room: A postmodern analysis of therapy. Family
Process, 33, 19–35. Retrieved from https://www.ncbi.
nlm.nih.gov/pubmed/8039565.
Hare-Mustin, R. T., & Marecek, J. (1990). Gender and the
meaning of difference: Postmodernism and psychol-
ogy. In R. T. Hare-Mustin & J. Marecek (Eds.), Making
a difference: Psychology and the construction of gen-
der (pp. 22–64). New Haven: Yale University Press.
James, K., & McIntyre, D. (1983). The reproduction of
families: The social role of family therapy? Journal of
Marital and Family Therapy, 9(2), 119–129. https://
doi.org/10.1111/j.1752-0606.1983.tb01494.x.
Johnson, P. (1976). Women and power: Toward a theory of
effectiveness. Journal of Social Issues, 32(3), 99–110.
https://doi.org/10.1111/j.1540-4560.1976.tb02599.x.
Knudson-Martin, C., & Mahoney, A. R. (2009). The myth of
equality. In C. Knudson-Martin & R. Mahoney (Eds.),
Couples, gender, and power (pp. 43–61). New York:
Springer.
Larner, G. (1995). The real as illusion: Deconstructing
power in family therapy. Journal of Family Therapy,
17(2), 191–217. https://doi.org/10.1111/j.1467-
6427.1995.tb00013.x.
Lyness, A. M. P., & Lyness, K. L. (2007). Feminist issues
in couple therapy. Journal of Couple and Relationship
Therapy, 6(1/2), 181–195. https://doi.org/10.1300/
J398v06n01_15.
McDonald, G. W. (1981). Structural exchange and martial
interaction. Journal of Marriage and Family, 43(4),
825–839. https://doi.org/10.2307/351340.
Prata, Giuliana
Mowbray, C. T., Lanir, S., & Hulce, M. (Eds.). (1984).
Women and mental health: New directions for change.
New York: Psychology Press.
Murphy, M. J., & Wright, D. W. (2005). Supervisees’
perspectives of power use in supervision. Journal of
Marital and Family Therapy, 31(3), 283–295. https://
doi.org/10.1111/j.1752-0606.2005.tb01569.x.
Murphy, M. J., Cheng, W. J., & Werner-Wilson, R. J. (2006).
Exploring master therapists’ use power in conversation.
Journal of Contemporary Family Therapy, 28(4),
475–484. https://doi.org/10.1007/s10591-006-9016-9.
Prouty, A. M., & Lyness, K. P. (2011). Feminist couple
therapy. In J. L. Wetchler (Ed.), Handbook of clinical
issues in couple therapy (pp. 271–289). New York:
Routledge.
Prouty, A., & Twist, M. L. C. (2015). Training feminist family
therapists. In K. Jordan (Ed.), Couple, marriage, and
family therapy supervision (pp. 345–368). New York:
Springer.
Tamasese, K. (2003). Gender and culture: Together.
In C. Waldegrave, K. Tamasese, F. Tuhaka, &
W. Campbell (Eds.), Just therapy-a journey:
A collection of papers from the just therapy team
(pp. 203–206). Adelaide: Dulwich Centre.
Viers, D., & Prouty, A. M. (2002). We’ve come a long way?
An overview of research of dual-career couples’ stressors
and strengths. Journal of Feminist Family Therapy, 13
(2/3), 169–190. https://doi.org/10.1300/J086v13n02_09.
Werner-Wilson, R. J., Price, S. J., Zimmerman, T. S., &
Murphy, M. J. (1997). Client gender as a process var-
iable in marriage and family therapy: Are women cli-
ents interrupted more than men clients? Journal of
Family Psychology, 11(3), 373. https://doi.org/
10.1037/0893-3200.11.3.373.
Zimmerman, T. S., Haddock, S. A., & McGeorge, C. R.
(2001). Mars and Venus: Unequal planets. Journal
of Marital and Family Therapy, 27(1), 55–68. https://
doi.org/10.1111/j.1750606.2001.tb01139.x.
Prata, Giuliana
Jessica M. Moreno
California State University, Sacramento,
Sacramento, CA, USA
Name
Prata, Guiliana
Introduction
Giuliana Prata was a medical doctor practicing
psychiatry in Milan, Italy. She is one of the
2285
originators of the Milan systemic approach and,
later, one of the four second-generation Milan
group members. She authored two books: A sys-
temic jolt to “family game”: The new method, in
1977, and A systemic harpoon into family games:
Preventative interventions in family therapy, in
1988. She also co-authored one book with col-
leagues of the Milan group – and several journal
articles. Her works were first published in Italian
then later translated to English, French, and
Spanish.
Career
Guiliana Prata was a practicing psychiatrist in
Milan, Italy, during the 1960s. In 1967, she became
one of the eight original psychiatrists of the Milan
group lead by Mara Selvini-Palazzoli. This original
Milan group disbanded in 1971, leaving Prata,
along with Selvini-Palazzoli, Luigi Boscolo, and
Gianfranco Cecchin, to form the second-generation
Milan Group. The group opened the Milan Centre
for the Study of the Family in Milan, Italy. In the
years that followed, the team split again, leaving
Prata to continue her work with Selvini-Palazzoli.
The team reorganized again years later with a youn-
ger group that included Selvini-Palazzoli’s son and
Anna Maria Sorrentino. In addition to her work
with the Milan group, Prata was the director of P
the Centro di Terapia Familiare Sistemica e di
Ricerca (Center for System Family Therapy and
Research) in Milan, Italy. She was also
Co-Director of the Nuovo Centro per lo Studio
della Famiglia (New Centre for Family Studies)
until June 30, 1985.
Contributions to Profession
Guiliana Prata was a part of the Milan group and
developed a family therapy model derived from
structural family therapy. However, group mem-
bers shifted their focus from the interactional pat-
terns of the family to their belief systems and
rituals. The goal of the Milan approach was to
assist families with becoming aware of these
behavioral patterns in addition to their beliefs in
2286
order to view themselves in a relational context to
other family members.
The Milan team began their sessions by pre-
scribing no change in symptomatic behavior.
They adapted the MRI technique of paradoxical
interventions through their own systemic lens
that viewed all of the family’s attitudes, behaviors,
and interactional patterns as moves designed
to perpetuate family games. With the use of
counterparadoxes – therapeutic double binds –
the team advised the family not to rush to change.
As a result, each family member felt more
accepted and unblamed for how they were, as
the team attempted to discover and counter the
family’s paradoxical patterns to disrupt repetitive,
unproductive games.
Another contribution of the Milan team was
the use of positive connotation. Positive conno-
tation refers to the act of reframing the family’s
behaviors that maintain familial interactional
patterns so that the family can view symptoms
positively because they maintain systemic bal-
ance, facilitate cohesion, and overall well-being.
The use of rituals is also a contribution by the
Milan group. The team believed rituals were
important aspects of the family relationship that
the therapist hypothesizes are significant for fam-
ily functioning regarding the presenting prob-
lem. Rituals are generally ceremonial acts
proposed by the therapist for temporary experi-
mentation. The therapist does not insist the fam-
ily engage in a ritual, but rather hints that it may
be useful. The team believed that carrying out
rituals clarifies differences in approach for family
members and provides greater awareness of how
their differences can cause confusion within the
family. Rituals help bring to the family’s atten-
tion the importance of consistency in order to
organize themselves to a certain level of
comfortability to eliminate dysfunctional inter-
actional patterns and behaviors.
According to Boscolo et al. (1987), one of
the main contributions by the Milan team to the
profession is that of the structured family session.
The structured family session is the classic Milan
therapeutic interview that consists of five seg-
ments: (1) presession, (2) session, (3) intersession,
(4) intervention, and (5) post session. The Milan
Prata, Giuliana
group believed that treatment began at the pre-
session, e.g., the initial telephone call from the
family. At this juncture, a team member, namely,
Prata, talked to the caller at length, taking note of
relevant information. According to Barrows
(1982), this was Prata’s main contribution to the
Milan systemic approach; the “intensive” tele-
phone interview conducted during the presession
at the Milan Family Institute.
Following the presession phone call, the team
discussed issues brought to light during intake and
proposed working hypotheses regarding the
family’s presenting problem. Team meetings
took place before each session, as the group met
to review the previous session and plan strategies
for the upcoming session. These tactics affirmed
the group’s belief that the family and therapists are
a part of the same system. During the session
itself, a major break in the family interview, the
intersession, occurred as the observation team had
an active discussion with the therapist outside the
family’s presence, where the team either adopted
or rejected their hypotheses. The therapist would
then return to the family to offer the team’s inter-
vention in the form of a prescription or ritual. The
post session discussion focused on analysis of the
family’s reaction to the intervention and gave the
therapist a chance to plan for the following session
(Boscolo et al. 1987).
Cross-References
▶ Cecchin, Gianfranco
▶ Circular Questioning in Milan Systemic
Therapy
▶ Family Rituals
▶ Milan Associates
▶ Milan Systemic Family Therapy
▶ Paradox in Strategic Couple and Family
Therapy
▶ Paradoxical Directive in Couple and Family
Therapy
▶ Positive Connotation in Milan Systemic
Therapy
▶ Prescribing Family Rituals in Couple and
Family Therapy
▶ Selvini-Palazzoli, Mara
Prayer in Couple and Family Therapy
References
Barrows, S. (1982). Interview with Mara Selvini and
Giuliana Prata. The American Journal of Family
Therapy, 10, 60–69.
Boscolo, L., Checchin, G., Hoffman, L., & Penn, P. (1987).
Milan systemic family therapy: Conversations in theory
and practice. New York: Basic Books.
Johnson, C. H. (1998). Using social work theory to engage
with gatekeepers in researching the sensitive topic of
intra-familial homicide. Qualitative Social Work, 17,
423–438.
Prata, G. (1988). A systemic jolt to “family game”: The
new method. Helsinki: Valtion.
Prata, G. (1990). A systemic harpoon into family games:
Preventative interventions in family therapy.
New York: Brunner/Mazel.
Prayer in Couple and Family
Therapy
Loren D. Marks1, Trevan G. Hatch1,
David C. Dollahite1 and Andrew H. Rose2
1
Brigham Young University, Provo, UT, USA
2
Texas Tech University, Lubbock, TX, USA
Introduction
Prayer, or the human effort to communicate with
God, is likely the most pervasive religious/spiri-
tual practice. Surveys and empirical research from
the past two decades consistently indicate that
although most Americans do not attend worship
services weekly, approximately 90 % of Ameri-
cans report praying at least some of the time and a
significant minority pray several times a day. Con-
sequently, prayer has drawn the attention of some
clinicians and researchers as a potential
therapeutic tool.
Careful and systematic research on prayer,
particularly as a potential intervention in couple
and family therapy, is a recent development, but
prayer in general has drawn the attention of
select leaders in the social sciences for more
than 100 years. William James (1902), often
credited as the father of American psychology,
referred to prayer as “the soul and essence of
religion” (p. 365). This identified salience of
2287
prayer holds particularly true in the Abrahamic
world faiths. In Judaism, the Shema prayer
(“Hear, O Israel, the Lord is our God; the Lord
is one”) is the centerpiece of morning and eve-
ning services – and for many observant Jews,
the Shema comprises the last words spoken each
day and, ideally, in life. For Muslims, prayer is
one of the Five Pillars of Islam, and the Arabic
word for prayer, salat, means connection. In
Catholic and Protestant forms of Christianity,
prayer is held as both sacred and central,
although the types of prayer (e.g., rote, ritualis-
tic, spontaneous, worship, novena) vary widely
in form and expression. Prayer holds a central
role in many religious traditions and is also
practiced by many who are not formally
religious.
The wide array of meanings and purposes
attached to prayer across faiths, families, couples,
and individuals requires both cultural competence
and idiosyncratic sensitivity in a therapeutic con-
text. Failing to seek to understand a client’s spir-
itual perspectives and/or sacred practices can limit
a therapist’s awareness and effectiveness. This is
particularly true when these beliefs and practices
are of fundamental importance to the client
(and research suggests that religion is the “most
important” aspect of life for about a quarter of
Americans).
P
Theoretical Framework
From the outset of research on couples and prayer,
researchers have applied goal theory to argue that
when marital conflict escalates, individuals within
a couple tend to shift from (1) cooperative and
synergistic goals that facilitate win-win outcomes
to (2) emergent goals that are conflictive, zero-
sum, and win-lose in nature. Scholars have pos-
ited that partner-focused prayer can promote
and engender a temperament that allows couples
to terminate destructive, self-focused patterns
of interaction and to shift their interactions back
toward cooperative and synergistic patterns – and
that when properly employed prayer can stimulate
positive transformative processes in couple
relationships.
2288
A second theoretical perspective regarding
prayer is based on two propositions from sacred
theory including: (1) when something (e.g.,
prayer) is designated as “sacred” it takes on spe-
cial salience and power and (2) it is how clients
live out and enact sacred beliefs that determines
whether sacred beliefs and practices (e.g., prayer)
help or harm family relationships (Burr
et al. 2012). Empirical work has indicated that
religious coping, including and perhaps especially
prayer, can be a facilitative resource when
employed in positive ways (e.g., “Lord, help my
partner and me draw closer and unite as we face
this challenge.”). However, prayer can also be a
“red flag” or destructive element when employed
in negative ways that frame life situations as
punishments – or when a client uses prayer to set
up an adversarial or triangulated relationship (i.e.,
me and God against my partner). Prayers vary in
relational effectiveness.
Rationale for the Strategy or
Intervention
A modest but developing body of empirical
research, including quantitative and qualitative
studies, indicates some associated potential bene-
fits of prayer on both individual and couple levels,
as well as a few family level implications.
Empirical Support for the Efficacy of Prayer
Individual Level On an individual level, prayer
has been found to lower depressive symptoms
while some forms of prayer (i.e., adoration,
thanksgiving) have been correlated with
improved self-esteem, optimism, meaning in life,
as well as satisfaction with life. Other studies have
found that prayer correlated with lower rates of
problem drinking – as well as avoidance of (and
more successful efforts in overcoming) drug
addiction. Decreased alcohol and drug abuse
yields not only individual-level but also couple-
level and systemic benefits (Koenig et al. 2012).
Couple Level Important early work regarding the
influence of prayer among couples suggested that
Prayer in Couple and Family Therapy
prayer creates a couple-God organization. This
couple-God organization can serve as a “soften-
ing” buffer for couples during conflict by facili-
tating a desire for reconciliation and problem
solving. Butler et al. (1998) further found that
prayer was related to the desirable outcomes
among couples, including: (1) reduction in hostile
feelings and decreases in emotional reactivity,
(2) increases in relationship and partner orienta-
tion and behavior, and (3) empathy and unbiased
perception. More recent and systematic research
(more than a dozen studies) conducted by
Fincham and colleagues (2010) has indicated
that, in terms of couple benefits, prayer is related
to increased feelings of relationship satisfaction,
gratitude, forgiveness, and lower rates of infidel-
ity. Related research also found that partner-
focused prayer tended to shift an individual’s
motivations in the direction of cooperative and
forgiving tendencies – and that prayer signifi-
cantly increased unity and trust. In addition to
the quantitative findings from the Fincham team,
large-scale qualitative work has similarly reported
that prayer was an instrument for overcoming
marital conflict and potentially instrumental in
positively changing one’s perceptions of their
partner (Hatch et al. 2016).
Parent-Child Relationships Relatively little
research has examined the influence of prayer on
parent-child relationships, although a rich litera-
ture addresses the broader topic of religious rit-
uals. Summary findings indicate that religious
rituals (including saying grace, family worship,
and family prayer) can serve as organizing,
structure-enhancing, and unifying practices
within the family and across generations. How-
ever, mandatory and compulsory participation in
home-based religious practices has been found to
be counterproductive. Some have emphasized that
if rituals like family prayer are to bless and
enhance parent-child relationships, it appears
that how these processes are carried out is of
fundamental importance (Burr et al. 2012).
Prayer is particularly prevalent as a coping
resource among women, African Americans, and
Latinos. Research also indicates that prayer may
Prayer in Couple and Family Therapy
be a frequently and disproportionately utilized
coping resource by the poor, due in part to limited
alternative resources (Koenig et al. 2012).
Description of the Strategy or
Intervention
Given the sensitive nature of religious topics in
general and prayer specifically, the therapist
should be respectful about stepping onto a client’s
“sacred ground.” Two related questions are
recommended as gateways or probes: (1) “Are
there any religious or spiritual beliefs that are
deeply meaningful to you as an individual or
couple that would be helpful for me to understand
and respect as your therapist?” (2) “Are there any
religious or spiritual practices, such as prayer, that
are deeply meaningful to you as an individual or
couple that would be helpful for me to understand
and respect as your therapist?” These questions, or
variations of them, place control of “sacred
ground” discussions squarely with the client(s).
Several clinicians and researchers who have
examined this domain have observed that it is
not necessary that the therapist share the clients’
beliefs or practices, but emphasize that informed
awareness is a positive step for both client and
therapist. If prayer is not raised as significant by
the client, no further discussion is warranted.
However, if clients consider prayer to be signifi-
cant and meaningful, therapists might consider
helping clients utilize prayer as a resource in
therapy.
Relationally based couple or family therapy
adds more complexity to this assessment as the
worldviews of more than one person will need to
be taken into consideration. For example, in cou-
ple therapy if one client views prayer positively
but their partner views prayer negatively,
recommending prayer would likely have a nega-
tive effect on the therapeutic alliance and on ther-
apy overall. Therapists need to determine what
role prayer has played in the relationship and use
this information to further inquire if the use of
prayer would or would not be facilitative.
It is important to understand how clients have
used prayer in their relationships in the past as
2289
prayer may have had a positive or negative
impact on the relationship. Therapists need to
help clients understand that in order for prayer
to be effective as an intervention it cannot be
compulsory wherein parents, children, or
romantic partners try to compel others to
change. Additionally, if couples pray in ways
that suggest they expect God to solve their mar-
ital problems for them without working and
changing themselves, it can negatively impact
the relationship. Finally, some triangulate God
through prayer, thereby invoking diety as an
ally against their spouse. Educating clients
about the negative impact of divisive or adver-
sarial prayer contrasted with the potential bene-
fits of unifying, and relationally focused prayer
might be a therapeutic asset for some couples.
If prayer is deemed appropriate, the foci of
prayers in relational work might be directed
at: (1) acknowledging one’s own personal short-
comings and mistakes and praying for help to
improve; (2) praying for the other partner
(or family members) in encouraging and non-
condemnatory ways; (3) praying for closeness,
mutual support, and unity; and (4) expressing grat-
itude for one’s partner and the positive things that
they are doing and striving to do. The above foci
may foster openness, empathy, humility, and grati-
tude. Some couples have found praying together to
be especially helpful and healing. P
Case Examples
Three case studies are used to better illustrate
the use of prayer as an intervention. The first
example is negative and the final two examples
are positive.
Case Study #1: Prayer as Adversarial Tri-
angulation Teresa and Stephen have been mar-
ried for 5 years and have no children. They report
that they frequently argue and do not feel under-
stood by each other. They are currently arguing
over money as they both have different ideas of
how they should spend their savings. Stephen
wants to buy a home and Teresa wants to use the
money to travel internationally. They both view
2290
prayer as important. As their therapist asks more
questions, she discovers that both individuals feel
that God is on their side.
Stephen argues that when he prays to God, he
knows that God supports him in his aspirations
to buy a home, because he feels that it will be a
sound investment in their future. He says that
God supports him in his responsible efforts to
provide financial security for their future. Con-
versely, Teresa says that she wants to explore the
beauties of the earth that she believes God cre-
ated. She says that when she prays, she feels that
God supports her in her decision to physically
and spiritually explore God’s creations. In this
example, the spouses both have competitive
(even conflicting) personal desires. Further,
both individuals have used prayer to establish
a divine alliance with God against their
partner – instead of employing prayer in a
healing or unifying way.
Case Study #2: Prayer as a Unifying
Intervention Jonathan and Sarah have been
together for 7 years and they have three children.
They have been arguing over finances because
Jonathan lost his job. Jonathan has been actively
looking for a job for a few weeks now since he
was let go, but the couple is behind on their bills
and do not see any prospective jobs. Jonathan and
Sarah share the belief that prayer is a powerful
way for them to connect with God. They also both
feel that they need to be more united in order for
them as a couple to overcome these challenges.
The therapist inquires more about their prayers
and the couple is open that they could do more
to try to be united in their desires. They work with
the therapist and decide that they want to try to
pray both morning and night as individuals and as
a couple. They also decide that they will focus on
the factors that are in their control and do what
they can do to change them.
They decide that they will pray for each other
and their relationship as they work as a team to
accomplish their goal of Jonathan finding a new
job. They also decide that in the problems that
they have no control, they will ask God to help
them, and they will accept whatever outcome they
feel God sees fit for them at this time. In this case
Prayer in Couple and Family Therapy
study, the couple is able to use prayer as a force to
bring them together to face their challenges in a
productive way.
Case Study #3: Prayer as a Tool for Promoting
Introspection and Empathy Hakim and Aisha
have been married for 25 years. They have four
adult, nonresidential children. Their youngest
child started college last month. With the kids
gone, Hakim and Aisha are having a hard time
figuring out their lives as a couple again. Aisha
feels “empty” and Hakim feels “lost.” Their focus
since their first child was born was on the children,
and they feel they are having to start a new rela-
tionship. When the therapist asks the couple about
prayer, they both say it is an important way for
them to connect to God and that they would like to
utilize prayer in addressing their problems. The
therapist is able to help the couple see that they
need to work together to be better able to resolve
their problems and to rebuild intimacy.
Hakim decides to pray to see things from his
wife’s perspective and to be more empathetic – to
understand her shift from full-time mother to
empty nester. Aisha decides to pray that she can
better see the good intentions in Hakim. As a
result, both spouses pray for the other in an
encouraging, uplifting, and noncondemnatory
way. Both pray to ask God what they can do to
“get the fire back.” They report that God has “put
it in their hearts” to go on a nightly walk together
and a dinner date each Friday.
References
Burr, W. R., Marks, L. D., & Day, R. (2012). Sacred
matters: Religion and spirituality in families. New
York: Routledge.
Butler, M. H., Gardner, B. C., & Bird, M. H. (1998). Not
just a time-out: Change dynamics of prayer for
religious couples in conflict situations. Family Process,
37(4), 451–475.
Fincham, F. D., Lambert, N. M., & Beach, S. R. H. (2010).
Faith and unfaithfulness: Can praying for your partner
reduce infidelity? Journal of Personality and Social
Psychology, 99, 649–659.
Hatch, T. G., Marks, L. D., Bitah, E. A., Lawrence, M.,
Lambert, N. M., Dollahite, D. C., & Hardy, B. P.
Precontemplation in Couple and Family Therapy
(2016). The power of prayer in transforming individ-
uals and marital relationships. Review of Religious
Research, 58, 27–46.
James, W. (1902). The varieties of religious experience.
New York: Longmans, Green.
Koenig, H. G., King, D., & Carson, V. B. (Eds.). (2012).
Handbook of religion and health (2nd ed.). New York:
Oxford.
Precontemplation in Couple
and Family Therapy
Carlo C. DiClemente and Alicia E. Wiprovnick
University of Maryland, Baltimore County,
Baltimore, MD, USA
Synonyms
Low readiness to change; Resistant; Unmotivated
Introduction and Theoretical Context
Stages of change represent a series of steps and tasks
that assist in understanding the multidimensional
nature of the process of intentional behavior change.
According to the transtheoretical model (TTM), the
process begins with an individual in pre-
contemplation (not considering change) through
contemplation (decision making), preparation
(planning and committing), and action (making the
change) to reach maintenance where the new behav-
ior is sustained and integrated into one’s life
(Prochaska and DiClemente 1984). When individ-
uals in couples and family therapy need to make
changes in behaviors, the stages can be helpful for
understanding their readiness and motivation. Thus,
assessing stage status enables therapists to match
their approaches to meet the needs of clients in
different stages. However, motivation may differ
for different members of the couple or family sys-
tem. Often family members disagree on who and
what needs to change. Applying the stages to cou-
ples and family behavior change is challenging
since the therapist must understand the specifics of
the needed behavior change and where each client is
2291
in their readiness. Moreover, stage status is specific
to each behavior and the goal related to that behav-
ior. This entry will describe precontemplation and
offer some strategies for addressing the needs of
individuals in this stage.
Application in Couple and Family
Therapy
The major tasks that the individual needs to accom-
plish to move out of precontemplation (not seriously
considering a change) is to gain the interest and
concern about the need for change that would
move them into contemplation. Often individuals
are unwilling to acknowledge a need for change.
Clients will use various strategies to stay in pre-
contemplation: not seeing the problem, reluctance
to change, rebelling against change, rationalizing,
and being comfortable with the current pattern of
behavior. Helping individuals move from pre-
contemplation requires empathy, patience, and
effective motivational communication strategies.
Although the stages have become a part of
many individual interventions, using the stages
with families and couples is complicated.
A therapist should define in collaboration with
the clients the target behaviors to address. Once
specific changes are identified, therapists should
assess the readiness of each member of the family. P
It is often best for each client to have a change
target so they can understand and empathize with
the challenges of the process of change.
Motivational interviewing (MI) strategies can
be used to help individuals move from pre-
contemplation to contemplation, using open-
ended questions, affirmations, reflections, and
summaries (Miller and Rollnick 2013). If a client
articulates any change talk (such as desires, abil-
ity, reasons, need to change), it is essential that the
therapist reflect this. Furthermore, the therapist
should not ignore any arguments against change
because they often elucidate barriers to change.
Additionally, reflecting concerns of other family
members may aid one in considering change.
Although providing feedback is not a core com-
ponent of MI, it is often a component of motiva-
tional brief interventions (Miller and Rollnick
2292
2013). The marriage checkup is one example of a
brief intervention that provides couples with
detailed feedback on the health of their marriage
(Cordova et al. 2005). This feedback can reveal
problems in the marriage and the need for change.
These skills and tools can aid clients in trans-
itioning to contemplation by engaging several
processes of change including consciousness rais-
ing and self/environmental reevaluation.
When working with family or couple members
that are in precontemplation, it is important to estab-
lish rapport with all clients. A great deal of research
emphasizes the importance of empathy and rapport
in both couples and family therapy (Heatherington
et al. 2005; O’Reilly and Parker 2013). Validating
emotions of family members when they are in dis-
agreement can also be helpful in building rapport
(Jacobson and Christensen 1998). It is important not
to validate the behavior, since it may be a behavior
targeted for change. For example, if a wife locks her
husband out of the house when he forgot their
anniversary, the therapist can say “It’s under-
standable that you were angry when he forgot
your anniversary.” But he/she should not say
“It’s understandable that you locked him
out. . .” Validating emotion aids clients in engag-
ing in the emotional arousal process of change
(allowing clients to express emotions), which
along with self/environmental reevaluation are
key processes in precontemplation.
Furthermore, there are several ways that thera-
pists can undermine rapport. Defaulting to parents’
decisions and opinions when working with families
may cause children to disengage from therapy
(O’Reilly and Parker 2013). Therapists should also
consider culture. Being incongruent with cultural
family values can promote resistance to change.
For example, encouraging a Chinese-American
daughter to confront her father may be unsuccessful;
she will likely stay in precontemplation for this
behavior (Hetherington et al. 2005).
Case Example
A couple, married 5 years, used to fight often
using verbally abusive language and threats.
Precontemplation in Couple and Family Therapy
They needed to develop conflict resolution
skills including better listening behaviors,
expressing emotions, and compromising.
Although both agree that there is a problem,
they are in different stages regarding each of
these behavior changes. He is in pre-
contemplation and views the problem as her
stubbornness and unwillingness to acknowl-
edge his expertise. She sees improved commu-
nication as the key to saving the marriage and
seems ready and willing to try (preparation
stage). Offering communication strategies as
homework seems problematic, likely leading
to greater conflict since he will generally sabo-
tage, show lack of engagement and undermine
the homework.
Cross-References
▶ Action as a Stage of Change in Couple and
Family Therapy
▶ Contemplation as a Stage of Change in Couple
and Family Therapy
References
Cordova, J. V., Scott, R. L., Dorian, M., Mirgain, S.,
Yaeger, D., & Groot, A. (2005). The marriage checkup:
An indicated preventive intervention for treatment-
avoidant couples at risk for marital deterioration.
Behavior Therapy, 36(4), 301–309.
Heatherington, L., Friedlander, M. L., & Greenberg,
L. (2005). Change process research in couple and fam-
ily therapy: Methodological challenges and opportuni-
ties. Journal of Family Psychology, 19, 18–27.
Jacobson, N. S., & Christensen, A. (1998). Acceptance and
change in couple therapy: A therapist’s guide to trans-
forming relationships. New York: Norton.
Miller, W. R., & Rollnick, S. (2013). Motivational
interviewing: Helping people change (3rd ed.).
New York: Guilford Press.
O’Reilly, M., & Parker, N. (2013). You can take a horse to
water but you can’t make it drink’: Exploring children’s
engagement and resistance in family therapy. Contem-
porary Family Therapy, 35, 491–507. https://doi.org/
10.1007/s10591-012-9220-8.
Prochaska, J. O., & DiClemente, C. C. (1984). Self change
processes, self efficacy and decisional balance across
five stages of smoking cessation. Progress in Clinical
and Biological Research, 156, 131–140.
Premack Principle in Social Learning Theory
Premack Principle in Social
Learning Theory
Atina Manvelian
University of Arizona, Tucson, AZ, USA
Name of Concept
Premack Principle in Social Learning Theory
Introduction
Developed by David Premack in 1965, the
Premack principle states that one can encourage
a low-frequency behavior by linking that low-
frequency behavior to a higher-frequency
behavior.
Description
A classic example of the Premack principle is,
“If you eat all of your vegetables, then you may
have dessert.” By pairing the lower-frequency
behavior (eating vegetables) with a higher-
frequency or more desirable behavior (eating
dessert), we can increase the likelihood that
the low-frequency behavior will occur. Premack
suggested that for “any pair of responses, the
more probable one will reinforce the less probable
one,” (Premack 1965, p. 132). In other words, by
pairing a less preferred behavior with a more pre-
ferred behavior, you can increase the probability
with which the lower-frequency or less desirable
behavior occurs. Using an example from the health
psychology literature, people may decide to link a
health habit (i.e., doing exercise) to a reward. For
example, “If I go to the gym three times this week,
then I can go out with my friends for dinner.”
A high-frequency behavior here (eating dinner
with friends) is used as a reward to reinforce the
lower-frequency behavior (exercise).
Premack’s model also suggests that the
amount of time a person spends on an activity is
2293
correlated with how much they value the activity.
The relative value of an activity is, therefore,
subjective and not equal for everyone. For
instance, for child A, eating candy may be the
more desirable activity, and for child B, playing
video games may be more desirable than eating
candy. Therefore, this technique must be tailored
for each individual based on the relative value
of activities in their life.
In everyday life, the Premack principle is
often used to reinforce less desirable behaviors
for children (i.e., brushing teeth or completing
chores) as well as low-frequency health behaviors
in patient populations (i.e., adhering to medica-
tion). In research, the vast majority of the litera-
ture that provides evidence for the Premack
principle has been conducted on experimental
animal studies and yielded considerable evidence
(i.e., Bauermeister and Schaeffer 1974; Holstein
and Hundt 1965; Hundt and Premack 1963;
Weisman and Premack 1966). Less work has
been published to demonstrate the utility of
the Premack principle in natural settings with
human subjects.
The few manipulation studies that take
place in more naturalistic settings have tested
this principle in youth, student, and patient
populations (i.e., Premack 1959, Ayllon and
Azrin 1968; Knapp 1976). In a review of the
studies completed with human subjects, there P
was actually little evidence found for the Premack
principle. High probability behaviors did not
always reinforce a lower probability response
in human populations, and low probability
behaviors did not always act as “punishers” for
high probability behaviors (Knapp 1976). This
lack of support may be due to the use of poorly
controlled studies and poor experimental condi-
tions. It could also be due to the fact that the
“reinforcer” designed in the study did not truly
act to reinforce the low-frequency behavior for
all patients. Instead of assuming that the same
kinds of reinforcers will apply to everyone,
measuring and examining each subject’s naturally
occurring high-frequency behaviors may be a
more effective way of encouraging behavior
change.
2294
Cross-References
▶ Applied Behavior Analysis in Family Therapy
▶ Cognitive Behavioral Couple Therapy
▶ Cognitive-Behavioral Family Therapy
References
Ayllon, T., & Azrin, N. H. (1968). Reinforcer sampling:
A technique for increasing the behavior of mental
patients. Journal of Applied Behavior Analysis, 1(1),
13–20.
Bauermeister, J. J., & Schaeffer, R. W. (1974).
Reinforcement relation: Reversibility within daily
experimental sessions. Bulletin of the Psychonomic
Society, 3(3), 206–208.
Holstein, S. B., & Hundt, A. G. (1965). Reinforcement of
intracranial self-stimulation by licking. Psychonomic
Science, 3(1–12), 17–18.
Hundt, A. G., & Premack, D. (1963). Running as both a
positive and negative reinforcer. Science, 142(3595),
1087–1088.
Knapp, T. J. (1976). The Premack principle in human
experimental and applied settings. Behaviour Research
and Therapy, 14(2), 133–147.
Premack, D. (1959). Toward empirical behavior laws:
I. Positive reinforcement. Psychological Review,
66(4), 219.
Premack, D. (1965). Reinforcement theory. In Nebraska
symposium on motivation (Vol. 13, pp. 123–180).
Lincoln: University of Nebraska Press.
Weisman, R. G., & Premack, D. (1966). Reinforcement and
punishment produced by the same response depending
upon the probability relation between the instrumental
and contingent responses. In Psychonomic Society
Meeting, St. Louis (No. 0, p. 0).
Premature (Early) Ejaculation
in Couple and Family Therapy
Negar Taslimi
Alliant International University – California
School of Professional Psychology, Irvine, CA,
USA
Name of Concept
Premature (Early) Ejaculation in Couple and Fam-
ily Therapy
Premature (Early) Ejaculation in Couple and Family Therapy
Introduction
Premature ejaculation (PE) is a common male
sexual complaint. The prevalence rate of PE is
20–30% (Althof 2007). However, only about
1–3% of individuals meet the formal criteria for
the diagnosis of PE (American Psychiatric
Association 2013). PE is characterized by signif-
icant distress due to ejaculation occurring before
or within approximately 1 min following vaginal
penetration and before it is desired. PE is diag-
nosed when the problem occurs for 6 months or
longer in approximately 75–100% of sexual
encounters with their partner. Men who suffer
from PE often feel alone and incompetent. Their
partners similarly feel alone and confused. Part-
ners may not fully understand the contributing
factors of PE and begin to feel emotionally dis-
tressed (Leiblum and Rosen 2000). Often as a
result of PE performance anxiety is developed,
self-esteem decreases, sexual activity is avoided,
partner feels angry, and the quality of the interper-
sonal relationship diminishes (Althof 2016). Indi-
viduals who suffer from premature ejaculation are
often reluctant to start a new relationship and at
times become concerned that their partner may
stray. Those in a relationship become frustrated
with their partner for not understanding the extent
of their feelings of humiliation and frustration.
Furthermore, an individual with PE may experi-
ence or feel that they lack control, and at times
ejaculation prior to penetration may lead to com-
plications in conceiving a child (American Psy-
chiatric Association 2013).
Theoretical Context for Concept
The first line of treatment for PE is typically
prescription medications that will help delay
ejaculation. A common side effect of antidepres-
sants is to delay orgasm. Currently, tricyclic anti-
depressants (TCAs) and selective serotonin
reuptake inhibitors (SSRIs) are prescribed for PE
(Giuliano and Clèment 2012).
A systemic model has effectively been used to
help individuals and their partners who suffer
from various sexual disorders, including PE
Premature (Early) Ejaculation in Couple and Family Therapy
(Betchen 2001, 2005). The systemic model
includes parts of psychoanalytic theory (Freud
1910/1957) and psychodynamic family-of-origin
work (Bowen 1978) alongside the basic sex ther-
apy tenets and exercises (Kaplan 1974, 1989). In
the aforementioned systemic model, it is at the
clinicians own discretion as to when behavioral
exercises or psychodynamic work will be
implemented (Betchen 2009).
Additionally, the integration of psychodynamic,
systems, cognitive, and behavioral approaches is
currently the supported psychotherapy for PE
(Althof 2016). The overarching goals for the treat-
ment of PE are to control ejaculation and to effec-
tively manage the escalating snowball effect PE has
on the couple, the partner, and the man. The inte-
gration of the aforementioned psychological
approaches is applied to meet the goals for an indi-
vidual and couple suffering from PE. The psycho-
dynamic approach addresses and works towards
resolving unconscious conflicts that commences
with their family of origin (Betchen 2009). Behav-
ioral clinicians work on improving the sensory
awareness and the man’s ability to cue in to the
differing levels of sexual excitement. Cognitive psy-
chotherapists examine and challenge the cognitive
distortions the man has that impact the PE (e.g.,
mind reading, catastrophizing, or overgeneralizing).
Family/relationship clinicians evaluate the power
and control struggles in the relationship and the
relational dynamic between the couple. Generally,
most therapists use an integrated psychological
approach and blend the ideas from the various the-
oretical schools (Althof 2016).
Description
The diagnostic criteria for PE state that the individ-
ual must experience significant clinical distress as a
result of the disturbance in order to be diagnosed.
Individuals that have experienced PE since they
became sexually active are diagnosed with lifelong
PE. Those who experience PE after a period of
reasonably normal sexual functioning are diagnosed
with acquired PE. It is also vital for a clinician to
specify if the individual experiences PE only with
certain types of stimulation, partners, or situations
2295
(Situational PE) or if the individuals experience with
PE is not limited to a particular stimulation, partner,
or situation (Generalized PE). Lastly, the current
severity of the disturbance has to be specified as
mild, moderate, or severe (American Psychiatric
Association 2013).
There are various factors that contribute to PE
(Hunter et al. 2017). For individuals who have
lifelong PE, genetic and epigenetic factors seem
to play a primary role for its etiology. For
Acquired PE, an interaction between genetics,
endocrine, and psychological factors contribute
to PE. For some individuals, their medical condi-
tion can be the root cause of PE (i.e., multiple
sclerosis, neurologic injury, epilepsy, and hyper-
thyroidism). Also, certain medications can have
side effects that can contribute to PE (e.g., desip-
ramine, or cold medications that have ephedrine;
Giuliano and Clèment 2012).
The interpersonal perspective holds that the
interpersonal distress between individuals in a
relationship may be expressed in sexual symp-
toms. When an individual experiences a fear of
commitment/intimacy or has unrealistic expec-
tations about sexual performances, it may con-
tribute to the individual experiencing PE
(Betchen 2001; Metz and McCarthy 2003).
According to Gottman (1994) poor communica-
tion among couples can lead to sexual problems.
Individuals experiencing PE often refrain from P
communicating their sexual needs and desires to
their partners for fear of being emotionally vul-
nerable or hurting their partner’s feelings. When
a couple begins to communicate more effec-
tively what their needs are (i.e. longer period
of foreplay) and what they are willing to com-
promise, they often experience an improvement
of the PE (Betchen 2009).
PE can result from sociocultural factors. Being
raised in a home with strict and rigid religious
values or strict moral code can lead to conflict
and guilt about gratifying one’s sexual urges.
Growing up in such environments teaches an
individual to not enjoy the sexual process and to
engage in intercourse as quickly as possible,
therefore contributing to PE (Betchen 2009).
Behavioral factors may also contribute to
PE. Men with psychosexual skill deficits are
2296
typically lacking in dating and interpersonal
skills. Some individuals who experience PE are
not aware of or recognize signs of ejaculation or
do not know how to adequately exert control over
their ejaculation (Masters and Johnson 1970).
For some men, the emotional and cognitive fac-
tors are what contribute to PE. Men with anxiety,
social anxiety, relationship distress, depression, low
self-confidence, and poor body image are increas-
ingly likely to experience PE (American Psychiatric
Association 2013). Psychological disorders such as
obsessive-compulsive disorder, bipolar disorder,
generalized anxiety disorder, dysthymic disorder,
and posttraumatic stress disorder can also contribute
to producing PE (Betchen 2009).
Application of Concept in Couple and
Family Therapy
When using the systemic model approach, both
partners are encouraged to attend the first session
so that the therapist can build an alliance with both
partners and to begin to help the couple understand
the systemic nature of PE. In the assessment phase, a
genogram is used to examine each partner’s sexual
history. The goal of the assessment phase is to arrive
at an accurate diagnosis, to explore the origins of the
sexual problems, and then to formulate a treatment
plan. As part of every treatment plan, the male
partner is referred for a comprehensive physical
examination (Betchen 2009).
The main objective of the treatment process for
PE is to teach the man how to tolerate increased
stimulation while remaining in control of his ejacu-
latory reflex. Incremental exercises are given to
assist the male partner in pacing himself to build
this tolerance. Once tolerance is built and the ejac-
ulatory reflex is controlled, sensate focus exercises
are assigned to reduce anxiety and create a more
intimate sexual environment for the couple (Masters
and Johnson 1970). For some couples, more sophis-
ticated exercises, such as the stop-start method, are
offered immediately (Semans 1956). During this
exercise, the partner suffering from PE is told to lie
on his back while his partner strokes his penis with a
dry hand. The male partner is to attend to the erotic
sensations in his penis. As he gets close to having an
Premature (Early) Ejaculation in Couple and Family Therapy
orgasm, he asks his partner to stop stroking but then
start again before he loses his erection. It is
recommended that couples engage in the stop-start
exercise three to five times a week until the partner
experiencing PE is able to maintain sufficient con-
trol and only stops two to three times within a
10 min time frame (Betchen 2009).
The next exercise applies the same steps as the
stop-start exercise with the addition of a water-
based lubricant. The lubricant increases the sen-
sations of pleasure and helps prepare for inter-
course. The exercise that follows is called slow-
fast penile stimulation. The partner with PE is
stroked by his partner until he achieves sexual
excitement, but instead of stopping, the stroking
only slows down to avoid orgasm. During the
fourth exercise, the male partner is stroked at a
high level of arousal without stopping. For het-
erosexual couples, the fifth exercise entails the
couple using the female superior position and
caressing her vagina with her partner’s penis.
The caressing is stopped right before the point of
ejaculation. In the sixth exercise, the female part-
ner inserts her partner’s penis and moves simply
to prolong the orgasm. In the final exercise, the
male superior position is used and the PE partner
is asked to practice slowing down and speeding up
his thrusting. Same-sex couples can adjust and
apply all the aforementioned exercises.
The combination of pharmacology and psycho-
therapy has been shown to be more effective than
treating PE with drugs alone (Althof 2016). The
reason for this is because it is essential for couples
to learn sexual skills, address the interpersonal,
intrapsychic, and cognitive issues that contribute to
or maintain the PE. Overall, improved couple inter-
action, emotional intimacy, and decreased with-
drawal are fundamental in successfully treating
PE. Helping couples work constructively with one
another to find solutions is a primary goal in rela-
tional therapy for PE (Althof 2016).
Clinical Example
Alex and Christy are in their mid-40s and have
been married for 10 years. Alex was diagnosed
with PE by therapist and received a referral to
Premature (Early) Ejaculation in Couple and Family Therapy
undergo a complete physical examination, which
ruled out any organic problems. The couple began
to have increased marital problems approximately
5 years ago after Alex discovered that Christy had
an extramarital affair. Alex was experiencing
problems with maintaining an erection prior to
the discovery of the affair as a result of previous
embarrassing sexual encounters with women.
Soon after finding out about the affair, Alex
began to have frequent occurrences of premature
ejaculation when having sex with Christy. He felt
anxious at the thought of being sexually intimate
with Christy as he felt that his poor sexual perfor-
mance was why his wife had the affair. The inse-
curity about himself and his marriage, combined
with the fear of not being able to sexually satisfy
his wife through intercourse, seemed to be
connected to his PE. As a result of the PE, Christy
felt that Alex was extremely selfish as he would
not try to meet her sexual needs. She began to
keep to herself and did not share her frustration
about the PE. Alex could sense that he was not
sexually satisfying his wife which made him
increasingly worried that she would have another
affair. Initially, neither partner realized that
Christy’s infidelity was connected to maintaining
Alex’s PE problem. However, throughout the
course of treatment, the couple discovered how
much the affair had impacted their sexual inti-
macy. Alex became extremely nervous and anx-
ious at the thought of engaging in sexual activities
with his wife. The sensate focus exercise was
initially assigned to help the couple create a
more intimate atmosphere and reduce any anxiety
that was present by allowing them to simply
embrace each other through touch without the
added pressure of engaging in sexual activities.
After several sessions, they were prescribed the
stop-start method to help Alex gain control in
maintaining an erection. Several sessions later,
they were provided with a handout of
recommended behavioral techniques and sex
exercises they could practice on their own. Simul-
taneously, the therapist worked with the couple in
resolving the hurt and pain the affair had caused
and also worked on improving the couple’s com-
munication skills. The clinician explored with
Alex his previous sexual encounters and how
2297
that impacted his sexual performance and contrib-
uted to his lack of self-esteem. Over the course of
6 months of psychotherapy, Christy was able to
communicate to Alex the reasons she was unfaith-
ful had to do with the lack of attention she
received from him. She shared with him how she
had concluded that he must not love her because
he only cares to have his own sexual needs meet.
Through the therapeutic process, she was able to
understand how embarrassed, frustrated, and
humiliated Alex felt every time he experienced
PE and that he did in fact care deeply for her.
Alex expressed to Christy how uncomfortable he
has been with his sexuality as a result of his
previous negative sexual experiences. After sev-
eral months, Alex was able to forgive Christy and
they slowly rebuilt the trust in their marriage.
They continued to practice the behavioral tech-
niques learned in session on their own and ejacu-
latory control was no longer a problem for them.
After approximately 1 year of treatment, the cou-
ple’s sexual problems were resolved as they were
able to address the intrapsychic, interpersonal,
and behavioral issues that maintained the PE.
Cross-References
▶ Communication in Couples and Families
▶ Premature (Early) Ejaculation in Couple and
P
Family Therapy
References
Althof, S. E. (2007). Treatment of rapid ejaculation: Psy-
chotherapy, pharmacotherapy, and combined therapy.
In S. Leiblum (Ed.), Principles and practice of sex
therapy (4th ed., pp. 212–240). New York: Guilford.
Althof, S. E. (2016). Psychosexual therapy for premature
ejaculation. Translational Andrology and Urology
(Ejaculatory Dysfunction), 5, 475–481.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Betchen, S. J. (2001). Premature ejaculation as symptom-
atic of age difference in a husband and wife with
underlying power and control conflicts. Journal of
Sex Education and Therapy, 26, 34–44.
Betchen, S. J. (2005). Intrusive partners-elusive mates:
The pursuer-distancer dynamic in couples. New York:
Routledge.
2298
Betchen, S. J. (2009). Premature ejaculation: An integra-
tive, intersystems approach for couples. Journal of
Family Psychotherapy, 20, 241–260.
Bowen, M. (1978). Family therapy in clinical practice.
New York: Aronson.
Freud, S. (1910/1957). Five lectures on psycho-analysis. In
J. Strachey (Ed. and Trans.), The standard edition of the
complete psychological works of Sigmund Freud (Vol.
11, pp. 9–55). London: Hogarth Press and the Institute
of Psychoanalysis.
Giuliano, F., & Clèment, P. (2012). Pharmacology for the
treatment of premature ejaculation. Pharmacological
Reviews, 64(3), 621–644.
Gottman, J. (1994). What predicts divorce? The relation-
ship between marital processes and marital outcomes.
Hillsdale: Lawrence Erlbaum Associates.
Hong, J. (1984). Survival of the fastest: On the origins of
premature ejaculation. Journal of Sex Research, 20,
109–112.
Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C.
(2017). Sexual problems. In C. L. Hunter, J. L. Goodie,
M. S. Oordt, & A. C. Dobmeyer (Eds.), Integrated behav-
ioral health in primary care: Step-by-step guidance for
assessment and intervention (pp. 187–206). Washington,
DC: American Psychological Association.
Kaplan, H. S. (1974). The new sex therapy: Active treat-
ment of sexual dysfunctions. New York: Times Books.
Kaplan, H. S. (1989). PE: How to overcome premature
ejaculation. New York: Brunner/ Mazel.
Leiblum, S. R., & Rosen, R. C. (Eds.). (2000). Principles
and practice of sex therapy. New York: Guilford Press.
Masters, W., & Johnson, V. (1970). Human sexual inade-
quacy. Boston: Little, Brown.
Metz, M., & McCarthy, B. (2003). Coping with premature
ejaculation: How to overcome PE, please your partner
and have great sex. Oakland, CA: New Harbinger
Publications.
Semans, J. (1956). Premature ejaculation: A new approach.
Southern Medical Journal, 49, 353–358.
PREP Enrichment Program
Kayla Knopp1, Lane L. Ritchie1, Shelby Scott2
and Aleja Parsons1
1
University of Denver, Denver, CO, USA
2
Denver Veterans Affairs Medical Center,
Denver, CO, USA
Name of Model
PREP (Prevention and Relationship Education
Program)
PREP Enrichment Program
Synonyms
Premarital relationship enhancement program;
Prevention and relationship enhancement
program
Introduction
PREP (the Prevention and Relationship Educa-
tion Program) is a research-based relationship
enhancement curriculum that provides educa-
tion, skills, strategies, and knowledge to help
couples build and maintain healthy, connected,
and committed relationships. PREP was initially
developed using a clinical science approach by
Dr. Howard Markman (Markman et al. 1988) as a
preventative (primary) intervention, designed
to prevent relationship distress through the use
of core communication and conflict manage-
ment skills that help to build safety, connection,
and intimacy in relationships. Current versions of
PREP now help couples improve relationship
quality and stability at all ages and stages. PREP
continues to be developed under the direction of
Dr. Markman and colleague Dr. Scott Stanley.
PREP is empirically informed, empirically tested,
and continually adapted based on evidence from
real-world practice. The theoretical background
and clinical application of PREP are described for
clinicians and consumers in the book Fighting for
Your Marriage (Markman et al. 2010). Many
components of the current version of PREP,
called PREP 8.0, are also available online at
www.preptoolbox.com.
Prominent Associated Figures
Dr. Howard Markman is the original developer
of the PREP intervention based on his research
beginning in the early 1980s. Dr. Markman
co-founded PREP, Inc., the company that cur-
rently develops and disseminates PREP, along
with Dr. Scott Stanley in the early 1990s.
Dr. Galena Rhoades has been involved in the
development and refinement of many curricula
in the PREP family of interventions, and she is
PREP Enrichment Program
a co-author of Within My Reach, an adaptation of
PREP developed for young singles.
Other prominent figures in the development of
PREP include Frank Floyd, who co-authored
the first research paper on PREP (Markman et al.
1988), and Susan Blumberg, who co-authored the
key book on PREP, Fighting for Your Marriage
(Markman et al. 2010). Finally, Natalie Jenkins is
a minority owner of PREP, Inc. and has been a
major contributor to the development of the PREP
family of programs (e.g., Markman et al. 2004).
Theoretical Framework
PREP represents a cognitive-behavioral appro-
ach to relationship intervention. The theoretical
basis underlying PREP evolved from the behav-
ioral marital therapy (BMT, also called behavioral
couple therapy, BCT) tradition, which is rooted in
social exchange theory (Thibaut and Kelley 1959)
and aspects of social learning theory (Bandura
1963). BMT emphasized a skill-focused approach
to intervention with couples, with the goal of
producing more positive and fewer negative inter-
actions. PREP follows the cognitive-behavioral
couple therapy (CBCT) approach that extended
BMT by incorporating a specific focus on each
partner’s thoughts, beliefs, and emotional experi-
ences as well as on behaviors and interactions.
The foundations of PREP were greatly influenced
by Dr. Markman’s collaborations with Dr. John
Gottman and Dr. Cliff Notarius exploring both
basic research and intervention in couples’ com-
munication processes. The initial version of PREP
was also strongly influenced by two curricula
developed by Dr. Bernard Guerney’s Relationship
Enhancement Program (Guerney 1991) and the
Couple Communication Program developed by
Dr. Sherod Miller and colleagues (Miller
et al. 1976).
PREP’s core concepts include communication
and conflict management, positive connections
(e.g., fun, friendship, sensuality, and sexuality),
commitment, and relationship safety. These core
components have a theoretical foundation in prin-
ciples of social exchange theory that emphasize
increasing positive interactions and relationship
2299
qualities while decreasing negative interactions
and harmful conflict. PREP encapsulates these
concepts for couples as the “three keys” to a great
relationship: “Do your part,” “Make it safe to con-
nect,” and “Decide, don’t slide.” Similar to other
interventions in the cognitive-behavioral domain,
PREP encourages change by teaching couples
plausible and practical strategies that they can
apply in their daily lives. PREP emphasizes
directed behavior change in terms of basic relation-
ship skills, such as communication and conflict
management, which is supplemented by
psychoeducation about the characteristics of
healthy and satisfying relationships. These behav-
ior changes reduce negative interactions and
enhance positive interactions in a way that builds
safety, understanding, connection, and intimacy.
Communication
Research in the 1970s involving observational
coding of couples’ communication dynamics
and their empirical associations with later rela-
tionship functioning (e.g., Birchler et al. 1975;
Gottman et al. 1977) was particularly influential
on the development of the communication inter-
ventions in PREP. These interventions emphasize
that it is not whether couples disagree, but rather
how they manage and communicate about dis-
agreements and conflicts that influences relation- P
ship stability and quality. PREP helps couples to
identify unhealthy communication patterns and
to learn strategies to interrupt those unhealthy
patterns through constructive communication
skills. Because differences between partners are
not seen as inherently problematic, PREP empha-
sizes discussion and understanding of problems
and differences as opposed to immediate problem-
solving.
Positive Connections
Drawing on its prevention roots, PREP takes a
strength-based approach to helping couples nur-
ture positive connections and avoid growing apart
over time. Interventions in PREP help couples
prioritize spending quality time with one another
and protect that bonding time from conflicts and
distractions.
2300
Commitment
PREP includes a strong focus on relationship
commitment, arising from both theoretical and
empirical research that has identified commitment
as a protective factor for couples’ happiness
across relationship transitions (e.g., Stanley et al.
2006). PREP promotes the idea that couples
should “Decide, don’t slide” when considering
important relationship decisions and includes
interventions to help couples think about, com-
municate about, and protect their commitment.
PREP’s approach to clarifying and solidifying
commitment has an implicit foundation in family
development theory (Rodgers and White 1993)
and encourages couples to make conscien-
tious decisions to proceed through relationship
transitions together as the relationship develops
over time.
Relationship Safety
Finally, PREP emphasizes the importance of
healthy relationships by including a focus on
safety throughout the curriculum. The strategies
used in PREP encourage and assume a context of
physical, emotional, and commitment safety.
Couples learn to use communication and conflict
management skills to help keep their relationships
safe from verbal or physical violence. PREP helps
couples maintain emotional safety in order to be
able to connect deeply with one another and to
avoid threatening their commitment in order to be
able to work safely and productively on relation-
ship issues.
Populations in Focus
PREP was originally developed as a premari-
tal intervention, providing an evidence-based
corollary to premarital education or Pre-Cana
counseling that couples might receive in their
communities or religious organizations. It is now
used as a relationship enhancement tool for cou-
ples at all relationship stages, including married
and unmarried couples. PREP has been adapted to
meet the needs of couples in a wide range of
settings, including several programs for military
couples (e.g., Strong Bonds); the Within Our
PREP Enrichment Program
Reach program that is optimized for lower-
income, higher-stress couples; PREP Inside
and Out, a program for couples with an incarcer-
ated partner; and programs for foster and adop-
tive parents (see Loew et al. 2012). PREP is
also disseminated internationally with culturally
appropriate adaptations for couples in countries
including Norway, Singapore, and Colombia. In
Singapore, for example, all couples who register
for marriage are offered the opportunity to partic-
ipate for free in a 2-h brief version of PREP before
they get married and a 12-h workshop after they
are married. Thus far, over 3,000 couples in Sin-
gapore have participated in the 2-h premarital
intervention and 300 in the full 12-h version.
PREP has also been extended to provide
healthy relationship education to individuals and
those in less committed relationships. The curric-
ulum Within My Reach (WMR), developed by
Dr. Stanley and Dr. Markman along with their
colleague Dr. Galena Rhoades, emphasizes rela-
tionship skills for individuals, regardless of their
current relationship status. Further, although
PREP was developed as a prevention and relation-
ship enhancement curriculum and not as an inter-
vention for existing relationship distress, PREP
has been used successfully with distressed cou-
ples as well in both workshop and individual
therapy formats.
Strategies and Techniques Used in the
Model
The core strategies taught in PREP relate to
the core concepts of communication, conflict
management, and relationship enhancement. The
most widely known PREP technique is the
Speaker-Listener Technique. In this technique,
couples learn to use effective speaking skills and
active listening in a turn-based conversation struc-
ture in order to avoid destructive communica-
tion patterns. In this way, the Speaker-Listener
Technique creates a safe space in which couples
can address important, difficult, or emotionally
charged topics. The Speaker-Listener Technique
uses a prop, often a tile-shaped card with printed
rules, to denote which partner is the speaker – the
PREP Enrichment Program
person who “has the floor” and will share their
own perspective and feelings – and which partner
is the listener, whose role is to paraphrase the
speaker’s statements. Couples trade the floor
back and forth so that both partners are able to
speak and listen in turn. Couples are explicitly
instructed to focus on discussing and understand-
ing the issue rather than problem-solving. By
using this structure that allows for having difficult
discussions without engaging in destructive fight-
ing, couples build emotional safety and are able to
express deeper and more vulnerable emotions
while feeling safe, understood, and accepted.
PREP pairs psychoeducation about how to
recognize “communication danger signs” (e.g.,
invalidation, withdrawal, negative interpreta-
tion, and escalation) with a specific strategy to
halt destructive conflict, called time-out. Time-
out represents a pre-agreed-upon procedure for
couples to recognize unhealthy communication
patterns when they’re happening, pause the con-
versation for a predetermined amount of time, and
check back in once both partners de-escalated any
intense emotions and are capable of speaking
and listening constructively. Couples are typically
encouraged to use the Speaker-Listener Tech-
nique to resolve any remaining issues after
returning to a conversation after a time-out.
Interventions in PREP to restore, protect, or
enhance positive connections encourage couples to
engage in a variety of activities both in and out of
session. For example, the “fun deck” is used to help
couples plan shared activities: each partner writes
several activities they would enjoy doing with their
partner on index cards, then the decks are switched,
and each person plans an activity from their part-
ner’s deck. Couples also learn about the importance
of nurturing intimacy and protecting quality time
together from outside influences such as conflict
and other obligations. Communication and conflict
management skills are used to support and protect
time for bonding and connecting. In addition to
these core techniques, PREP includes information
and activities that help couples solidify commit-
ment, address relationship expectations, increase
safety and support, manage stress, explore deeper
issues, collaborate to solve problems, and under-
stand and accept personality differences.
2301
PREP is typically administered in a group
workshop setting and is facilitated by certified
instructors and/or coaches, who may or may not
be trained therapists. The current version of PREP
is module-based, with different relationship skills
and concepts taught in modules that can be incor-
porated into workshops in an “a la carte” fashion.
Because of this, workshops can vary in length,
with brief versions lasting for as few as 2 h and
longer versions lasting for several days. Common
formats include weekend retreats, Saturday semi-
nars, and a series of 1- or 2-hour-long classes over
the course of several weeks. A typical PREP
workshop involves lecture about important prin-
ciples and skills with illustrative slides and exam-
ple video clips, followed by activities in which
couples are guided in applying the skills and con-
cepts to their own relationship. Couples also prac-
tice communication skills during workshops with
guidance from coaches. In between PREP ses-
sions, couples are encouraged to complete home-
work by practicing these skills at home.
PREP may also be incorporated as part of couple
therapy. This application typically involves one cou-
ple working with a therapist or co-therapists, rather
than a group setting, and uses the PREP skills and
psychoeducation to address more serious problems
in the relationship. PREP in couple therapy may be
combined with other evidence-based couple therapy
techniques to build relationship skills (e.g., effective P
communication skills) that scaffold the resolution of
deeper relationship issues (e.g., sexual dissatisfac-
tion). PREP is also available as an online interven-
tion for couples or individuals, called ePREP
(available at lovetakeslearning.com).
Research About the Model
The development of PREP was informed by basic
science research about couples and about related
cognitive and behavioral phenomena. The infor-
mation, skills, and strategies included in the PREP
curriculum are based on empirical data, and the
curriculum has been refined over time to reflect
the most recent research findings. PREP has also
been adapted to meet the specific needs of a
diverse range of individuals and couples.
2302
As one of the most thoroughly researched rela-
tionship education programs, the effectiveness
of PREP has also been tested in outcome studies.
The majority of these studies find that the PREP
intervention is associated with higher-quality com-
munication, better conflict management skills,
lower aggression, and greater relationship satisfac-
tion (see Markman and Rhoades 2012 for a review).
Evidence of PREP’s effectiveness extends to
couples with a variety of demographic and expe-
riential backgrounds. For example, adaptations of
PREP have shown positive effects in low-income
samples (e.g., Rienks et al. 2011), incarcerated
samples (Einhorn et al. 2008), Army samples
(Allen et al. 2011), and international samples
(Hahlweg et al. 1998). The online version of
PREP, ePREP, has also demonstrated efficacy in
reducing relationship and personal distress
(Braithwaite and Fincham 2007).
In addition to effects on communication skills,
there is also some evidence that participation in
PREP is linked to higher relationship stability. For
example, a randomized clinical trial of PREP in
the US Army demonstrates that couples who
received the intervention were less likely to be
divorced after 2 years than those who did not
receive the intervention (Stanley et al. 2010).
PREP is listed in the National Registry
of Evidence-based Programs and Practices
(NREPP), which is a database maintained by the
Substance Abuse and Mental Health Services
Administration (SAMHSA).
Case Example
Adapted from case examples in Fighting for your
Marriage (Markman et al. 2010):
Art and Pam were in their 40s and had been
married for less than 1 year. Their relationship was
happy, but about 6 months after marrying, they
began to have frequent conflicts and started bick-
ering over many small things. They worried that if
things continued as they were, they would fall out
of love with each other and eventually divorce.
They came to a PREP workshop because they
were concerned that their relationship might be
in trouble and they wanted help making it better.
PREP Enrichment Program
When they first came in to the workshop
together, Pam and Art had a fallen into a pattern of
conflict that reflected many of the communication
danger signs. Art tended to use invalidating lan-
guage during fights. For example, during a conflict
about a missed bank appointment, Art told Pam, “I
can’t believe you forgot again! You are so
irresponsible. . . It’s like nothing matters to you.”
Pam tended to make overly negative interpretations
when Art expressed any kind of unhappiness and
then to withdraw from any further interaction with
him. For example, their fight about the bank
appointment began when Art asked Pam why she
didn’t get to the bank on time. Pam thought, “Oh no,
here we go again. . . Art is always on my case about
every little thing. He must think I’m a terrible wife.”
Pam then withdrew from the conversation by
abruptly leaving the room in order to avoid the
criticism that she was expecting.
As Art and Pam fell into the traps of the com-
munication danger signs, their conflict began to
escalate: the more Art felt Pam become defensive
and withdrawn, the more vocal and critical he
became in order to get his point across, which in
turn led Pam to withdraw even further. By the end
of the evening, Pam and Art were both feeling
hopeless and wondering whether their relation-
ship was doomed. Art called these fights “rela-
tionship extinction events.”
Pam and Art’s repeated negative interactions
began to erode their sense of happiness and safety
in their relationship. Both partners had been mar-
ried and divorced before and were somewhat cyn-
ical about the idea of their marriage working out.
Their arguments repeatedly escalated to the point
of questioning whether they should have ever
gotten married, which threatened their commit-
ment safety and undermined their efforts to work
on their relationship together. Furthermore, their
use of the communication danger signs damaged
the emotional safety in their relationship, because
both partners routinely felt defensive and discon-
nected from one another.
During their first PREP class, Art and Pam
learned about the communication danger signs and
about their power to destabilize an otherwise happy
relationship. Pam and Art practiced identifying
these damaging communication strategies in
PREP Enrichment Program
example videos and in their own behaviors. They
both agreed to be careful to avoid these habits during
conflict with one another. Further, they learned a
specific tool to help them interrupt negative interac-
tions before they got nasty: they agreed that when
either person noticed the communication danger
signs creeping into their discussion, they would
call a time-out, which would pause the conversation
for 30 min. During those 30 min, both partners
would work to calm themselves down; Pam pre-
ferred to go for a walk with their dog, whereas Art
preferred to watch something on TV to distract
himself. After 30 min, they would check in with
each other and either try again to have a productive
conversation, decide to plan a better time for the
conversation, or decide to let the conflict go after
they both cooled off.
Art and Pam experienced an immediate benefit
from knowing about the communication danger
signs and adding time-out to their relationship
toolbox. They were fast learners. With practice,
they were able to identify when Art began to curse
or put Pam down and when Pam began to feel
attacked and to check out of the conversation.
They began to use time-out to stop their argu-
ments at the first sign of trouble, rather than letting
conflict escalate to the point of becoming damag-
ing to their relationship. However, even after they
both calmed their “hot” emotions, Pam still had a
difficult time reengaging in conversations that felt
difficult. That’s where the Speaker-Listener Tech-
nique came in.
During their second PREP class, Pam and Art
learned to use the Speaker-Listener Technique to
help them have difficult discussions in a way that
felt safe to Pam and helped her to avoid withdraw-
ing. At first, taking turns and paraphrasing felt
awkward and artificial to them. However, their
PREP coach helped them understand that slowing
down the conversation and interrupting their “nat-
ural” conflict style was actually the purpose of the
Speaker-Listener Technique, and before long, Art
and Pam easily learned to share their own per-
spectives and truly listen to one another. Art was
able to understand why Pam felt vulnerable and
insecure when he criticized her, and Pam was able
to understand how her withdrawal made Art feel
that he was unimportant to her. By using the
2303
Speaker-Listener Technique to help them under-
stand one another during moments that felt safe
from destructive conflict, Pam and Art began to
feel more close and connected.
Once Art and Pam had established this sense
of safety in their relationship by stopping negative
interactions from interfering with their connection
and commitment, they were able to start tackling
some of the more important and fulfilling work
in their relationship. Another PREP class challenged
Art and Pam to think about how to preserve and
enhance their positive connection. They had already
taken the biggest first step, which was to protect
their positive connection from conflict. They con-
tinued to enhance their relationship by scheduling
quality time together during which they could talk as
friends, and they kept this quality time separate from
times when they needed to work out a relationship
issue or deal with everyday life stressors. In their
PREP class, they learned to use a “fun deck”: they
wrote down fun activities to do together on index
cards that they used later to plan dates together. They
also learned how to use the Speaker-Listener Tech-
nique to provide meaningful emotional support to
one another in the face of life stresses and other
challenges outside the relationship. This focus on
enhancing the positive aspects of their relationship
helped Pam and Art worry less about falling out of
love. Rather than feeling as though being in love
was something out of their control, they learned that P
their love could be kept alive if they continued to
work at it and to protect it from conflict.
Finally, one of their PREP classes prompted
Pam and Art to consider how everyday conflicts
in their life may be linked to deeper issues. Using
the “issues and events” model, Pam and Art
connected the dots between their frequent fights
about small daily events and the bigger issue of
money. Like many couples, Art and Pam found
themselves in conflict almost any time a topic
related to money came up. They used the
Speaker-Listener technique to have a difficult dis-
cussion about this high-conflict topic in a way that
still felt safe and productive to both of them.
Through further discussion, Art was able to
express that handling money represented a deeper,
hidden issue for him about trust. In his previ-
ous marriage, his ex-wife’s dishonest use of their
2304
shared funds was heavily intertwined with the end
of their marriage, so when he became concerned
that Pam was not handling money-related matters
responsibly, he became afraid that it indicated
something seriously wrong with their relation-
ship. Pam, in turn, shared that for her, money
was related to a hidden issue of shame. While
she was growing up, her parents were very judg-
mental about others’ use of money, and even as
an adult, she continued to feel nervous and
ashamed when she was tasked with taking on
responsibility for handling money. Through this
discussion, Pam and Art reached a greater under-
standing and acceptance of one another, and
money became a source of conflict for them
much more rarely. Although they had learned
skills for collaborative problem-solving in a dif-
ferent PREP class, Art and Pam found that the
problem about money resolved itself fairly natu-
rally once they reached this understanding: Art
started taking on more of the responsibility for
managing their shared money, which felt more
comfortable to both partners, while Pam took
on more responsibility in other areas of their
shared life.
By the end of their PREP workshop, Art and
Pam were regularly using skills to interrupt nega-
tive interactions and manage conflict. When they
needed to work out an important relationship
issue, they made an intentional decision to do so
and used communication skills to scaffold the
conversation so that it did not threaten their emo-
tional safety or their commitment. Their differ-
ences and disagreements remained, but the way
they handled those differences and disagreements
as a couple had changed drastically for the better.
They scheduled weekly time to be together as
friends and to enjoy shared activities and felt
more deeply connected than they had before.
Most importantly, Pam and Art felt much more
confident about the future of their marriage. The
skills they had learned helped them to stop threat-
ening their commitment to one another, so their
fights no longer escalated to “relationship extinc-
tion events.” And they learned to nurture their
love for one another so that they felt more confi-
dent that it would not fade in the face of time and
conflict.
PREP Enrichment Program
Cross-References
▶ Cognitive Behavioral Couple Therapy
▶ Communication Training in Couple and Family
Therapy
▶ Markman, Howard
▶ Problem-Solving Skills Training in Couple and
Family Therapy
▶ Rhoades, Galena
▶ Scott, Stanley
▶ Within My Reach Enrichment Program
References
Allen, E. S., Stanley, S. M., Rhoades, G. K.,
Markman, H. J., & Loew, B. A. (2011). Marriage edu-
cation in the Army: Results of a randomized clinical
trial. Journal of Couple and Relationship Therapy,
10(4), 309–326.
Bandura, A. (1963). Social learning and personality devel-
opment. New York: Holt, Rinehart and Winston.
Birchler, G. R., Weiss, R. L., & Vincent, J. P. (1975).
Multimethod analysis of social reinforcement exchange
between maritally distressed and nondistressed spouse
and stranger dyads. Journal of Personality and Social
Psychology, 31, 349–360.
Braithwaite, S., & Fincham, F. (2007). ePREP: Computer
based prevention of relationship dysfunction, depres-
sion and anxiety. Journal of Social and Clinical Psy-
chology, 26(5), 609–622.
Einhorn, L., Williams, T., Stanley, S., Wunderlin, N.,
Markman, H., & Eason, J. (2008). PREP inside and
out: Marriage education for inmates. Family Process,
47(3), 341–356.
Gottman, J. M., Markman, H. J., & Notarius, C. I. (1977).
The topography of marital conflict: A sequential anal-
ysis of verbal and nonverbal behavior. Journal of Mar-
riage and the Family, 39, 461–477.
Guerney, B. G. (1991). Relationship enhancement: Skill-
training programs for therapy, problem prevention,
and enrichment. San Francisco: Jossey-Bass.
Hahlweg, K., Markman, H. J., Thurmaier, F., Engl, J., &
Eckert, V. (1998). Prevention of marital distress:
Results of a German prospective longitudinal study.
Journal of Family Psychology, 12, 543–556.
Loew, B., Rhoades, G., Markman, H., Stanley, S., Pacifici, C.,
White, L., & Delaney, R. (2012). Internet delivery of
PREP-based relationship education for at-risk couples.
Journal of Couple & Relationship Therapy, 11(4),
291–309.
Markman, H., Floyd, F., Stanley, S., & Storaasli, R. (1988).
The prevention of marital distress: A longitudinal
investigation. Journal of Consulting and Clinical Psy-
chology, 56, 210–217.
PREPARE/ENRICH
Markman, H. J., Stanley, S. M., Blumberg, S. L.,
Jenkins, N. H., & Whiteley, C. (2004). 12 hours to a
great marriage: A step-by-step guide for making love
last. San Francisco: Wiley.
Markman, H. J., Stanley, S. M., & Blumberg, S. L. (2010).
Fighting for your marriage. San Francisco: Jossey-Bass.
Markman, H. J., & Rhoades, G. K. (2012). Relationship
education research: Current status and future directions.
Journal of Marital and Family Therapy, 38(1), 169–200.
Miller, S., Nunnally, E. W., & Wackman, D. B. (1976).
A communication training program for couples. Social
Casework, 57(1), 9–18.
Rienks, S. L., Wadsworth, M. E., Markman, H. J.,
Einhorn, L., & Moran Etter, E. (2011). Father involve-
ment in urban low-income fathers: Baseline associa-
tions and changes resulting from preventive
intervention. Family Relations, 60(2), 191–204.
Rodgers, R. H., & White, J. M. (1993). Family development
theory. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R.
Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family
theories and methods: A contextual approach
(pp. 225–254). New York: Plenum Press.
Stanley, S. M., Rhoades, G. K., & Markman, H. J. (2006).
Sliding versus deciding: Inertia and the premarital
cohabitation effect. Family Relations, 55, 499–509.
https://doi.org/10.1111/j.1741-3729.2006.00418.x.
Stanley, S. M., Allen, E. S., Markman, H. J.,
Rhoades, G. K., & Prentice, D. (2010). Decreasing
divorce in Army couples: Results from a randomized
clinical trial of PREP for strong bonds. Journal of
Couple and Relationship Therapy, 9, 149–160.
Thibaut, J. W., & Kelley, H. H. (1959). The social psychol-
ogy of groups. Oxford: Wiley.
PREPARE/ENRICH
David H. Olson
Family Social Science, University of Minnesota,
St. Paul, MN, USA
Name and Type of Measure
The PREPARE/ENRICH couple assessment is an
online self-report measure of couple and family of
origin relationships.
Introduction
The PREPARE/ENRICH is a comprehensive
assessment that is based on a systemic model that
2305
has several important components. First are the ten
core scales that include the following: communica-
tion, conflict resolution, partner style and habits,
financial management, sexuality, leisure activities,
roles, and spiritual beliefs. Second is the SCOPE
personality assessment of each person, which is
based on the “Big Five” personality assessment.
Third are the relationship dynamics of each person
related to assertiveness, self-confidence, avoidance,
and partner dominance. Fourth is the Couple and
Family Map that assesses cohesion/closeness and
flexibility in the couple’s relationship and in their
family of origin. Lastly, the cultural context is taken
into account based on the norms and expectations of
different cultural groups (Fig. 1).
One of the advantages of the PREPARE/
ENRICH assessment is that it is compatible with
many other theoretical models and therapeutic
approaches. The main goals of the PREPARE/
ENRICH assessment provide data that can be
used to help couples improve their relationship
by completing some of the couple exercises:
• Identifying and exploring relationship strength
and growth areas
• Strengthening communication skills by teach-
ing assertiveness and active listening
• Resolving conflict using a ten-step model
• Understanding their couple and family rela-
tionship on the dimensions of closeness and P
flexibility
• Identifying and resolving major stressors
• Understanding personality similarities and
differences
Typology of married couples. Five distinct
types (patterns) of married relationships and four
types of premarital couples were discovered when
cluster analysis was used with the ten core cate-
gories in PREPARE/ENRICH. The five basic
types of married couples range from very high in
marital satisfaction to very low: vitalized, harmo-
nious, conventional, conflicted, and devitalized
(not a premarital type). About 15–20% of couples
fall into each of these types that serve to describe
and explain the complexity and differences
between marriages (Olson 2014). Other findings
can also be linked to these types, further helping
2306
PREPARE/ENRICH,
Fig. 1 Systemic
components of PE
understand differences between marriages. For
instance, research shows that with the happiest
type – vitalized – there is very little spouse
abuse, but abuse tends to be very high in the
conflicted and devitalized types (Fig. 2) (Asai
and Olson 2003).
The vitalized couples are the happiest cou-
ples, and they have the highest positive couple
agreement (PCA) scores across most of the ten
core areas of PREPARE/ENRICH. These cou-
ples have the lowest divorce rate and have
strengths in most areas of their relationship.
Harmonious couples are also happy, but at
lower levels of PCA across the ten core areas
than vitalized couples. Conventional couples
are more traditional and have more strengths
in traditional roles and spiritual beliefs and
more growth areas in communication and con-
flict resolution. Conflicted couples have only
strengths in roles and spiritual beliefs.
Devitalized couples have few strengths (very
low PCA scores) across all ten core areas, and
both spouses tend to be very unhappy and tend
to get divorced. Conflicted and devitalized cou-
ples are the ones that most typically seek marital
therapy (Olson 2014).
PREPARE/ENRICH
Developers
David Olson is the primary developer of a variety
of assessments, including AWARE for individ-
uals, PREPARE/ENRICH for dating to married
couples, a self-directed couple checkup for cou-
ples, and FACES for families. He has revised
these and other assessments several times to
improve their scientific rigor (i.e., for reliability,
validity, and national norms). These assessments
have become popular both nationally and in over
25 other countries.
Description of the Measure
PREPARE/ENRICH is a totally online assess-
ment that is tailor-made to each couple based on
questions they answer related to their marital sta-
tus, children, and other background information.
After both persons in a couple relationship com-
plete the assessment online, the facilitator
(counselor, clergy, mentor couple, therapist) who
is trained on PREPARE/ENRICH can view, store,
and print the 25-page PE Personal Report. Those
who utilize PREPARE/ENRICH in couple
PREPARE/ENRICH 2307

PREPARE/ENRICH, FIVE TYPES OF MARRIED COUPLES

Fig. 2 Five types of
married couples 90
80
VITALIZED
70
60 HARMONIOUS
50
40 CONVENTIONAL

30
20 CONFLICTED

10
DEVITALIZED
0
COM

PAR ITS

SEX TIONSH

SPIR FS
CON LUTION

FINA GEMEN

LEIS ITIES

FAM

REL S
& HA

REL

BEL
RES

MAN

ACT

ROL
MUN

UAL
TNE

ATIO

IE
ILY/F
A
URE

ITUA
FLIC

NCIA

IV
O

E
B

A
R ST
IC

NS
T

L
RIEN
L
ATIO

HIP
YLE

IP

DS
T
N

therapy or couple enrichment have the flexibility
of using only the assessment or the assessment
plus any or all of the 20 couple exercises available
as part of the feedback program.
Couple and Family Map. PREPARE/ENRICH
measures both family of origin and the couple
system using the Couple and Family Maps.
These are derived from the Circumplex Model of
Marital and Family systems, originally developed
by David Olson, Douglas Sprenkle, and Candyce
Russell. The Couple and Family Maps use less
clinical language so that they can be easily under-
stood by the couple. The Maps share the same
theoretical ideas and scales as the Circumplex
Model. The Maps are based on the two key
dimensions of closeness and flexibility.
Closeness is defined as the emotional bonding
that couple and family members have toward one
another and how they balance separateness versus
togetherness. The Couple and Family Maps have
five levels of closeness ranging from “discon-
nected” to “overly connected,” as shown in
Fig. 3. It is hypothesized that the three central or
balanced levels of closeness are most functional
for marriages and families over time.
Flexibility is the amount of change in leader-
ship, role relationships, and relationship rules, and
it focuses on how couples and families balance
stability versus change. The Couple and Family
Maps have five levels of flexibility ranging from
“inflexible” to “overly flexible.” As with close-
ness, it is hypothesized that the three central or
balanced levels of flexibility are more conducive
to healthy couple and family functioning.
Combining the 5 levels of closeness and the
5 levels of flexibility creates 25 types of relation-
ships. There are nine balanced types, twelve mid-
range types, and four unbalanced types. P
Theoretically, the main hypothesis is that couples
and families that are balanced on closeness and
flexibility (nine central cells in the Map) are most
healthy and happy compared to those that fall into
the unbalanced types (four corner cells).
In taking the online assessment, couples
respond to statements about both their families
of origin and their couple relationship. These
responses are plotted onto the Couple and Family
Maps. In the couple exercise for the Couple and
Family Map, each person is asked to reflect on
what they would like to bring from their family of
origins into their couple relationship and what
they would like to intentionally leave behind.
Value of PREPARE/ENRICH for counselors/
facilitators. Counselors can use PREPARE/
2308
PREPARE/ENRICH, Fig. 3 Couple and Family Map
ENRICH in many formats (individual, group,
mentor), and specialized versions are available
that deal with issues such as parenting and adop-
tion. The program can help counselors and facil-
itators work with couples by:
PREPARE/ENRICH
• Providing comprehensive and objective data
about the couple’s relationship
• Helping to identify strengths and growth areas
• Showing areas of couple agreement and
disagreement
PREPARE/ENRICH
• Empowering couples to work on their
relationship
Value of PREPARE/ENRICH for couples.
Couples can benefit from taking PREPARE/
ENRICH in many ways. The process of
responding to the items creates curiosity about
how their partner responded. In addition, using
PE with couples improves various aspects of
their relationship (Knutson and Olson 2003;
Futris et al. 2011), such as the following:
• Stimulates dialogue between couple about
important relationship topics
• Increases self and partner awareness
• Helps couples apply concepts and skills most
relevant to their unique relationship
• Increases their relationship skills and
satisfaction
Psychometrics
PREPARE/ENRICH has high reliability, high
validity, and a large national norm based on over
100,000 couples from various ethnic and cultural
backgrounds (Olson 2014). Numerous studies
have demonstrated the rigor of the assessments
and its relevance to couples from a variety of
ethnic groups (Allen and Olson 2001). PRE-
PARE/ENRICH has been found to be psychomet-
rically sound and rated as one of the best couple
assessment instruments for couples across the
family life cycle (Olson 2014).
Example of Application in Couple and
Family Therapy
Mary and Nick were married for 12 years and
had two young children – ages 6 and 8. They had
a conflicted style on PREPARE/ENRICH,
which indicated that they had seven growth
areas (i.e., communication, conflict resolution,
parenting, finances, leisure, sexual relationship,
and roles) and three relationship strengths. On
the Circumplex Model, they both reported
overly low levels of cohesion (disengaged) and
2309
overly high levels of flexibility (chaotic). They
had high stress in the couple relationship and
parenting.
Intervention focused on improving the couple’s
growth areas with teaching specific relationship
skills that they could use with their partner and
children, such as communication and conflict reso-
lution. Several strategies were designed to improve
the couple cohesion, which was very low, and to
provide more structure to their parenting, which was
chaotic. By strengthening the couple relationship,
the couple could begin operating more as a
parenting team.
Post assessment, after about eight sessions of
marital and family therapy, the partners were
closer emotionally and were more organized as a
couple. Their parenting skills improved and their
teamwork resulted in the children become more
well behaved. Overall, the couple reduced the
number of growth areas from seven to three and
increased their strengths from three to seven.
Cross-References
▶ Circumplex Model of Marital and Family Sys-
tems, The
▶ Communication in Couples and Families
▶ Olson, David P
▶ PREPARE/ENRICH Enrichment Program
References
Allen, W. D., & Olson, D. H. (2001). Five types of African-
American marriages. Journal of Marital and Family
Therapy, 27(3), 301–314.
Asai, S.G., & Olson, D.H. (2003). Spouse abuse & marital
system based on ENRICH. Retrieved from https://
www.prepare-enrich.com/pe/pdf/research/abuse.pdf.
Futris, T. G., Baron, A. W., Aholou, T. M., & Seponski,
D. M. (2011). The impact of PREPARE on engaged
couples: Variations by delivery format. Journal of Cou-
ple and Relationship Therapy, 10(1), 69–86.
Knutson, L., & Olson, D. H. (2003). Effectiveness of PRE-
PARE program with premarital couples in a community
setting. Marriage & Family: A Christian Journal, 6(4),
529–546.
Olson, D. H. (2014). PREPARE/ENRICH facilitator’s
manual. Roseville: PREPARE/ENRICH, Inc.
2310
PREPARE/ENRICH Enrichment
Program
David H. Olson
Family Social Science, University of Minnesota,
St. Paul, MN, USA
Name of Model
PREPARE/ENRICH Program
Introduction
The PREPARE/ENRICH program has two com-
ponents: a customized couple inventory and a
skill-building program for premarital and married
couples. It is one of the most widely used pro-
grams for premarital and marital counseling and
education, and more than 100,000 professionals
(including marital and family therapists, social
workers, clergy, psychologists, and other counsel-
ing professionals) have been trained and use the
PREPARE/ENRICH assessment and program.
This is because PREPARE/ENRICH is an effi-
cient, reliable, and valid assessment of a wide
range of interpersonal, personality, couple, and
family characteristics. Over 4 million couples
have benefited from the program, which includes
3.5 million couples from the United States and
half a million couples from ten other countries.
PREPARE/ENRICH (PE) contains both an
online couple assessment and a semi-structured
feedback process for counseling and/or education.
The online couple assessment is tailor-made to
each couple based on questions they answer
related to their marital status, children, and other
background information. After both persons have
completed the assessment, a 25-page PE Facili-
tator’s Report is created and a 25-page PE Cou-
ple Workbook that contains over 20 couple
exercises is used in the feedback process.
As part of this feedback process, couples
increase their self-and-partner-awareness while
they are taught relationship skills such as commu-
nication and managing conflict. Those who utilize
PREPARE/ENRICH Enrichment Program
PREPARE/ENRICH in their therapy or couple
enrichment have the flexibility of using the assess-
ment only or the assessment plus any of the
20 couple exercises available as part of the pro-
gram. This program is built on extensive research
and is focused on improving couples’ relation-
ships by identifying and building on their couple
strengths.
This entry will describe the theoretical founda-
tions, key assessment and skill-building areas, and
the effectiveness of the program and training to use
the PREPARE/ENRICH. First, the theoretical foun-
dations and components of PREPARE/ENRICH are
described. This includes an overview of the couple
typology and the Couple and Family Map, based on
the Circumplex Model of Marital and Family Sys-
tems. The six goals of the program are presented,
and the value of the assessment and program to
counselors and couples is described. The effective-
ness of the program is discussed and how counselors
are trained to use the program.
Prominent Associated Figures
David Olson is the primary developer of a variety of
assessments including AWARE for individuals,
PREPARE/ENRICH for dating to married couples,
a self-directed Couple Checkup for couples, and
FACES for families. He has revised these and
other assessments several times to improve their
scientific rigor (i.e., reliability, validity, and national
norms). These assessments have become popular
both nationally and in over 25 other countries.
Theoretical Framework
The PREPARE/ENRICH is a comprehensive
assessment that is based on a systemic model
that has several important components. First,
there are the ten core scales that include the fol-
lowing: communication, conflict resolution, part-
ner style and habits, financial management,
sexuality, leisure activities, roles, and spiritual
beliefs. Second is the SCOPE personality assess-
ment of each person. Third are the relationship
dynamics of each person related to assertiveness,
PREPARE/ENRICH Enrichment Program
self-confidence, avoidance, and partner domi-
nance. Fourth is the Couple and Family Map that
assesses cohesion/closeness and flexibility in the
couple’s relationship and in their family of origin.
Lastly, the cultural context is taken into account
by creating national norms for different countries
(Fig. 1).
One of the advantages of the PREPARE/
ENRICH program is that it is compatible with
many other theoretical models and therapeutic
approaches. Therapists can integrate techniques
and ideas from their preferred theory or integrated
theory and use their preferred style of interaction.
A cognitive behavioral therapist may use a couple’s
results to focus on challenging thoughts and
restricting beliefs while exploring the relationship
between these thoughts and the emotional experi-
ences of each person. A narrative therapist may use
PREPARE/ENRICH as a foundation for discussion
while still creating space for new ways of thinking
about growth areas by using techniques such as
externalizing and exploring unique outcomes.
The feedback component of PREPARE/
ENRICH includes interventions based on the the-
oretical schools of psychoeducation, solution-
focused, and structural approaches. It uses couple
exercises to help teach the couple relationship
skills that each couple needs based on the assess-
ment results for the couple. The PREPARE/
ENRICH program contains over 20 exercises
PREPARE/ENRICH
Enrichment Program,
Fig. 1 Systemic
components of PREPARE/
ENRICH
FAMILY MAP
PERSONALITY
2311
that align with the scales contained in the
assessment.
The main goals of the PREPARE/ENRICH
program align with couple exercises:
• Identifying and exploring relationship strength
and growth areas
• Strengthening communication skills by teach-
ing assertiveness and active listening
• Resolving conflict using a ten-step model
• Understanding their couple and family rela-
tionship on the dimensions of closeness and
flexibility
• Identifying and resolving major stressors
• Understanding personality similarities and
differences
There are several assumptions behind how the
assessment and program were developed and how
it is delivered. First, it is assumed that if a couple is
taught relevant relationship skills, they will be
able to deal more effectively with their current
and any future problems. Second, it is assumed
that the PREPARE/ENRICH couple assessment
will significantly increase the effectiveness of the
intervention and the couple relationship. This
assumption was verified in several studies
(Halford et al. 2010), including one completed
using PREPARE/ENRICH (Knutson and Olson
2003). Third, it is assumed that the impact of the P
CULTURAL CONTEXT
COUPLE MAP
RELATIONSHIP RELATIONSHIP
DYNAMICS DYNAMICS
FAMILY MAP
10
CORE
SCALES
SCOPE SCOPE
PERSONALITY
2312
assessment and exercises are systemic, so that
making a positive change in any component will
have an impact on the entire system. This was, in
fact, found in a study that used six couple exer-
cises and found improvement in ten major areas
(Knutson and Olson 2003).
A similar finding was reported in a study using
the RELATE couple inventory, where skill-based
training in addition to assessment and feedback
resulted in the best relationship satisfaction and
skill outcome (Halford et al. 2010). Lastly, it is
assumed that the program empowers couples to
take greater control over their own relationship
and enables them to apply these principles to
help their relationship grow.
Strategies and Techniques Used in
Model
Training in use of PREPARE/ENRICH. In order to
be able to use PREPARE/ENRICH with couples, a
person needs to attend a 1-day workshop conducted
by a PREPARE/ENRICH seminar director or take
the on-demand self-training program. Persons with
a master’s or doctoral degree in a field of profes-
sional counseling may choose to complete an
on-demand self-training option instead of a work-
shop. Counselors may choose to receive seven con-
tinuing education credits upon receiving a minimum
score of 70% on a post-test.
Giving feedback to a couple. Since the assess-
ment and skill-building exercises provide a useful
foundation for working with couples, many
counseling training programs have integrated
training on PREPARE/ENRICH into their couple
programs. The semi-structured approach provides
clinicians with a tool to bring relevant concepts
and issues to the couples with whom they work
and exercises that help couples further process
these concepts and issues. The objective summary
of the couple that is provided by the facilitator’s
report is useful for diagnosis and for determining
treatment planning and goal setting. In working
with a couple, it is useful to share with them the
Typology of Marriage so they have a frame of
reference for their marital type and how it com-
pares with other marital types. The Couple and
PREPARE/ENRICH Enrichment Program
Family Map is another useful teaching tool to
illustrate how they perceive their relationship
with their partner and family of origin in terms
of cohesion and flexibility.
Typology of married couples. Five distinct
types (patterns) of married couples and four
types of premarital couples were discovered
when cluster analysis was used with the ten
core categories in PREPARE/ENRICH. The
five basic types of married couples range from
very high in marital satisfaction to very low:
vitalized, harmonious, conventional, conflicted,
and devitalized (not a premarital type). In a
replication study with African American mar-
ried couples by Allen and Olson (2001), the
same five couple types were found as identified
with Caucasian couples. About 15% to 20% of
couples fall into each of these types that serve to
describe and explain the complexity and differ-
ences between marriages. Other findings can
also be linked to these types, further helping
understand differences between marriages. For
instance, research shows that with the happiest
type – vitalized – there is very little spouse
abuse, but abuse tends to be very high in the
conflicted and devitalized types (Fig. 2).
The vitalized couples are the happiest couples,
and they have the highest positive couple agreement
(PCA) scores across most of the ten core areas of
PREPARE/ENRICH. These couples have the low-
est divorce rate and have strengths in most areas of
their relationship. Harmonious couples are also
happy but at a lower level of PCA across the ten
core areas than vitalized couples. Conventional cou-
ples are more traditional and have more strengths in
traditional roles and spiritual beliefs and more
growth areas in communication and conflict resolu-
tion. Conflicted couples have fewer couple strengths
especially in communication, conflict resolution,
and partner habits and only strengths in role and
spiritual beliefs. Devitalized couples have few
strengths (very low PCA scores) across all ten core
areas, and both spouses tend to be very unhappy and
tend to get divorced. Conflicted and devitalized
couples are the ones that most typically seek marital
therapy.
Couple and Family Map. PREPARE/ENRICH
measures both family of origin and the couple
PREPARE/ENRICH Enrichment Program 2313

FIVE TYPES OF MARRIED COUPLES

90

80
VITALIZED
70

60
HARMONIOUS
50
CONVENTIONAL
40

30
CONFLICTED
20

10
DEVITALIZED
0
COMMUNICATION

CONFLICT
RESOLUTION

PARTNER STYLE
& HABITS

FINANCIAL
MANAGEMENT

LEISURE
ACTIVITES

SEXUAL
RELATIONSHIP

FAMILY/FRIENDS

RELATIONSHIP
ROLES

SPIRITUAL
BELIEFS
PREPARE/ENRICH Enrichment Program, Fig. 2 Five types of married couples

system using the Couple and Family Maps. These
are derived from the Circumplex Model of Marital
and Family Systems, originally developed by David
Olson, Douglas Sprenkle, and Candyce Russell.
The Couple and Family Maps use less clinical lan-
guage so that they can be easily understood by the
couple. The Maps share the same theoretical ideas
and scales as the Circumplex Model.
The Maps are based on the two key dimensions
of closeness and flexibility. Closeness is defined
as the emotional bonding that couple and family
members have toward one another and how they
balance separateness versus togetherness. The
indicators of closeness are the I vs. We balance,
the emotional connection, loyalty, and depen-
dence versus independence. The Couple and Fam-
ily Maps have five levels of closeness ranging
from “disconnected” to “overly connected,” as
shown in Fig. 3. It is hypothesized that the three
central or balanced levels of closeness are most
functional for marriages and families.
Flexibility is the amount of change in leadership,
role relationships, and relationship rules, and it
focuses on how couples and families balance stabil- P
ity versus change. The indicators of flexibility are
the amount of change, leadership, role sharing, and
discipline of children. The Couple and Family Maps
have five levels of flexibility ranging from “inflex-
ible” to “overly flexible.” As with closeness, it is
hypothesized that the three central or balanced levels
of flexibility are more conducive to healthy couple
and family functioning.
Combining the 5 levels of closeness and the
5 levels of flexibility creates 25 types of relation-
ships. There are 9 balanced types, 12 midrange
types, and 4 unbalanced types. Theoretically, the
main hypothesis is that the couples and families
that are balanced on closeness and flexibility (nine
central cells in the Map) are most healthy and
happy compared to those that fall into the unbal-
anced types (four corner cells). In taking the
online assessment, couples respond to statements
2314 PREPARE/ENRICH Enrichment Program

PREPARE/ENRICH Enrichment Program, Fig. 3 Couple and Family Map

about both their families of origin and their couple
relationship. These responses are plotted onto the
Couple and Family Maps. In the couple exercise
for the Couple and Family Map, each person is
asked to reflect on what they would like to bring
from their family of origins into their couple rela-
tionship and what they would like to intentionally
leave behind.
Value for Counselors/Facilitators. Coun-
selors can use PREPARE/ENRICH in many
PREPARE/ENRICH Enrichment Program
formats (individual, group, mentor), and spe-
cialized versions are available that deal with
issues such as parenting and adoption. The pro-
gram can help counselors and facilitators work
with couples by:
• Providing comprehensive and objective data
about the couple’s relationship
• Helping to identify strengths and growth areas
• Helping to set relationship goals
• Teaching practical relationship skills like com-
munication and conflict resolution
• Allowing for additional resources and counsel-
ing skills to be integrated into the feedback
process
• Empowering couples to work on their
relationship
Value for Couples. Couples can benefit from
taking PREPARE/ENRICH in many ways. The
process of responding to the items creates curios-
ity about how their partner responded. In addition,
the results can:
• Stimulate dialogue between couple about
important relationship topics.
• Increase self and partner awareness.
• Help couples apply concepts and skills most
relevant to their unique relationship.
• Increase their relationship skills and
satisfaction.
Populations in Focus
The PREPARE/ENRICH assessment has high
reliability, high validity, and a large national
norm based on over 100,000 couples from var-
ious backgrounds (Olson 2014). Numerous
studies have demonstrated the rigor of the
assessments and its relevance to couples from
a variety of ethnic groups (Allen and Olson
2001). The affiliated PREPARE/ENRICH
assessment has been found to be psychometri-
cally sound and rated as one of the best instru-
ments for premarital and marital counseling and
education (Olson 2014; Futris et al. 2011).
2315
Research About the Model
Whether used with an individual couple or in a
group setting, studies have found that the PRE-
PARE/ENRICH program helps premarital cou-
ples get their relationship off to a good start and
helps married couples increase their relation-
ship skills and satisfaction (Olson 2014). One
study (Knutson and Olson 2003) compared
three levels of premarital programming; one
group took the PREPARE/ENRICH assessment
and received four feedback sessions (P/E Feed-
back), the second group only took the assess-
ment (P/E only), and the third group acted as a
control group (they received P/E and feedback
after the study was complete). The P/E feedback
group had the most positive change with
improvement on eight of the ten major areas,
which include communication, conflict resolu-
tion, and concerns about relationships with fam-
ily and friends. The P/E only group improved in
three of the ten major areas, and the control
group made no significant change. The P/E
feedback group experienced a 52% increase in
the number of “vitalized” (most happy) couples
and an 83% decrease in the number of “con-
flicted” (least happy) couples.
Another study compared the PREPARE/
ENRICH program when delivered in an individ-
P
ual format (one couple and one facilitator) and a
group format and found that both approaches
were equally effective (Futris et al. 2011). It
was found that couples who completed PRE-
PARE/ENRICH in both delivery formats had
gains in relationship knowledge and confidence
in their relationships, had more positive conflict
management behaviors, and were more satisfied
with their relationship.
Case Example
Counseling Couple with Marital and Parenting
Problems. Mary and Nick were married for
12 years and had two young children—ages
6 and 8. They had a conflicted style on PRE-
PARE/ENRICH, which indicated that they had
seven growth areas (i.e., communication, conflict
2316
resolution, parenting, finances, leisure, sexual
relationship, and roles) and three relationship
strengths. On the Circumplex Model, they both
reported overly low levels of cohesion
(disengaged) and overly high levels of flexibility
(chaotic). They had high stress in
the couple relationship and parenting.
Intervention focused on improving the cou-
ple’s growth areas with teaching specific relation-
ship skills, like communication and conflict
resolution, that they could use with their partner
and children. Several strategies were designed to
improve the couple cohesion, which was very
low, and provide more structure to their parenting,
which was chaotic. By strengthening the couple
relationship, the couple became closer and began
operating more as a parenting team.
Post assessment, after about eight sessions of
marital and family therapy, the couple were closer
emotionally and were more organized as a couple.
Their parenting skills improved, and their team-
work resulted in the children becoming more
well-behaved. Overall, the couple reduced the
number of growth areas from seven to three and
increased their strengths from three to seven.
Cross-References
▶ Circumplex Model of Marital and Family Sys-
tems, The
▶ Communication in Couples and Families
▶ Olson, David
▶ PREPARE/ENRICH Enrichment Program
References
Allen, W. D., & Olson, D. H. (2001). Five types of African-
American marriages. Journal of Marital and Family
Therapy, 27(3), 301–314.
Futris, T. G., Baron, A. W., Aholou, T. M., & Seponski,
D. M. (2011). The impact of PREPARE on engaged
couples: Variations by delivery format. Journal of Cou-
ple and Relationship Therapy, 10(1), 69–86.
Halford, W. K., Wilson, K., Watson, B., Verner, T., Larson,
J., Busby, D., & Holman, T. (2010). Couple relation-
ship education at home: Does skill training enhance
relationship assessment and feedback? Journal of Fam-
ily Psychology, 24, 188–196.
Prescribing Family Rituals in Couple and Family Therapy
Knutson, L., & Olson, D. H. (2003). Effectiveness of
PREPARE program with premarital couples in a com-
munity setting. Marriage & Family: A Christian Jour-
nal, 6(4), 529–546.
Olson, D. H. (2014). PREPARE/ENRICH facilitator’s
Manual. Roseville: PREPARE/ENRICH, LLC.
Prescribing Family Rituals in
Couple and Family Therapy
Lorna London
Midwestern University, Downers Grove, IL, USA
Name of Concept
Prescribing Rituals in Family Therapy
Introduction
Celebrating special occasions and acknowledging
family traditions are parts of the rituals that fam-
ilies experience. Rituals can have healing proper-
ties for clients dealing with an array of clinical and
non-clinical issues. Some rituals reflect history,
others reflect tradition, while others serve to be
the glue that holds families together. When some
families experience the absence of rituals, mental
health professionals can prescribe family rituals,
with the intent of healing the family and promot-
ing stronger ties.
Theoretical Context for Concept
Family rituals are anchored in systemic family
therapy. The theoretical basis for prescribing
family rituals rests on the assumption that fam-
ily rituals serve four important functions:
(1) organize the family, (2) mediate individual
expectations, (3) recognize and regulate subsys-
tems, and (4) absorb the impact of change and
facilitate transitions (Roy 1990). Rituals allow
for healthy life transitions and the establish-
ments of traditions that can bond a family and
bring about cohesion.
Prescribing Family Rituals in Couple and Family Therapy
Description
The establishment of rituals – whether around
holidays, anniversaries, life transitions, or family
celebrations – has been shown to help clients with
clinical and non-clinical concerns. For example,
work by Kiser et al. (2005) demonstrated a corre-
lation between family rituals and child well-being.
Prescribing rituals also requires action on the part
of the family to be able to effect change in quick
fashion. The therapist joins the family and finds
some creative ways to help them develop rituals
that will reframe troublesome issues into more
potential solutions (Bergman 1990).
Exploring a family’s rituals provides insight
into the family’s covert rules and the ways in
which those rules impact the family’s functioning.
For mental health providers who work with clients
from a family therapy perspective, exploring a
family’s rituals allows for an in-depth look at the
inner beliefs and insights into the family’s world.
For those families dealing with medical and psy-
chological issues like grief and bereavement, hav-
ing an opportunity to develop healthy rituals can
prevent additional pain and promote healthy
healing (Rogers and Holloway 1991).
Application of Concept in Couple and
Family Therapy
There have been researchers to examine the role
of prescribing rituals for clients who have been
experiencing medical and psychological issues, as
well as families who present as healthy. Clinicians
working with families see the benefits of prescrib-
ing rituals which serve a protective role of family
ritual functioning focusing on adjustment to ill-
ness and disability (Kiser et al. 2005). Family
therapists have used prescribing rituals to bring
attention to and redefine roles within a family, to
draw attention, in a sometimes covert style, to
patterns that may not be working within the fam-
ily. The subtle use of symbolism is important and
carries with it important meaning. It helps to
engage the family in finding meaning in its behav-
iors and feelings associated with situations that
occur within their family.
2317
Rituals may be prescribed once or may occur
repeatedly. It is important that the family be
engaged in behavioral, cognitive, and affective
aspects of preparing for and the implementation
of the ritual (Roberts 2003).
Clinical Example
The Stephens family consists of parents Stan
and Sue and their two children John (18 years
old) and Lisa (15 years old). John recently left
home to attend college 5 h away, leaving the
family with mixed feelings of joy at this next
phase of John’s life but sadness at missing his
presence in the family. Lisa was very close to
her brother and was protective of him in his
absence. The family, who had been accustomed
to rituals – such as sharing family dinners –
found themselves feeling sad with the loss of
this tradition. The chair where John would sit
was now empty as he was no longer home for
meals. Lisa felt angry if anyone attempted to sit
in what had been known as John’s chair, as she
felt it would be sending a message that John was
no longer an important member of the family
and that their family would fall apart. The ther-
apist prescribed a ritual in which each day at
dinnertime, someone would sit in what had been
John’s seat. The purpose was to sit with the P
feelings and emotions that this action triggered.
Each time this was done, the family was asked to
speak about their day and focus on each other,
rather than to dwell on the fact that John was no
longer there to share meals. The family was led
to focus on their new way of life. In order to help
the family reestablish some semblance of nor-
malcy and to cope with their difficult feelings,
the therapist prescribed, as part of the ritual,
setting up a weekly FaceTime visit between
John and the rest of the family, with one of the
family members sitting in John’s chair. This
allowed for regular contact and a way to bond
in a meaningful way, and an opportunity for all
to realize that no matter where anyone sat, their
family would still be strong in the face of this
systemic change. This ritual did not take the
place of what used to be but allowed for the
2318
family to prevent future spiraling into sadness
and depression and promoted a healthy way of
adjusting to this life change.
Cross-References
▶ Family Rituals
▶ Milan Systemic Family Therapy
▶ Odd and Even Day Ritual in Couple and Family
Therapy
References
Bergman, J. (1990). Clinical road maps for prescribing
rituals. In J. Zeig & S. Gilligan (Eds.), Brief therapy:
Myths, methods and metaphors. New York: Brunner/
Mazel.
Kiser, L., Bennett, L., Heston, J., & Paavola, M. (2005).
Family ritual and routine: Comparison of clinical and
non-clinical families. Journal of Child and Family
Studies, 14(3), 357–372.
Roberts, J. (2003). Setting the frame: Definition, functions
and typology of rituals. In E. Imber-Black, J. Roberts,
& R. Whiting (Eds.), Rituals in families and family
therapy (pp. 3–48). New York: Norton.
Rogers, J., & Holloway, R. (1991). Family rituals and the
care of individual patients. Families, Systems & Health,
9(3), 249–259.
Roy, A. (1990). Family rituals: Functions and significance
for clergy and psychotherapists. Group, 14(1), 59–64.
Prescribing the Symptom in
Couple and Family Therapy
Linna Wang
Alliant International University, San Diego,
CA, USA
Name of Concept
Prescribing the Symptom
Synonyms
Invariant prescription; Paradoxical directive
Prescribing the Symptom in Couple and Family Therapy
Introduction
Prescribing the Symptom is the most well-known
paradoxical directives. It is one of the hall mark
interventions in Strategic Family Therapy.
Theoretical Framework
Strategic Family Therapy is considered by many
as more pragmatic than theoretical. It is very much
influenced by Milton Erickson, and its theoretical
roots are deeply connected to researches of theo-
rists of Mental Research Institute (MRI), such as
Paul Watzlawick and Don Jackson.
Milton Erickson broke away from the psychi-
atric foundations of his time. He viewed the
unconscious mind as having the wisdom to solve
problems and heal, rather than destructive. The
therapist’s job was to help patients to gain access
to that wisdom. Instead of devoting lengthy effort
to interpret patients’ behavior, Erickson focused
on the symptoms, developed different ways,
including paradoxical interventions, to change
people’s behavior and solve their problems as
quickly as possible. Influenced by Milton
Erickson, the strategic therapists believe that
people can make rapid changes once the therapist
gets the change process started. The therapists,
rather than the clients, should take on the respon-
sibility for changes by designing strategies and
directing clients to behavioral actions. Their goal
is to help clients to solve their problems by what-
ever means that works.
Researchers of MRI group took a similar prag-
matic approach to understand human communi-
cation and its function in problem formation and
problem solving. They believed that it is impossi-
ble to accurately understand how the unconscious
mind works. The effort to understand “why” or
intention of human behavior is just an unverifiable
hypothesis. They adopted the concept of “black
box” from the field of telecommunication as an
analogy of the “why.” It is impossible to know the
inner work of the black box from the outside, and
any effort to get into the black box (crack it open)
will destroy the box and its content. Instead of
trying to understand or guess what is going on
Prescribing the Symptom in Couple and Family Therapy
inside the black box, sometimes it is much more
efficient to bypass the black box entirely, focus
only on the observable relationship between what
goes into (input) and what comes out of (output)
the black box. The sequence or pattern, rather than
the intention, of human behavior can provide
much more useful information. Symptoms are no
longer viewed as an expression of intrapsychic
conflict but some kind of input into the family
system (Watzlawick et al. 1967).
Similar to intrapsychic dynamics, past experi-
ence was also viewed by MRI researchers as an
unreliable explanation of the current behavior.
With the intrapsychic dynamics and past
experiences assume only secondary importance in
understanding human behavior, MRI group
focused exclusively on the here and now, the
behavior sequences, the circular causality of
human interactions (the output of one black box
may be the input of another black box), and the
interaction between symptoms and its context
(Watzlawick et al. 1967). Instead of “why,” they
focused on “what for” or the function of symptoms.
The intensely pragmatic research focus on human
interaction leads to MRI group’s simple yet power-
ful principles of problem formation and problem
solution. Problem becomes a problem when
(1) people persistently attempt to solve a problem
that has no solutions (therefore regular annoying
difficulties in life are turned into problems);
(2) problems result from flawed family hierarchy
and/or boundaries; and (3) problems result from
family members’ attempts to protect or control
each other, thus serve a function in the family
(Nichols and Schwartz 1991). Problem solutions
are equally pragmatic and situated in here and now,
following a four-step procedure: (1) Clearly define
the problem in concrete terms; (2) investigate solu-
tions that have been attempted; (3) clearly define
desired outcome in concrete terms; and (4) design
and implement a plan to produce the desired out-
come (Watzlawick et al. 1974).
Family is a rule-governed organism that may
be stuck but not sick. Rules have to be changed to
have the family unstuck. Rule change, however, is
often experienced as too much to the family’s
taste. The family reacts to it as “negative feed-
back” and reverses the change to return to its
2319
original uncomfortable stability, homeostasis.
Strategic family therapists believe that people
can make rapid changes once the therapist get
the change process started, often in a small way.
Starting the change process is to have clients
either take on a new behavior in the old context
or continue the old behavior in a new context. It is
much more difficult, especially at the beginning,
to have clients to take on a new behavior than to
allow them to continue the old behavior and
change some aspect of the context. Family tends
to perceive the change to some aspect in the con-
text much more manageable than taking on a new
behavior, thus responds to the change with “pos-
itive feedback,” to amplify the change.
Prescribing the Symptom is NOT simply asking
clients to continue to do what they are already doing.
It is a sophisticated eight-stage intervention (Haley
1987) (see the entry of ▶ “Paradoxical Directive in
Couple and Family Therapy”). The therapist needs
to do an intense investigation on the symptoms’
meanings, timing, location, frequency, etc., i.e., dif-
ferent aspects in the context of the symptom. While
permitting clients to continue with the symptoms,
the therapist also asks them to make a slight change
on one or more aspects of the context. For example,
client can continue the symptoms, but in a different
place, or at a different time, or different frequency, or
for a different purpose.
P
Description
Prescribing the Symptom has two functions:
intensify the behavior patterns and deal with
resistance.
Intensify behavior patterns: Unless in crisis,
family members are stuck in an uncomfortable
yet stable pattern of behaviors. The uncomfortable
part makes them want to change, and the stable
part makes them want to resist the change. The
behavior patterns are uncomfortable because they
are ridiculous, yet the ridiculousness is not clearly
visible to clients. Prescription of symptoms in this
case is usually to increase the frequency of the
behavior patterns. It intensifies the discomfort to
an unbearable level, also making the ridiculous-
ness of the relationship dynamic explicit.
2320
Dealing with resistance: Prescribing the
Symptom creates an illusion that clients have
the choice to continue to do what they know
how, therefore takes the wind out of the sail of
resistance. The therapist asks clients to continue
the symptoms with only a slight change in some
aspect of the symptoms: time, location, or fre-
quency. This change is so slight that is per-
ceived manageable, yet it changes the context
of the symptoms. While continuing the symp-
toms, clients start to do something different.
Application of Concept in Couple and
Family Therapy
The first therapeutic task is to have clients do
something, anything, to break out of their habitual
patterns of behaving or thinking. The first move is
the hardest, as every family member is blaming
everyone else and waiting for everyone else to
make the first move. Prescribing the Symptom
gives permission to everyone in the family to
continue to do what they are already doing, only
with a very slight, sometimes playful, twist that is
considered manageable by the family members.
Unknowingly, clients start the change process
already.
Clinical Example
A couple reported that they both had “short fuse”:
They could escalate from minor disagreement to
physical fight within minutes. Once the fight was
over, they could return to intimacy just as quickly.
They reported that their house was destroyed by
the fights: “Everything in the house was broken,
including the couch!” The couple’s goal was to
get into physical fights less.
The presenting problem was physical fight.
Why the couple fought was the “black box” that
the therapist was not interest in figuring out. The
therapist conducted a detailed assessment of the
problem: the location, frequency, timing, and
meaning of their fights, and solutions they had
attempted. She found that the couple took
mutual responsibility for the fights. The
Prescribing the Symptom in Couple and Family Therapy
physical fights would happen couple of times
each week. They had promised each other many
times never do it again. The only location in the
house where they had not fought was the bath-
room (people usually go to bathroom one at a
time.)
The therapist decided to prescribe the symptom
of “physical fight”. The directive was: “Living
room is for relaxation; bedroom is for love mak-
ing; and kitchen is where you nourish your bodies.
You don’t want to contaminate these places in
your house. Let’s keep the dirty fights to where
they belong, bathroom. Next time, I would like
you to fight in the bathroom. When you get into
the bathroom, you (the husband) need to take off
your clothes, get into the bathtub. You (the wife)
need to take off your pants and sit on the toilet.
Then fight.”
Therapist allowed them to carry on the
symptom (physical fight) that they were very
skilled at but changed one aspect of the symp-
tom, the location. The taking off clothes part
was just to make it fun. This change was slight
and playful enough that clients believed they
could handle.
The following week, the couple reported that
they indeed got into another fight. This time,
both of them raced towards the bathroom. “We
didn’t quite make it. We started to fight outside
the bathroom door. But that was funny. We
laughed and didn’t fight much.” The therapist
insisted their compliance to the Prescribing the
Symptom directive: “Hold on! I didn’t ask you
to fight less. I only ask you to run faster! The
one who gets into the bathroom first wins the
fight!”
The therapist changed the context of the symp-
tom further: The behavior that needed attention
was not the physical fight anymore, but the run-
ning. The definition of “fight” started to change as
well, from clients’ original “physical fight” to
“fight to stop fight.” This directive also blocked
the desired behavior (fight less).
The couple reported in the third session that
they started laughing on the way to the bathroom.
By the time they got there, they were hugging and
making fun of each other. The therapist was puz-
zled by how all that happened.
Pretend Technique in Couple and Family Therapy
Cross-References
▶ Paradoxical Directive in Couple and Family
Therapy
▶ Strategic Family Therapy
References
Haley, J. (1987). Problem-solving therapy (2nd ed.).
San Francisco: Jossey-Bass Publishers.
Nichols, M., & Schwartz, R. C. (1991). Family therapy:
Concepts and methods (2nd ed.). Boston: Allyn and
Bacon.
Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1967).
Pragmatics of human communication: A study of
interactional patterns, pathologies and paradoxes.
New York: W. W. Norton.
Watzlawick, P., Weakland, J., & Fish, R. (1974). Change:
Principles of problem formation and problem resolu-
tion. New York: W. W. Norton.
Pretend Technique in Couple
and Family Therapy
Andrea S. Meyer and Morgan A. Stinson
Mercer University School of Medicine,
Macon, GA, USA
Name of the Strategy or Intervention
Pretend Technique in Couple and Family Therapy
Synonyms
Directive; Paradoxical intervention; Pretending
Introduction
Family therapists help to alter problematic inter-
actions within families. Over time, family mem-
bers’ styles of interacting can become entrenched;
this may leave the family feeling stuck and hope-
less. The pretend technique, developed by Cloe
Madanes (1980), provides a creative clinical
2321
intervention for family therapists. By utilizing
the pretend technique, therapists help shift the
family system in ways that can reduce individual
symptoms and transform the problematic family
interactions.
Theoretical Framework (e.g., “This Is
Utilized Most in X Models and
Y Theories”)
The pretend technique stems primarily from struc-
tural and strategic origins, where altering the pre-
senting problem occurs through modifying the
interactions between family members. The focus
of strategic family therapy is to break the cycle of
families through straightforward or paradoxical
directives (Piercy et al. 1996). Therapists are
responsible for creating specific interventions for
the presenting problem while attending to social
and developmental contexts of the family system
(Madanes 1981).
Rationale for the Strategy or
Intervention
Therapists use the pretend technique to help
individuals and families separate themselves
from problematic symptoms. In the pretend P
technique, the symptoms are enacted outside
of the context in which they are embedded.
The approach encourages a shift in control
over the symptom. Ultimately therapists using
the pretend technique will help families to
establish new responses to the problem, which
can reshape the family interactions and lead to
symptom reduction.
Description of the Strategy or
Intervention
The therapist begins by determining the identified
client with the problem symptom. After joining
and assessment, the therapist hypothesizes about
the function of the symptom within the family
system. The therapist then crafts the pretend
2322
directive, which changes the pattern of interaction
around the symptom. In creating the symptom
outside of the typical context in which it occurs,
the symptomatic individual can experience a
sense of psychological distance and control over
the symptom. The family members are invited to
react in alternate prescribed ways to the symptom,
thus allowing family members to change behavior
(Piercy et al. 1996). When interactions are
shifted in the family, the symptom is no longer
maintained within the system.
Case Example
Amira, a 9-year-old girl, and her parents, Stella
and Sarah, were referred to Owen, a medical
family therapist by their pediatrician. Amira was
experiencing intense headaches and nausea (three
to four school nurse visits per week) for the past
month. Each time Amira visits the school nurse,
the parents are called. These calls have led to
multiple interruptions for parents at work. Initially
the parents were concerned and would pick up
Amira from school. Over time the parents have
grown increasingly frustrated. The parents also
disagree about how to manage the headaches
which has led to more conflict within the couples’
relationship.
The pediatrician has been unable to deter-
mine a physiological explanation for the head-
aches. Stella and Sarah describe how the
headaches began approximately 3 months after
they adopted their youngest child, David. The
parents adopted David when he was approxi-
mately 6 months old. Owen offered to meet
separately with the family to address the symp-
tom and family concerns.
Owen determined that the headaches began
due to a change in parent child interactions and
family structure when David arrived. Owen
hypothesized that the headaches allowed
Amira to feel closer with her parents while
encouraging the parents to show concern and
care toward Amira. Owen asked the family to
participate in the pretend technique to address
Pretend Technique in Couple and Family Therapy
the symptom. Owen directed the parents to set
an alarm each night an hour before Amira’s
bedtime. The parents were asked to turn to
Amira and say “it is now time for you to have
your headache.” Amira was instructed to “pre-
tend” that she was having a headache and dis-
play the typical symptoms that would lead to her
seek out the school nurse. The parents would
then take Amira to her room and would lie with
Amira in bed for 15 minutes. During this time,
the parent would gently caress Amira’s head
saying “let’s make that headache go away!” At
the end of the 15 minutes, the family would
return to the normal nightly routine.
The therapist directed the family to pretend
together every day for the next 2 weeks. At the
next session, the parents reported that the calls
from school dissipated. The therapist advised the
family to continue pretending at home each night
until the headaches reduce even further. Through
the pretending directive, Amira could feel close
and nurtured by her parents, and the parents could
alter the previous negative responses to Amira.
The headaches no longer serve to maintain close-
ness between Amira and her parents; therefore the
symptoms reduced over time, and a new family
interaction that maintains closeness and connec-
tion was created.
Cross-References
▶ Brief Strategic Family Therapy
▶ Directives in Couple and Family Therapy
▶ Madanes, Cloe
References
Madanes, C. (1980). Protection, paradox, and pretending.
Family Therapy Process, 19, 73–85.
Madanes, C. (1981). Strategic family therapy.
San Francisco: Josey-Bass Publishers.
Piercy, F. P., Sprenkle, D. H., Wetchler, J. L., and
associates. (1996). Family therapy sourcebook
(2nd ed.). New York: The Guilford Press.
Primary Adaptive Emotions in Emotion-Focused Therapy
Primary Adaptive Emotions in
Emotion-Focused Therapy
Rhonda N. Goldman1 and Irene C. Wise2
1
Illinois School of Professional Psychology,
Argosy University, Chicago, IL, USA
2
Illinois School of Professional Psychology at
Argosy University, Schaumburg, IL, USA
Name of Concept
Primary adaptive emotions
Introduction
Therapists conducting emotion-focused therapy
for couples (EFT-C) assess the type of emotion
the client is expressing in the session, and this
informs the nature of the empathic response or
choice of intervention (Greenberg and Goldman
2008). Various in-session responses include
increasing emotional awareness, containing or
soothing overwhelming feelings, exploring and
deepening emotions, or bypassing an emotion to
uncover another. One major aim of the EFT-C
therapist is to listen for and guide the couple to
access, symbolize, and express to each other one
particular class of vulnerable feelings known as
primary adaptive emotions. Research has shown
that having each partner reveal and respond to
these vulnerable emotions and their associated
needs is the single most effective means to
resolve couple conflict (Meneses and Scuka
2015).
Theoretical Context for Concept
From an evolutionary point of view, emotions
allow mammals to flexibly adapt to situations to
increase survival (Greenberg 2011). The brain
processes emotions separately from thought
with emotional processing being automatic and
2323
faster than cognition (LeDoux 1996). Emotional
experience also involves autonomic bodily
responses. A primary adaptive emotion incor-
porates these elements and therefore refers to
the immediate and emotional response that acti-
vates an individual to take action consistent
with the situation at hand. For example, adap-
tive anger in the face of a threat motivates a
person to assertively take protective action
and, if necessary, prepares the body to fight
(Greenberg and Paivio 1997).
Description
Of the four types of emotions in emotion-
focused therapy (EFT), primary emotions are
the most immediate, initial, and fundamental
reaction to a person or situation. (Please refer to
the entries listed in the Cross-References to learn
about other types of emotions in EFT.) In con-
trast to a primary maladaptive emotion, a pri-
mary adaptive emotion is the biologically
adaptive response that is appropriate to a situa-
tion, and as such, action and expression gener-
ated from primary adaptive emotion is much
more likely to ensure needs will be met, wishes
fulfilled, and emotional processing will remain
fluid. Primary adaptive emotions include anger
arising in response to violation, sadness arising P
from loss, and fear arising from threat
(Greenberg and Goldman 2008). Attachment
and identity systems in couples are formed
around primary adaptive emotions. Subse-
quently, healthy attachment and identity pro-
cesses for each partner in a couple are
maintained by awareness of these emotions in
one’s self and in the other.
Application of Concept in Couple and
Family Therapy
The essence of EFT-C is to promote the aware-
ness and expression of primary adaptive emo-
tions within a couple (Greenberg and Goldman
2324
2008). The EFT-C therapist works with clients
to transform their reactive emotions and blame
toward their partners into the underlying pri-
mary adaptive emotions of shame, fear, or hurt.
Creating safety within the couple’s interaction
and helping the couple get in touch with these
primary adaptive emotions allow each partner to
access needs for intimacy and recognition while
simultaneously promoting empathy and valida-
tion in the other partner. For example, intimacy
is deepened when one partner appropriately
responds with caring and comfort to soothe his
partner’s sadness over a loss. For couples, the
expression of primary adaptive emotions elicits
a reciprocal and appropriate response from the
partner, leading to the development and mainte-
nance of positive interactional cycles.
Clinical Example
Clinical examples include feeling sadness in rela-
tion to loss or anger in response to violation. In the
context of couple therapy, one partner might, for
example, be pushing the other away (a secondary
emotional process and behavior) so as not to feel
sadness in relation to the loss of a parent. In this
example, the sadness and grief is adaptive, and
therapy would therefore focus on allowing the
experience and expression of sadness so that the
person and, by extension, the couple can move
forward.
Cross-References
▶ Emotion-Focused Therapy for Couples
▶ Greenberg, Leslie
▶ Instrumental Emotional Response in Emotion-
Focused Therapy
▶ Restructuring the Bond in Emotion-Focused
Therapy
▶ Secondary Reactive Emotions in Emotion-
Focused Therapy
▶ Stabilization in Emotion-Focused Therapy
Primary Emotions in Emotionally Focused Therapy
References
Greenberg, L. S. (2011). Emotion-focused therapy.
Washington, DC: American Psychological Association.
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-
focused couples therapy: The dynamics of emotion,
love, and power. Washington, DC: American Psycho-
logical Association.
Greenberg, L. S., & Paivio, S. C. (1997). Working with
emotions in psychotherapy. New York: The Guildford
Press.
LeDoux, J. (1996). The emotional brain: The mysterious
underpinnings of emotional life. New York: Simon &
Schuster Paperbacks.
Meneses, C. W., & Scuka, R. F. (2015). Empirically
supported humanistic approaches to working with cou-
ples and families. In D. Cain, K. Keenan, & S. Rubin
(Eds.), Humanistic psychotherapies: Handbook of
research and practice (2nd ed., pp. 353–386).
Washington, DC: American Psychological Association.
Primary Emotions in
Emotionally Focused Therapy
Ashley M. Harvey
Colorado State University, Fort Collins, CO, USA
Introduction
As its name suggests, emotionally focused ther-
apy (EFT) utilizes emotion as a key mechanism of
change in couple therapy. Unlike many couple
and family therapy models that consider emotion
to be a disorganizing force and a signal for the
therapist to refocus clients in a more “rational”
manner, EFT conceptualizes emotion as a “lead-
ing element” of change (Johnson 1998). Emotion
makes one pay attention, influences physiology
and cognition, and propels one into action. Instead
of avoiding emotion, the EFT therapist learns to
capitalize on it, evoking and highlighting emo-
tional experiences in the room in order to change
a couple’s pattern of interacting and promote
connection.
More specifically, EFT distinguishes between
two levels of emotion: primary and secondary.
Primary emotions are more vulnerable, often
Primary Emotions in Emotionally Focused Therapy
unconscious, and usually related to fears about
one’s own worth or the responsiveness of others.
Secondary emotions are expressed in response to
primary emotions, such as becoming angry when
one is scared. People are typically more conscious
of, and able to name, secondary emotions and less
aware of their primary emotions.
Theoretical Context for Concept
The concept of primary emotion is rooted in both
affect and attachment theories. It is suggested that
“affect is the engine that drives us” (Nathanson
1992, p. 59). Intense emotion can override other
cognitive processes and act as an alarm system
that primes the individual to respond to the per-
ceived threat (Johnson 1998). Further, the neuro-
biological research on attachment indicates that
attachment and fear systems are interrelated (Bell
2009). When a human being experiences fear,
attachment figures can alleviate distress and
calm the fear system (Beckes and Coan 2015;
Bell 2009). In addition, separation, or perceived
separation, from attachment figures triggers the
primitive fear system.
Within attachment theory, Bowlby’s conceptu-
alization of internal working models (IWM) pro-
vides a structure for understanding primary
emotions. Bowlby indicated that all people have
two types of internal working models or mental
representations: IWM of self and our IWM of
others. These mental models are built through
our earliest relationships with caregivers. When
caregivers are generally sensitive and responsive,
children develop a model of themselves as basi-
cally good and lovable, and a model of others as
available and trustworthy (Bretherton and
Munholland 1999). IWM developed in childhood
can be challenging to shift and tend to serve as a
prototype for future relationships, but are also
malleable and responsive to current situations
and dynamics (Mikulincer and Shaver 2016).
Therapists are, in many ways, helping clients
change their IWM, and EFT therapists are specif-
ically doing this within the couple relationship so
that each partner feels that they are valued and
2325
seen by the other, and that their partner is acces-
sible and trustworthy. Negative IWM of self and
others are associated with primary fear. In their
process research, Bradley and Furrow (2007)
found that EFT therapists guided clients in
experiencing and sharing fears associated with
their models of self and others. The goal, then, is
for each partner to take a risk and share soft
emotions. For example, clients may be helped to
deepen their fear that their partner does not really
want to “see” all aspects of themselves and to ask
for reassurance from their partner. By doing so,
clients are thus shifting their IWM of self to one of
being worthy and lovable, and their IWM of
others to one in which others are caring and avail-
able. This powerful bonding exchange in stage
2 of EFT is designed to shift IWMs and calm
conflict-driving fears. Earlier research indicated
that the number of softening events was correlated
with increased relationship satisfaction (Johnson
et al. 1999). The therapist orchestrates “bonding
events” by helping clients experience painful fears
in an affirming and coherent way, share these
primary emotions with their partner, and ask for
and receive reassurance and comfort (Johnson
2004). Affect and attachment theories thus guide
the use of primary emotions to restructure prob-
lematic interactional patterns and build secure
attachments in couples.
P
Description
In EFT, emotion “is both a target and agent of
change” (Johnson 2004, p. 44). Secondary emo-
tions are the affective states we initially display:
typically anger or shutting down. These second-
ary emotions are in reaction to primary emotions –
our deeper, attachment-related emotions – that are
often unarticulated and unconscious and are usu-
ally fear-based: fear of isolation, abandonment, or
unworthiness.
As Johnson (1998) noted, “Emotional cues
pull for responses from others” (p. 5). In argu-
ments, individuals typically express secondary
responses of anger or shutting down, which cue
a partner to either distance or pursue. However, if
2326
therapists can guide partners in unpacking and
expressing primary emotions, such as fear or
shame, this is more likely to cue a compassionate
partner response. In early EFT process research,
emotionally vulnerable self-disclosures associ-
ated with primary emotions were more likely to
lead to positive and supportive partner responses.
Helping partners to experience, process, and
express soft feelings is a key change element in
EFT (Bradley and Furrow 2007; Johnson et al.
1999) that can bring couples together in a way that
anger, defensiveness, or shutting down does not.
Application of Concept in Couple and
Family Therapy
EFT therapists use five specific skills to unpack
these “raw spots” and help “order and distill”
painful primary emotions: reflection, validation,
evocative responding, heightening, and
empathic conjecture (Johnson 2004; see Harvey,
Secondary Emotions in Emotionally Focused
Therapy, this volume, for definitions of each of
these five skills). It is crucial that the therapist use
these skills while maintaining a therapeutic alli-
ance characterized by empathic attunement and a
nonjudgmental, accepting stance. In addition,
therapists also utilize the RISSSC approach to
heighten painful or vulnerable emotions.
RISSSC is an acronym that stands for: Repeat:
repeat key words and phrases; Image: use images
to capture emotion; Simple: keep phrases simple;
Slow: slow the pace down so that emotion can
unfold; Soft: use a soft and more soothing voice;
and Client: use client’s words and images
(Johnson 2004). Therapists and clients are, in
essence, walking around in the client’s emotional
experience, and slowly, gently unpacking it. EFT
is an experiential approach, and thus clients
reflect on primary emotions while experiencing
them. Clients are encouraged to tune into the
detailed aspects of primary emotions, such as
sensations in the body (e.g., blood rushing in
ears), or metaphors (e.g., stepping off a cliff;
Johnson et al. 2005). Here are examples of the
use of the five basic skills when exploring pri-
mary emotions:
Primary Emotions in Emotionally Focused Therapy
Reflection: “A part of you is afraid that if you reach
for him, he won’t be there.”
Validation: “You’re right, it is so scary to let some-
one see these dark and twisty parts of ourselves.”
Evocative responding: “What is happening for you
right now as you hesitate and hold your arms?
You’re not sure she will like this?”
Heightening: (in a soft, slow voice) “In this
moment, you worry that you’re crazy somehow,
that if you let yourself stay in this space, you’ll
just disintegrate into pieces?”
Empathic conjecture: “At this moment, you are
wondering—does she really want to see this part
of me?”
In stage 1 (of three stages) of EFT, primary
emotions are identified and situated in the cou-
ple’s interactional cycle. In stage 2, the goal is for
partners to “deepen, distill, and disclose” their
own primary emotions (Johnson et al. 2005,
p. 169), and also accept the primary emotions of
the other. The core attachment emotions explored
in stage 2 tap into fears associated with the ade-
quacy of ourselves and the trustworthiness of
others: our internal working models (Bradley
and Furrow 2007; Johnson et al. 2005).
Clinical Example
Angela and Alicia often argued about Alicia work-
ing too much. Angela would express anger, and
Alicia typically expressed defensiveness and frus-
tration (all secondary emotions). The EFT therapist
helped Angela and Alicia deepen their awareness
and expression of primary emotions, or attachment-
related needs and fears. Angela was helped to
understand and express, for example, “When you
are working a lot, I get scared that I’m not important
to you.” In tapping into and expressing her own
primary emotions, Alicia learned to say, “When
you are angry at me for working too much, I get
worried that I’m a disappointment to you.” Primary
emotions often drove their conflict: Alicia and
Angela thought they were arguing about Alicia’s
work, but the argument was actually driven by the
primary emotion of fear: the fears of being discon-
nected and not being valued.
Primary Maladaptive Emotions in Emotion-Focused Therapy
When the therapist asked Angela and Alicia
about what they were “feeling” during the argu-
ment, she often heard secondary emotions such as
mad, frustrated, angry, or upset from Angela, and
defensive, attacked, or a shoulder shrug accompa-
nied by “I don’t know—not good” from Alicia.
There was more than one simple step between
Angela and Alicia’s displayed secondary emo-
tions and each partner’s ability to disclose her
attachment needs and fears. It was a slow process
in which the therapist, using the five skills for
exploring emotion and the RISSSC approach,
helped both Angela and Alicia focus and reflect
on their current emotional state, validate their
feelings, and then take small steps to expand and
deepen their emotional awareness (Johnson
2004). Using the metaphor of an onion, the ther-
apist helped Angela and Alicia slowly peel back
each layer, experiencing and expressing each
emotional state to each other, until they reached
their core primary emotions and unmet attachment
needs. Accessing and disclosing these soft emo-
tions was the “antidote” to Angela and Alicia’s
conflict (Bradley and Furrow 2007) and an effec-
tive path to helping them have a successful and
secure connection (Johnson 1998).
Cross-References
▶ Attachment Theory
▶ Bowlby, John
▶ Circle of Security: “Understanding Attachment
in Couples and Families”
▶ Emotion in Couple and Family Therapy
▶ Emotional Reactivity in Emotion-Focused
Couple Therapy
▶ Emotionally Focused Couple Therapy
▶ Emotion-Focused Therapy for Couples
▶ Greenberg, Leslie
▶ Johnson, Susan
▶ Primary Adaptive Emotions in Emotion-
Focused Therapy
▶ Primary Maladaptive Emotions in Emotion-
Focused Therapy
▶ Secondary Reactive Emotions in Emotion-
Focused Therapy
2327
References
Beckes, L., & Coan, J. A. (2015). The distress-relief
dynamic in attachment bonding. In V. Zayas &
C. Hazan (Eds.), Bases of adult attachment: Linking
brain, mind, and behavior (pp. 11–33). New York:
Springer.
Bell, D. C. (2009). Attachment without fear. Journal of
Family Theory & Review, 1(4), 177–197. https://doi.
org/10.1111/j.1756-2589.2009.00025.x.
Bradley, B., & Furrow, J. (2007). Inside blamer softening:
Maps and missteps. Journal of Systemic Therapies,
26(4), 25–43.
Bretherton, I., & Munholland, K. A. (1999). Internal work-
ing models in attachment: A construct revisited. In
J. Cassidy & P. Shaver (Eds.), Handbook of attach-
ment: Theory, research, and clinical application
(pp. 89–111). New York: Guilford.
Johnson, S. M. (1998). Listening to the music: Emotion as
a natural part of systems theory. Journal of Systemic
Therapies, 17(2), 1–17.
Johnson, S. M. (2004). The practice of emotionally focused
couple therapy: Creating connection (2nd ed.).
New York: Brunner-Routledge.
Johnson, S. M., Bradley, B., Furrow, J., Lee, A., Palmer,
G., Tilley, D., & Woolley, S. (2005). Becoming an
emotionally focused couple therapist: The workbook.
New York: Routledge.
Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler, D.
(1999). Emotionally focused couples therapy: Status
and challenges. Clinical Psychology: Science and
Practice, 6(1), 67–79. https://doi.org/10.1093/clipsy/
6.1.67.
Mikulincer, M., & Shaver, P. R. (2016). Attachment in
adulthood: Structure, dynamics, and change
(2nd ed.). New York: Guilford Press.
Nathanson, D. L. (1992). Shame and pride: Affect, sex, and P
the birth of the self (1st ed.). New York: Norton.
Primary Maladaptive
Emotions in Emotion-Focused
Therapy
Rhonda N. Goldman and Shannon Iverson
Illinois School of Professional Psychology,
Argosy University, Chicago, IL, USA
Introduction
Emotion-focused therapy for couples (EFT-C) is
a blend of systemic and experiential therapies
designed to enhance couple interaction by
2328 Primary Maladaptive Emotions in Emotion-Focused Therapy
decreasing escalating conflict and increasing
vulnerable emotional expression between part-
ners. First developed by Les Greenberg and Sue
Johnson in 1988, Les Greenberg and Rhonda
Goldman expanded the original model to include
five stages. In EFT-C, transforming interpersonal
interactions within a couple is largely dependent
on partners’ ability to learn to access and express
core emotions to one another. Core emotions
are also referred to as primary emotions in emo-
tion theory, and they can be adaptive or maladap-
tive in nature. Research has demonstrated the
effectiveness of EFT-C in that it helps couples
express primary adaptive emotions and transform
primary maladaptive emotions. A more detailed
description of emotion theory tenets and primary
maladaptive emotions is discussed below.
Theoretical Context for Concept
Emotion theory posits that emotions are adaptive
in nature, and individuals learn to emotionally
respond in ways that are adaptive to them given
their circumstances or experiences. Ultimately,
EFT-C helps partners experience and express
core emotions to one another to cultivate intimacy
and couple bonding. Three emotion responses can
be distinguished in individuals and couples:
instrumental emotions, secondary (or reactive)
emotions, and primary (or core) emotions.
In EFT-C, direct expression of primary and sec-
ondary emotions, rather than instrumental emo-
tions, is encouraged. Instrumental emotions are
expressed in order to influence one’s partner or
evoke a particular response in them.
Secondary emotions are defined as reactive
emotions that serve to protect oneself against
experiencing a more vulnerable, underlying feel-
ing. They are defensive in nature and cover pri-
mary emotions. For example, many individuals
may feel scared or hurt by their partner, but
instead of expressing this core emotion, they
may express a secondary emotion such as anger
or blame. This “reaction to the reaction” obscures
the original emotion and leads to actions that are
not well-suited for the current situation. From an
EFT-C perspective, secondary emotions must be
explored, validated, and bypassed in order to
arrive at primary emotions. Helping couples
access, experience, and express primary emotions
is a fundamental change process in EFT-C.
Description
Primary emotions can be adaptive or maladaptive.
When primary adaptive emotions are present in
couples, the expression of these core emotions is
sufficient for couples to restructure their bond and
interactions. For example, if a person has experi-
enced a profound loss, they may need to express
their core sadness and sense of loss to their part-
ner. Primary maladaptive emotions, however,
need to be accessed, transformed, and expressed
to one’s partner. Primary maladaptive emotions
are direct reactions to past situations that no lon-
ger help the person cope constructively with situ-
ations that elicit them in the present. Because they
interfere with current functioning, these emotion
responses need to be transformed to help the per-
son effectively feel and behave in their current
life. For example, a fragile client may have
learned that closeness was generally followed by
physical or sexual abuse. Therefore, caring or
closeness, as a potential violation, will be auto-
matically responded to with anger and rejection.
Application of Concept in Couple and
Family Therapy
Primary maladaptive emotions are typically
rooted in past emotional wounds and are usually
regarded as initially adaptive to the particular
circumstance. As a person develops, however,
sometimes what was once adaptive for an individ-
ual is no longer adaptive, and their way of emo-
tionally responding to similar situations becomes
maladaptive. This emotional and relational learn-
ing often manifests in a romantic relationship and
may lead to difficulty in the person’s ability to
develop intimacy with their romantic partner.
In EFT-C, the exploration and identification of
Primary Maladaptive Emotions in Emotion-Focused Therapy
maladaptive emotions is imperative because it
allows the therapist to help the couple process
emotional learning that occurred in significant
past relationships. Accessing and transforming
the maladaptive emotion of one partner is a key
emotional change process because it facilitates the
vulnerable expression of primary emotion in both
partners. This leads to a fundamental, positive
shift in the couple interaction.
Clinical Example
Below is an example of a couple who becomes
hooked in a negative interactional cycle where the
wife criticizes her husband and the husband’s
sense of inadequacy is triggered. This segment
focuses on the therapist helping the husband
explore his internal reactions and identify a pri-
mary maladaptive emotion. This example also
illustrates the historical roots of the husband’s
past emotional wound, a deeply felt fear of being
worthless which he begins to believe about him-
self because of his wife’s criticism.
T: So somehow, [therapist turns to the wife] when
you feel he isn’t looking hard enough to find a
“real” job, you feel scared but end up showing
him you’re angry, and you scold him. . . and
I guess [therapist turns to the husband] you end up
feeling criticized by her when she blames you,
almost like she’s looking down on you. . .and then
inside, you feel not good enough?
P: Yeah, she is always judging me and telling me
“That’s not good enough,” or I’m not working hard
enough, or I need to be doing “this or that” better.
I heard that enough growing up from my mom. She
used to always tell my dad he was worthless and
couldn’t hold a job, and then she would turn to me
and say, “Don’t be like your father.”
T: [talking to the husband] So you used to hear your
mom put your father down, and that would make
you feel. . .?
P: Well, umm, I don’t know. I never thought about it
before. Probably that I would never be able to be
good enough either. I mean, my dad and me have
very similar personalities – we’re a lot alike.
T: Mh-hm, I see, so you automatically compare
yourself to your dad, which makes you feel not
good enough too, or at least afraid of being
worthless. . .
P: Yeah, I never thought about it like that before.
I guess when she [talking about his wife] says those
2329
things it’s like I already know it’s true [looks down
and puts his palm on his forehand].
T: So when she [gently pointing to the wife] tells
you you’re not good enough, there’s a part of you
that really believes it. And I guess you sort of take to
heart that you’re worthless or can’t do anything
right.
As this example illustrates, the experience of
primary maladaptive emotions originates from
emotional wounds that occurred in significant,
past relationships. If unacknowledged or left
untouched, these emotions persist in one’s present
romantic relationships. However, EFT-C has the
potential to transform primary maladaptive emo-
tions and shift couple dynamics through a power-
ful interpersonal process.
Cross-References
▶ Emotion in Couple and Family Therapy
▶ Emotional Reactivity in Emotion-Focused
Couple Therapy
▶ Emotionally Focused Couple Therapy
▶ Emotion-Focused Therapy for Couples
▶ Goldman, Rhonda
▶ Greenberg, Leslie
▶ Johnson, Susan
▶ Primary Adaptive Emotions in Emotion-
P
Focused Therapy
▶ Restructuring the Bond in Emotion-Focused
Therapy
▶ Secondary Reactive Emotions in Emotion-
Focused Therapy
▶ Softening in Emotion-Focused Therapy
▶ Stabilization in Emotion-Focused Therapy
References
Bradley, B., & Furrow, J. L. (2004). Toward a mini-theory
of the blamer softening event: Tracking the moment-
by-moment process. Journal of Marital and Family
Therapy, 30(2), 233–246.
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-
focused couples therapy: The dynamics of emotion,
love, and power. Washington, DC: American
Psychological Association.
Greenberg, L. S., & Johnson, S. (1988). Emotionally
focused couples therapy. New York: Guilford Press.
2330 Problematic Sexual Behavior in Couple and Family Therapy
Problematic Sexual Behavior
in Couple and Family Therapy
Natasha Helfer Parker
Symmetry Solutions, Wichita, KS, USA
Name of Concept
Problematic Sexual Behavior in Couple and Fam-
ily Therapy
Introduction
A common issue within the field of Couple and
Family Therapy is that “problematic sexual behav-
ior” is treated by clinicians from the construct and
model of “sex or porn addiction.” This creates prob-
lems for a variety of reasons, including aspects that
affect accurate assessment and diagnosis, best prac-
tice treatment approaches, and adequate sexual edu-
cation. Just this past year, the American Association
of Sexuality Educators Counselors and Therapists
(AASECT) developed a position statement that
includes the following quote: “AASECT 1) does
not find sufficient empirical evidence to support
the classification of sex addiction or porn addiction
as a mental health disorder, and 2) does not find the
sexual addiction training and treatment methods and
educational pedagogies to be adequately informed
by accurate human sexuality knowledge. Therefore,
it is the position of AASECT that linking problems
related to sexual urges, thoughts or behaviors to a
porn/sexual addiction process cannot be advanced
by AASECT as a standard of practice for sexuality
education delivery, counseling or therapy”
(AASECT position statement 2016). The field of
sex therapy is important to integrate within systemic
approaches to treating couples and family systems
within the context of sexuality, to ensure ethical
treatment and avoid unintentional harm of clients.
Theoretical Context for Concept
Arguments against sex and porn addiction have
been based on several factors, some of which are
listed below: (a) the concept of sex/porn addiction
being a social phenomenon, instead of a clinical or
medical approach backed by evidence-based,
peer-reviewed research (no current diagnosis
exists in DSM 5 or ICD 10) (Ley 2014); (b) the
lack of shown effectiveness of sex addiction treat-
ment modalities to help couples and individuals
deal with sexual concerns that are reported as “out
of control,” including expensive in-patient treat-
ment centers not usually covered by insurance
companies; (c) the diversity of presenting difficul-
ties that are often influenced by familial, cultural,
or religious bias in regards to sexual mores
(Grubbs et al. 2014); (d) the existence of various
many sexual education groups that misrepresent
make false claims by misrepresenting scienti-
fic studies and yet, are allowed in school and
church systems to present misleading their infor-
mation to vulnerable youth and parents (i.e.,
Fight the New Drug, Sons of Helaman, etc.)
(Prause et al. 2016a, b); (e) the reality that men,
in general, but particularly gay and bisexual
men and white, upper-class men, are much
more likely to receive the label of sex addict; (f)
the general trend by media and even the social
sciences to pathologize sexual behavior that is
not deemed heteronormative, creating ethical
dilemmas for practitioners (practicing clinicians
generally present with large gaps in sexuality
training as well as lack of awareness on personal
bias within sexuality training) (Hecker et al.
1995); (g) the legal trend to hold “sex addicts”
less criminally accountable in the court systems
of the United States as well as sexual offenders
being mislabeled as sex addicts and therefore
receiving inadequate or inappropriate treatment;
and (h) the treatment of high sexual desire as a
disorder with implications within low-libido/
high-libido marriages/relationships (Steele et al.
2013). Josh Grubbs of Bowling Green University
in Ohio (2015) has conducted longitudinal
research demonstrating that identifying oneself
as a sex or porn “addict” predicts greater life
problems and distress, regardless of the fre-
quency of sex or porn use. The self-identification
of addict becomes linked to sexual shame, a
damaging self-concept, that teaches people to
fear their own sexual desires and needs (Griffin
Problematic Sexual Behavior in Couple and Family Therapy
et al. 2016). Therefore, sex-positive understand-
ing and treatment of sexual behavior that pre-
sents as problematic in a therapy setting is vital
to positive clinical results.
By drawing on effective methods from the fields
of psychotherapy that have been deemed best-
practice due to empirical, peer-reviewed research
that supports efficacy, clinicians can take
approaches to sexual problems that will be helpful
to individuals, marital/long-term partnerships and
family systems. These can include such modalities
as Systems Therapy, Cognitive Behavioral Ther-
apy, Narrative Therapy, Behavioral Therapy, Posi-
tive Psychology, Motivational Interviewing,
Mindfulness, Solution-Focused Therapy, etc.
Description
To simplify the issues that can arise from sexual
problems clients generally present in a therapeutic
setting, the following three categories can be use-
ful towards assessment and diagnosis. (1) Sexual
behavior can present as problematic. Meaning a
person can be acting in ways that go against their
religious/moral codes, that do not meet the expec-
tations of how their society/culture expects them
to act, or that impedes upon a relational sexual
contract (one partner is comfortable with some-
thing the other is not or is keeping certain behav-
ior secretive). (2) Sexual behavior can present as
maladaptive. Meaning the behavior has become
such a focus in the person’s life that it now inter-
feres with the quality of their daily living (i.e.,
work is hampered, finances spent, time manage-
ment, social/relational ramifications, etc.). (3) Sex-
ual behavior can present as nonconsensual and/or
criminal. Meaning coercion, boundary-crossing,
violence, and power differentials are at play.
Problematic sexual behavior can be explored
in a nonbiased, nonshaming therapeutic environ-
ment to help the client better understand what
their assumptions about healthy sexuality are,
what they want them to be and how others’ beliefs
around these issues are impacting their personal
authority. Work can center on conflicts between
values and behavior and why they might exist,
developing sexual maturity/responsibility and
2331
sex education (often normalizing what people
mistakenly think is not normal). Work often
includes marriage/relational counseling where
couples are taught to sexually contract in ways
they may not usually have considered. These
types of interventions are at the foundation of
taking a sex-positive approach.
Maladaptive sexual behavior is usually a
symptom of underlying issues. Helping a client
explore their relationship with sexual behaviors,
instead of being predominantly focused on the
behavior itself, is an important distinction in sex
therapy work. And correct clinical assessment is
vital, where certain diagnoses are considered as
well as any trauma history (i.e., clinical depres-
sion, anxiety disorders, developmental disorders,
personality disorders, substance dependence,
etc.). Best-practice treatment approaches for all
of these diagnoses exist – none of which include
sex addiction treatment. Braun-Harvey and
Vigorito (2015) have developed a comprehensive,
sex-positive model that addresses assessing and
treating out-of-control sexual behavior in males.
This model holds promise for females as well and
needs clinicians to apply its tenets to this popula-
tion so that clinical applications can be studied
and researched.
When criminal sexual behavior presents, a
therapist needs to take caution to understand
their own limitations of scope of practice and be P
willing to refer to those who are trained and adept
at treating sex offenders.
Application of Concept in Couple and
Family Therapy
When conducting couple or family therapy from a
sex-positive approach, clinicians are better able to
assess, diagnose, and treat issues that may be
presenting through the lens of sexually problem-
atic behavior. Making sure one has participated in
continuing education opportunities focused on
sexuality is an important responsibility of profes-
sionals working within the couple and family
fields of study. Accredited programs should be
diligent in making sexual health classes an inte-
gral part of their clinical training and curriculums.
2332
One such training that can be useful in challenging
therapist bias is the Sexuality Attitude
Reassessment (SAR) – often offered by AASECT
as well as other venues.
Taking a comprehensive sexual history is an
important first step to treatment. Using systemic
approaches to assessment will be an asset some-
one with MFT training can bring to incoming
clients a given situation. It will also be imperative
to include the six principles of sexual health
developed by the World Health Organization.
These principles imply that sexual encounters
should (1) include consent, (2) be nonexploitative,
(3) take precautions to protect from disease and
unwanted pregnancy, (4) include honesty, (5) be
conducted in a way that include shared values of
the participating parties, and (6) prioritize mutual
pleasure.
As clinicians continue the assessment process
with their clients, it is important to look for factors
such as untreated mental health conditions,
untreated past trauma, unresolved relational
issues, erotic templates and/or libidos that are
not well matched within the relationship, erotic
templates and/or behaviors that are frowned upon
by a cultural, religious, or familial component,
and issues around poor impulse control or bad
habits.
Clinical Example
Trent (43) and Kate (41), a heterosexual, white,
cisgender, married couple of the Mormon faith
entered marital therapy after a disclosure from
Trent to his wife that he had been watching
pornography on a “regular basis.” The couple
had been married 19 years and had four children
ranging in ages from 8 to 17. Trent had also
recently experienced a faith transition where
he was still attending church with his family
but no longer felt he believed the “truth claims”
of his religion. Kate presented as highly dis-
tressed over both of these issues and felt that
Trent was ruining their marriage, tearing the
family apart and talked readily about her hus-
band’s “porn addiction” and the possibility of
divorce.
Problematic Sexual Behavior in Couple and Family Therapy
After further assessment and questioning, the
following information came to fruition: Trent had
watched pornography and masturbated as a teen at
the frequency of about once a week. He felt much
shame from this behavior since it did not match
with his religious values and as he prepared to
attend a Mormon mission he started a pattern of
lying to his ecclesiastical leaders about his activ-
ities. This quickly became a cycle of shame where
at certain times Trent would “confess,” feel tem-
porary relief, at some point masturbate or watch
pornography again, feel hopelessness and despair
at his inability to “control his sexual urges” (even
though at this point this was only happening once
every 2–3 months), and stay in a cycle of secrecy
and shame until he could muster the courage to go
through the confession process again.
Although both partners married as virgins,
Trent’s sexual history was seen as highly deviant
from the cultural context of Mormonism. Kate
reported never masturbating as a teen and
expecting that all sexual interaction would happen
within the context of her marriage.
It was Trent’s recognition of his patterns being
unhealthy, including suicidal thoughts, that
started the process of Trent doubting his faith.
When he told his wife about his history and that
he had continued to masturbate and look at por-
nography secretly within his marriage, she imme-
diately went to talk to their bishop who referred
them to a sex addiction treatment center and a
12-step group hosted by the church. Trent went
along for a while with this approach but eventu-
ally communicated to his wife that he did not feel
that his behavior warranted being treated like he
was a “broken sexual being”. At that point, they
soughtt help from a Certified Sex Therapist who
was also trained as an MFT.
The clinician started with a comprehensive sex
history, marital history, and mental health assess-
ment. Neither presented with sexual trauma. Trent
reported symptoms of generalized anxiety disor-
der and clinical depression and Kate of clinical
depression. Both reported their marriage being
strong and enjoying their sexual intimacy together
until Trent’s disclosure to Kate – at which point
she felt extreme betrayal, emotional
dysregulation, a sense of deep distrust, and a
Problematic Sexual Behavior in Couple and Family Therapy
pulling away from sexual intimacy with her hus-
band. The clinician, who was culturally compe-
tent in the Mormon faith tradition, started the
work by normalizing their experience, offering
some basic sexual education, and sensitively
introducing the difference between behavior that
goes against one’s religious values and behavior
that is clinically significant (never minimizing the
hurt and betrayal that Kate had felt due to the
cultural construct she was very much a part of).
Interventions were developed that addressed
regaining trust in the relationship, and focusing
on the many assets the couple had within their
primarily positive history. Recognizing how the
religious culture had informed their sexual devel-
opment, expectations, and values (without the
clinician ever denigrating their faith) was useful
in allowing for different meanings and framings
between the couple. Working on differentiation
skills, honesty that would be met with safety,
self-soothing strategies, and sexual contracting,
they could both agree upon all helped increase
the sense of emotional intimacy the couple shared.
Over a period of 6 months, Kate had become
more comfortable with seeing her husband from
the perspective of a culturally shamed young man
who had not been taught how to normalize his
own sexual development and the implications this
had going into their marriage. Trent had been able
to take responsibility for his role in keeping much
of his sexual angst hidden from Kate and was
more willing to share with her his erotic tastes
and desires. He had also stopped keeping behav-
iors secret even if his honesty was uncomfortable
for Kate. A year later, the couple reached out to the
clinician to give her an update. They reported that
Kate was still attending church but had become
more relaxed in her faith traditions and was more
aligned with her husband’s religious views
(he was no longer attending). They reported that
their couple agreement included Trent watching
pornography when he wanted an outlet or to help
them manage libido differences and that this no
longer threatened intimacy between them. In fact,
at times Kate would join him and enjoy the erotic
nature of such shared activity. They also reported
feeling better able to handle their libido and erotic
taste differences without ascribing harmful
2333
meanings that would erode the quality of their
relationship (i.e., you don’t love me, you don’t
prioritize me, you are oversexed, you are under-
sexed, etc.). Both reported less symptoms with
anxiety and depression and were content with
the results of the services they had received.
Cross-References
▶ Acceptance in Couple and Family Therapy
▶ Acceptance Versus Behavior Change in Couple
and Family Therapy
▶ Alliance Repair in Couple and Family Therapy
▶ Anxiety Disorders in Couple and Family
Therapy
▶ Assessment in Couple and Family Therapy
▶ Boundary Making in Couple and Family
Therapy
▶ Bowen, Murray
▶ Circle of Security: “Understanding Attachment
in Couples and Families”
▶ Circumplex Model of Marital and Family Sys-
tems, The
▶ Conjoint Sex Therapy
▶ Couple Distress in Couple and Family Therapy
▶ Cultural Competency in Couple and Family
Therapy
▶ Cultural Values in Couples and Families
▶ Depression in Couple and Family Therapy P
▶ Differentiation of Self in Bowen Family Sys-
tems Theory
▶ Ethics in Couple and Family Therapy
▶ Forgiveness in Couple and Family Therapy
▶ Function of the Symptom in Family Systems
Theory
▶ Gender in Couple and Family Therapy
▶ Gender Roles
▶ Identified Patient in Family Systems Theory
▶ Marital Fusion in Couples
▶ Marital Schism in Couples
▶ Obsessive Compulsive Disorder (OCD) in
Couple and Family Therapy
▶ Perel, Esther
▶ Positioning in Couple and Family Therapy
▶ Positive Reinforcement in Couples and
Families
▶ Problem-Solving Family Therapy
2334 Problem-Saturated Stories in Narrative Couple and Family Therapy

▶ Problem-Solving Skills Training in Couple and

Family Therapy Problem-Saturated Stories in
▶ Reframing in Couple and Family Therapy Narrative Couple and Family
▶ Religious Practices in Couple and Family Therapy
Therapy
▶ Research in Relational Science David Drustrup1 and Donna Rosana Baptiste2
1
▶ Roles in Couples and Families University of Iowa, Iowa City, IA, USA
2
▶ Separation-Individuation in Families The Family Institute at Northwestern University,
▶ Sexism in Couple and Family Therapy Evanston, IL, USA
▶ Solution-Focused Couple and Family Therapy
▶ Values in Couple and Family Therapy
Name of Concept

References Problem-saturated stories

AASECT position statement. (2016). https://www.aasect.

org/position-sex-addiction. Synonyms
Braun-Harvey, D., & Vigorito, M. A. (2015). Treating out
of control sexual behavior: Rethinking sex addiction.
New York: Springer Publishing Company. Problem stories
Griffin, B. J., Worthington, E. L., Leach, J. D., Hook, J. N.,
Grubbs, J., Exline, J. J., & Davis, D. E. (2016). Sexual
congruence moderates the associations of hypersexual
Introduction
behavior with spiritual struggle and sexual self-concept.
Sexual Addiction & Compulsivity, 23(2–3), 279–295.
Grubbs, J. B., Exline, J. J., Pargament, K. I., Hook, J. N., & In narrative therapy, a foundational tenet is that
Carlisle, R. D. (2014). Transgression as addiction: Reli- people naturally tell stories about their lives and
giosity and moral disapproval as predictors of per-
experiences. These personal stories or narratives
ceived addiction to pornography. Archives of Sexual
Behavior, 44(1), 125–136. reveal how people understand and relate to them-
Grubbs, J. B., Stauner, N., Exline, J. J., Pargament, K. I., & selves, their family members, social contexts, and
Lindbert, M. J. (2015). Perceived addiction to internet the world. Unsurprisingly, when clients enter ther-
pornography and psychological distress: Examining
apy, their personal narratives are dominated by
relationships concurrently and over time. Psychology
of Addictive Behaviors, 29(4), 1056–1067. themes of resentments and negative thoughts or
Hecker, L. L., Trepper, T. S., Wetchler, J. L., & Fontaine, emotions. For example, couples or families might
K. L. (1995). The influence of therapist values, religi- emphasize recurring fights, unmet needs, and over-
osity and gender in the initial assessment of sexual
whelmed feelings. Such concerns frame how clients
addiction by family therapists. The American Journal
of Family Therapy, 23(3), 261–272. view the future, and often many feel hopeless about
Ley, D. L. (2014). Myth of sex addiction. Lanham: changing things (White and Epston 1990).
Rowman & Littlefield Publishers. Narrative approaches to couple and family
Prause, N., Siegle, G. J., Deblieck, C., Wu, A., & Iacoboni,
therapy often begin where clients begin, with
M. (2016a). EEG to primary rewards: Predictive utility
and malleability by brain stimulation. PLOS One. storylines dominated by problems and concerns.
https://doi.org/10.1371/journal.pone.0165646. Therapists enter problem-saturated conversations
Prause, N., Steele, V. R., Staley, C., Sabatinelli, D., & with compassion and with the goal of helping
Hajcak, G. (2016b). Prause et al. (2015) the latest
clients to uncover empowering themes buried in
falsification of addiction predictions. Biological Psy-
chology, 120, 159–161. their dominant narratives. In doing so, narrative
Steele, V.R., Staley, C., Fong, T, & Prause, N. (2013). Sexual therapists hope to lead clients to articulate their
desire, not hypersexuality, is related to neurophysiologi- preferred outcomes, i.e., layers of information
cal responses elicited by sexual images. Socioaffective
hidden in the past and current circumstances,
Neuroscience & Psychology, 3, 20770. http://www.socio
affectiveneuroscipsychol.net/index.php/snp/article/view/ which offer hope for change in perspectives, emo-
20770/28995# tions, or choices (Walsh and Keenan 1997).
Problem-Saturated Stories in Narrative Couple and Family Therapy
Theoretical Context
Michael White, the founder of narrative therapy,
drew on the work of Michael Foucault to articulate
the concept of problem-saturated stories (White
and Epston 1990). Foucault believed that fre-
quently told storylines in which people disclose
ideas about self, others, and the world are
privileged in the sense that they seem most real or
true (Guilfoyle 2012). If people only see them-
selves and their lives through privileged themes,
this can lead to faulty and reductionist beliefs about
self and relationships. But Foucault believed that
hidden beneath privileged storylines are subjugated
stories that are invalidated or silenced by people
themselves or society. When people’s narratives
expand to include information from their subju-
gated knowledge bases, this can alter their sense
of identities and values leading to more hopeful
ways of relating to self and others (Guilfoyle
2012).
White drew on Foucault’s work to explore the
negative impact of problem-saturated storylines
on clients’ lives, (White and Epston 1990). Fou-
cault (1980) believed that knowledge and power
in social spheres shape people’s views of them-
selves. Similarly, White and Epston (1990) sug-
gest that life narratives shape the dominant
storylines that lead people to feel overwhelmed
by problems and failures. Foucault (1980)
suggested that amplifying subjugated knowledge
can increase personal agency and empowerment.
White and Epston (1990) incorporated this notion
in the technique of deconstruction. Through Fou-
cauldian logic, White and Epston (1990) proposed
that therapy conversations expand client’s narra-
tives to include preferred stories or “unique out-
comes,” that is, personal stories that offer fresh
perspectives on self and situations and hope for
change.
Description
White and Epston (1990) believed that when cli-
ents come to therapy, there are several substories
or alternative narratives that do not fit into the
dominant storyline. When clients’ narratives are
2335
problem saturated, accessing and articulating sub-
stories, through skilled questioning, revive hope
and initiative. Substories create an entry point for
re-storying, or more balanced narratives that help
clients to view their problems in new ways. This
allows them to understand how problems con-
strain their lives or relationships, to identify
ways to manage concerns or difficulties, and to
examine value. The therapist’s goal is to employ
techniques that reveal substories to enrich the
clients’ understanding of their lived experiences.
Applications to Couple and Family
Therapy
The following are suggestions for how therapists
might work with problem-saturated stories in cou-
ple and family therapy. Each member of a couple
or family might have a different lens on their
presenting concerns, and while their personal
accounts are self-serving, they help the therapist
to understand patterns that drive problem
sequences. During problem-saturated accounts,
therapists should listen for substories where nar-
ratives might be enriched.
Skilled questioning begins the process of
shifting from a problem focus to one that reveals
clients’ competence or resilience. To capture such
postures, therapists might externalize problems, P
that is, help clients to frame problems as afflic-
tions and as separate from themselves. External-
izing conversations challenge clients to separate
themselves and their identities from their problem
conditions and attempt to gain agency in their
lives.
In the narrative therapy framework, most prob-
lems or concerns can be externalized, for exam-
ple, feelings, relationship dynamics, behaviors,
and sociocultural experiences. Externalizing
begins by giving the problem or concern a name.
From here, the externalized problem by name
(e.g., insecurity) is framed as having a life of its
own, which can be investigated for how it nega-
tively affects a couple’s interactions. The therapist
then invites clients to survey how the problem, by
name, shapes their sense of reality. Clinical exam-
ples will be presented in the following section.
2336
For the new story to be meaningful, it must be
retold outside of therapy. The therapist might
encourage clients to tell friends, coworkers, and
loved ones their new understanding of battling
insecurity. White and Epston (1990) referenced
the need to consider the “audience” when
re-storying. When outside parties are engaged,
the new story is put into action, and the clients
must take responsibility to live it out.
Clinical Example
For example, a couple might assess “Insecurity” in
self, at work, during sexual encounters, etc. This
might also be posed as a question, for example:
“Can you tell me how ‘Insecurity’ has worked its
way into other areas of your life as well?” Through
such explorations, many clients unwittingly provide
information about preferred outcomes or values they
would like to exhibit when faced with their concern.
For example, a partner might say: “When I let
‘Insecurity’ take over, I don’t get the whole picture
because I’m too worried and I lash out.” The thera-
pist might then explore other times in the clients’
lives when they controlled “Insecurity” to exhibit
their preferred traits. Past occurrences of exhibiting
preferred traits or behaviors are unique outcomes,
which the therapist can actively link to current and
future ways of responding to problem situations (e.
g., when “Insecurity” arises). The therapist can
frame the task of noticing in a concrete way, for
example, “What does it say about the two of you
that you are still together despite how hard ‘Insecu-
rity’ has been fighting against you?” “What are
some ways you can rise above ‘Insecurity’ over
the next week before I see you again?” The clients’
narratives now include threads of success and hope-
fulness that were not present before.
Cross-References
▶ Absent but Implicit in Narrative Couple and
Family Therapy
▶ Collaborative and Dialogic Therapy with Cou-
ples and Families
Problem-Solving Family Therapy
▶ Deconstruction in Narrative Couple and Family
Therapy
▶ Externalizing in Narrative Therapy with Cou-
ples and Families
▶ Narrative Couple Therapy
▶ Narrative Family Therapy
▶ Problem-Saturated Stories in Narrative Couple
and Family Therapy
▶ Training Narrative Family Therapists
▶ White, Michael
▶ Witnessing in Narrative Couple and Family
Therapy
References
Bubenzer, D., West, J., & Boughner, S. (1994). Michael
White and the narrative perspective in therapy. The
Family Journal, 2(1), 71–83.
Foucault, M. (1980). Two lectures. In C. Gordon (Ed.),
Power/knowledge: Selected interviews and other writ-
ings 1972–1977 (pp. 78–108). New York: Harvester
Wheatsheaf.
Guilfoyle, M. (2012). Towards a grounding of the agentive
subject in narrative therapy. Theory & Psychology,
22(5), 626–642.
Walsh, W., & Keenan, R. (1997). Narrative family therapy.
Family Journal: Counseling and Therapy for Couples
and Families, 5(4), 332–336.
White, M., & Epston, D. (1990). Narrative means to ther-
apeutic ends. New York: Norton.
Problem-Solving Family
Therapy
David Hale1 and Dale E. Bertram2
1
University of Louisiana, Monroe, LA, USA
2
Abilene Christian University, Abilene, TX, USA
Name of Model
Problem-Solving Family Therapy
Synonyms
Brief strategic; Communication approach; Inter-
actional approach; MRI
Problem-Solving Family Therapy
Prominent Associated Figures
Problem-solving family therapy began, most nota-
bly on the West Coast, as an evolution of the Greg-
ory Bateson Team research project that spawned
Communication/Interactional theory and present
day family therapy. Jay Haley (1987) is often asso-
ciated with this approach because he wrote a book
with the title Problem-Solving Therapy. Yet, there
are many more people associated with the creation
of problem-solving therapy: Gregory Bateson, Don
D. Jackson, Milton Erickson, John Weakland, Jay
Haley, and William Fry. Don Jackson founded the
Mental Research Institute (MRI), one of the first
free-standing marriage and family therapy training
institute in the United States where he and Richard
Fisch, John Weakland, and Paul Watzlawick devel-
oped the Brief Therapy Center, as part of the MRI,
in which problem-solving family therapy was prac-
ticed and refined (Weakland et al. 1995). Virginia
Satir was brought on as the first director for training
at the MRI. It was at the MRI where Steve de Shazer
began developing what would become Solution
Focused Therapy, as a way of doing therapy focus-
ing on solutions as opposed to focusing on
problems.
Introduction
Problem-solving family therapy provides a systemic
approach to resolving family issues, and this is often
mistaken as an epistemology instead of an approach.
Systems is the epistemology and problem-solving
family therapy is an approach based on systemic
epistemology. To understand problem-solving fam-
ily therapy, one must first know the systemic com-
ponents that inform the approach. The confusion
between the epistemology and the approach will
become obvious because of the many overlapping
components of each. It is impossible to describe a
systemic epistemology without it sounding like
describing problem-solving family therapy. For this
reason, we will outline the problem-solving
approach which is imbedded in this epistemological
structure.
A systemic epistemology begins with the pre-
mise that all things are connected and people are
2337
connected through their interactions. To borrow
from the popular phrase, “no person is an island.”
Everyone is a product of his or her interactions
beginning in the womb and carrying on through-
out life. With that being said, problems don’t just
pop up one day as a result of an internal flaw in
someone. Problems begin through interactions
and are maintained through interactions and are
resolved through interactions.
From a systemic epistemology, behavior is
nonpathological. Pathology represents cause and
effect thinking, or someone behaves in a way that
is the direct effect of a particular cause. Non-
pathology represents behavior that is normal to a
given situation that has yet to be explained in a
way that the behavior makes sense. Someone
viewing problem behavior from a pathological
lens will begin looking for the cause of the behav-
ior, faulty cognitions, or a brain chemical imbal-
ance, whereas someone viewing problem
behavior through a nonpathological lens will be
curious about what is taking place in the person’s
life that their behavior makes sense at this point in
time (Ray et al. 2009). A problem-solving family
therapist wants to examine the person’s context
and most likely expand the context in an attempt
to see how the behavior makes sense.
While there are some models that address why
something is, or how something came to be, the
problem-solving family therapy model is a model P
that addresses change. Using the Mental Research
Institute Brief Therapy approach as well as Jay
Haley’s Strategic approach we will explain how
problem-solving family therapy works. Indeed,
focusing exclusively on Haley’s work minimizes
the contributions to this approach by MRI. Both
MRI and Haley significantly contribute to the
development of problem-solving therapy. For
example, Weakland et al. (1974) offer five main
principles of their work at MRI that are very
similar to those seen in Haley’s (1987) work.
Theoretical Framework and Strategies
and Techniques
For all therapy, success is predicated on the client/
therapist relationship. Problem-solving family
2338
therapy is no different. This leads to the first step
in the problem-solving family therapy approach.
How well the client and therapist connect will go a
long way in determining success or failure. Jay
Haley referred to this as “joining” with the family
and others have referred to it as the therapeutic
alliance. It may not be mandatory, but it is
extremely important to make a connection with
the family for the rest of therapy to work. Next,
after establishing rapport with the family, it is
important to obtain a clear definition of what
exactly the problem is the family wants to address.
In problem-solving therapy, this means a clear
“behavioral” definition of what the problem
is. For example, “we don’t communicate” is a
nice start but too general for a problem. Obtaining
a clear definition of what is meant by “communi-
cate” will usually garner some behavior of some
kind, or some action of some kind that can be
addressed easier than a broad term such as “com-
municate.” Likewise, such stated problems as
depression, anxiety, loneliness, etc., need to be
further clarified, in behavioral terms, to increase
the chances of achieving a successful outcome.
With a clearly stated behavioral definition of the
problem, the establishing of a workable goal is
more readily agreed upon by both the clients and
therapist. Typically, a goal for therapy cannot be
established unless a clear definition of the prob-
lem precedes it. When a goal is elusive, it is most
likely that a clear definition of the problem has not
been reached. Defining the problem is never as
easy as it may seem. To define a problem, from a
problem-solving approach, as mentioned previ-
ously, it is important to explore the context in
which the presenting behavior may make sense.
If a family presents with a child that is acting out,
defining the problem will include what exactly is
meant by “acting out,” what specific behaviors
represent “acting out” and in what context does
the behavior present itself. At this point in the
problem definition phase, it is important to find
out who is doing what to whom and how is it a
problem? This immediately addresses the interac-
tive nature of the problem.
Once both the therapist and the client/family
accept a clear behavioral definition, the attempted
solutions can then be addressed. In this step, the
Problem-Solving Family Therapy
therapist inquires as to what solutions have been
attempted to resolve the specific problem being
presented. What will be uncovered typically is
that, from a problem-focused approach, the very
efforts attempted to resolve the problem are what
perpetuates the problem and also helps to main-
tain the problem. In other words, the attempted
solutions become the problem. In this approach,
interrupting the unsuccessful “solution” behavior
will resolve the problem to the point that the
problem will go away without any further inter-
vention. Using the example of the “acting out”
child above, the repeated attempts by the family to
resolve the child’s behavior by such means as
spanking, grounding, and taking away privileges
eventually maintain the problem as opposed to
resolve the problem. Is what needs to take place
is an interruption of the solution behavior because
it is not working anyway.
Producing change or the discontinuance of the
problem behavior is the goal of problem-solving
family therapy. How is change achieved? First,
the therapist and the client/family collaboratively
agree upon a goal. When the desired goal is
achieved, usually the client/family reports that
the problem has ceased to be a problem anymore.
Many models hope to achieve change through
insight, or common sense. A problem-focused
family therapist assists client/families to change
through indirectly influencing the client/family to
act, or behave differently. In other words, com-
mon sense interventions do not work. If they did,
therapy would be nothing more than someone
telling someone else to “stop” their behavior.
Doing something different leads to behavioral
change. By that it means, stop doing “more of
the same” attempted solution behaviors that per-
petuates and maintains the problem and try some-
thing different. The MRI Brief Therapy approach
suggests such interventions as prescribing the
symptom. For example, instead of asking a
screaming child to stop screaming, suggest that
the child scream louder or while screaming try and
scream to the tune of their favorite song. “Com-
mon sense” tells parents to try and get their child
to stop screaming, but all of the threats and spank-
ings prove unfruitful. Doing something different
like asking the child to continue to scream louder
Problem-Solving Family Therapy
or scream to the tune of their favorite song is
suggesting they “do something different” and par-
ents may be surprised at the response from the
child. Instead of asking insomniacs to try and do
mind exercises to get them to go to sleep, suggest
they get up and do chores or read a book since
they are unable to sleep anyway.
Jay Haley (1987) was a huge proponent of
interventions such as those stated above. He pro-
moted paradoxical interventions as a way of
“doing something different.” Sometimes change
is produced as simply as that. There is certainly no
harm in suggesting a paradoxical intervention
because whatever is suggested will either have
the desired effect of producing change, or nothing
will be different so nothing is wasted in making
the suggestion.
Haley and the MRI team were both influenced
by the work of Milton Erickson. Haley (1993)
captured Erickson’s influence, highlighting his
ability to conceptualize problems in ways similar
to those mentioned above. Erickson’s influence on
the MRI team is also captured in Weakland and
Ray (1995). Erickson’s footprint is noticeable in
the intervention strategies of both Haley and the
MRI. Strategies such as utilizing the problem to
bring about change through altering its structure,
prescribing symptoms, looking closely at what
solution attempts have been repeatedly tried, see-
ing problems as an extension of everyday difficul-
ties with living and a number of similar strategies
are all influenced by Erickson.
Clinical Populations in Focus
Problem-solving family therapy has a long history
dating back to the formation of family therapy as a
treatment modality. As a result, some believe it is
one of the most influential and most effective
approaches in the field of family therapy today.
Because of its lengthy history, problem-solving
family therapy has been successfully useful over
the widest range of presenting clinical issues such
as schizophrenia, chronic mental illness, child and
adolescent acting out, addictions and other sub-
stance abuse, marital conflict, domestic violence,
depression, severe emotional problems, anorexia,
2339
and bulimia, just to name a few. The problem-
solving approach has even transcended family
therapy and has been successfully applied in
areas such as business consultation and educa-
tional settings.
Research About the Model
Outcome studies have shown a success rate of
72% in early studies (Weakland et al. 1974) to
96% in later studies (Chubb 1995; Nardone and
Watzlawick 2007). There is currently a research
project underway in France that intends to provide
the evidence basis of the effectiveness of the
problem-solving family therapy approach, the
MRI Brief Therapy model specifically, or the
Palo Alto model as it is sometimes labeled. Hale
and Frusha (2016) notes the problem-solving
approach has endured the test of time with over
70 years of unwavering evidence of its
effectiveness.
The following is a brief case study that illus-
trates the problem-solving family therapy
approach previously described, including the sys-
temic theoretical base of the approach.
Case Example
P
Nine-year-old Jimmy was brought to therapy by
his mother in late April because his behavior in
school was so poor Jimmy was not only going to
fail, he was going to be expelled from school if his
behavior did not improve. It would have been so
easy to isolate Jimmy from his mother and address
why he was misbehaving, but practicing from a
systemic/problem-solving approach, Jimmy was
seen with his mother. Mom explained that Jimmy
had already been expelled from regular school as
well as the alternative school, and he was on the
verge of being expelled from the alternative to the
alternative school. She was at her wits end and
was looking for any help possible. From this
approach, we were not interested in what caused
Jimmy to behave the way he did, we were inter-
ested in what context did his behavior make sense
or, what was going on in Jimmy’s life that
2340
misbehaving in school served a purpose for him?
Through questioning we discovered that Jimmy
was a bright child and this year his behavior
really took a downturn. In an attempt to expand
the context to try and make sense of Jimmy’s
behavior, the therapist asked mom, “When
Jimmy gets in trouble at school, how does dad
find out?” Mom replied that Jimmy’s behavior
had become such that she no longer told the dad
of Jimmy’s school troubles. She went on to
explain that her husband did not interact much
with Jimmy and that he worked long hours and
upon arriving at home at 8 pm would eat dinner
and shower and go to bed. The therapist then
formed a hypothesis that Jimmy’s behavior may
possibly be an out of conscious awareness
attempt on his part to draw his parents together
to “fix” him. If that hypothesis was supported, it
appeared that Jimmy’s behavior was not work-
ing and, therefore, he needed to misbehave
more. The therapist decided to test the hypoth-
esis by giving mom a homework assignment
between then and the next session 1 week later.
It was explained to her that since we did not
know what was taking place yet, because it
was just the first session, the assignment would
probably make no sense at all and that we had no
idea what to expect. We just wanted mom to try
something different. The assignment was for
mom to go through her regular nightly routine
when dad came home with one exception. The
exception was that when dad went into the bed-
room to prepare for bed, mom was to go in the
room with him for 15 min and then come out and
resume her nightly routine. She was advised not
to do anything special during the 15 min in the
room. She could talk with her husband if she
chose to, she could read or nap or do whatever
she wanted, but she was only to do it for 15 min
and then come out. She agreed.
A week later when Jimmy and his mom
returned we asked if she was able to complete
the assignment. She said she had. We then asked
her if anything was different or had she recog-
nized any difference of any kind. She immediately
responded that Jimmy had received only three
demerits during the week between sessions. She
pointed out that this was significant because he
Problem-Solving Family Therapy
usually had anywhere between 25 and 50 demerits
weekly. When asked what sense she made of it she
was at a loss to explain. She volunteered that she
did not see any connections between the home-
work and Jimmy’s behavior, but she was very
pleased with Jimmy for doing so well. We told
her that we were also at a loss and we warned her
that chances were strong that it was probably a
fluke and Jimmy will most likely revert to old
behavior patterns. Since things appeared different
we asked mom if she would try the experiment
another week but this time increase the time to
30 min. She agreed.
When they returned the next week mom imme-
diately told us that Jimmy had received 0 demerits
during the week and that had never happened
since he began attending that school. When she
was asked how she made sense of the situation she
replied, “I don’t really know but I think it might
have to do with my husband and I.” Jimmy was
not able to make sense of his behavior other than
to say that he just did not feel like misbehaving.
Therapy continued for another four to six sessions
with mom continuing to work the experiment. She
even increased the time spent with her husband.
At the time therapy ended, mom and dad had
started to “date” again and they were going to
enroll Jimmy in regular school when the new
school year began.
Imagine working with Jimmy alone to correct
“faulty cognitions” or to medicate him in an effort
to get him to conform to behavior standards. Nei-
ther of those scenarios would work because nei-
ther involved Jimmy’s interactions nor the context
in which Jimmy’s behavior made sense. Based on
information provided by Jimmy and his mother,
steps were taken to expand the context and then an
intervention was offered, in essence, to test a
hypothesis that was supported by the results of
the experiment. The family “did something differ-
ent” and the problem was resolved. Jimmy’s
behavior was not pathologized. His behavior
was seen as normal, especially after the context
was expanded to show that his behavior might
have been an attempt to draw mom and dad closer
together.
Jimmy’s “problem” was dealt with in the here
and now, and there was no effort on the part of the
Problem-Solving Skills Training in Couple and Family Therapy
therapist to “locate” a cause for his behavior or
search for any “historical” evidence to support his
“acting out” behavior.
In conclusion, the problem-solving approach is
one that captures many of the ideas of systemic
family therapy. It includes ideas from MRI, Jay
Haley’s strategic work, with the influence of Mil-
ton Erickson being evident in every aspect of this
way of working. It is an approach which gave
clinical applicability to seminal notions such as
nonpathologizing, problems are an extension of
everyday living, family lifecycle assessment, par-
adoxical interventions, unusual approaches that
usually defied common sense, and a cybernetic
systems framework that informed everything they
did. As the field evolves overtime, the footprint of
problem-solving therapy is evident in every
direction.
References
Chubb, H. (1995). Outpatient clinic effectiveness with the
MRI brief therapy model. In J. Weakland & W. Ray
(Eds.), Propagations: Thirty years of influence from the
Mental Research Institute (pp. 129–132). New York:
The Haworth Press.
Hale, D., & Frusha, C. (2016). MRI brief therapy: A tried
and true systemic approach. Journal of Systemic Ther-
apies, 35(2), 14–24.
Haley, J. (1987). Problem-solving therapy. San Francisco:
Josey-Bass, Inc.
Haley, J. (1993). Uncommon therapy: The psychiatric
techniques of Milton H. Erickson, M.D. New York:
W.W. Norton & Company.
Nardone, G., & Watzlawick, P. (2007). Brief strategic
therapy. New York: Aronson.
Ray, W., Schlanger, K., & Sutton, J. (2009). One thing
leads to another, redux: Contributions to brief therapy
from John Weakland, Ch.E., Paul Watzlawick, Ph.D.
and Richard Fisch, M.D. Journal of Brief, Strategic,
and Systemic Therapies, 3, 15–37.
Weakland, J., & Ray, W. (Eds.). (1995). Propagations:
Thirty years of influence from the Mental Research
Institute. New York: The Haworth Press.
Weakland, J., Fisch, R., Watzlawick, P., & Bodin,
A. (1974). Brief therapy: Focused problem resolution.
Family Process, 13, 141–168.
Weakland, J., Watzlawick, P., & Riskin, J. (1995). Intro-
duction: MRI – A little background music. In
J. Weakland & W. Ray (Eds.), Propagations: Thirty
years of influence from the Mental Research Institute
(pp. 1–15). New York: The Haworth Press.
2341
Problem-Solving Skills
Training in Couple and Family
Therapy
Nicholas S. Perry and Brian R. W. Baucom
Department of Psychology, University of Utah,
Salt Lake City, UT, USA
Name of the Strategy or Intervention
Problem-Solving Training.
Synonyms
PST
Introduction
Problem-solving training (PST*) is a central com-
ponent of cognitive-behavioral couple therapy
and featured prominently in behavioral marital
therapy (BMT; also known as traditional behav-
ioral couple therapy). PST* can be thought of as a
specialized form of communication training that is
specific to helping couples effectively navigate
P
conflict around specific problematic behaviors or
circumstances. PST* is aimed at developing the
skills for distressed couples to collaborate on gen-
erating solutions to especially challenging prob-
lems in their relationship (e.g., how to divide
financial responsibilities, how to manage in-laws
at family dinners).
An important first emphasis in training couples
in PST* is that this approach to problem-solving is
not necessarily appropriate for all problems.
Learning to make the distinction between what
problems are and are not resolvable with PST* is
an important skill for couples. Briefly, resolving
feelings is not a primary goal of PST*, although
emotions play a major role in couples’ arguments.
Negative emotions that drive conflict are not eas-
ily solved with a structured, concrete, behavioral
solution. However, conflicts related to discrete,
problematic behaviors are appropriate for PST*.
2342 Problem-Solving Skills Training in Couple and Family Therapy
For PST* to be effective, partners must have
volitional control over the behavior to be changed;
for example, planning how to divide up certain
household tasks or disagreements about parenting
are excellent candidates for PST*.
After a problem is determined to be a good fit
for PST*, the therapist helps the couple make a
plan for problem-solving. Problem-solving typi-
cally occurs in a structured setting and includes an
agenda that is set in advance. Discussion of a
problem should occur for only brief chunks of
time, and only one problem should be discussed
in a given sitting. In the problem definition phase
of PST*, the couple must agree what the problem
to be solved is. Partners are instructed to begin
with a positive statement, similar to communica-
tion skills training. They are then asked to be
specific and behavioral in the description of the
problem, take responsibility for their own role in
the problem, and be succinct. In the problem
solution phase, the couple works to generate
potential solutions to their problem. In doing so,
they are encouraged to brainstorm all possible
solutions, regardless of the quality or feasibility.
The emphasis in this step is for both partners to be
generative and to feel comfortable doing so with
one another. Partners are explicitly instructed to
avoid judgment or comment on each other’s
suggested solutions during this phase. The next
step of PST* is joint evaluation of the possible
solutions, with each partner providing feedback
on potential solutions that feel unhelpful or
unachievable, and both aiming to collaborate and
compromise in selecting a solution. After the cou-
ple arrives at an agreed-upon solution, they make
an action plan of behavioral steps each partner
will take toward the solution. Therapists encour-
age couples to write out the agreed-upon solution,
with the possibility of renegotiating it if the solu-
tion does not prove helpful.
Theoretical Framework
PST* is most often used in behavioral and
cognitive-behavioral theories about relationship
distress. It was first developed in the 1970s and
used in BMT (Jacobson and Margolin 1979).
Early treatment outcome research suggested that
a significant proportion of couples (approximately
half) did not respond to traditional behavioral
couple therapy and an additional number of cou-
ples did not maintain gains made in behavioral
couple therapy over time (e.g., Jacobson et al.
1987). In response to these findings, newer couple
therapies were developed that focused on negative
or difficult emotions that partners experience and
their patterns of thinking. These next iterations of
couple therapy sought to improve on the suc-
cesses of behavioral couple therapy and retained
the components of communication/skills/
problem-solving training and behavior exchange.
However, how these communication skills are
conceptualized and applied in more modern ther-
apies differs somewhat from their original form.
In integrative behavioral couple therapy (IBCT),
the emphasis is on acceptance-based strategies for
differences between partners that cannot change
(Christensen et al. 2014; Jacobson and
Christensen 1996). Within this approach, behav-
ioral strategies and PST* are applied in ways that
can augment emotional acceptance techniques.
Similarly, in cognitive-behavioral couple therapy,
these strategies are used alongside strategies to
address distorted cognitions both partners
engage in.
Finally, PST* and behavioral strategies have
also formed the basis of couple-based interven-
tions developed for couples where one partner has
a specific form of psychopathology. For example,
in cognitive-behavioral conjoint therapy for
PTSD (Monson et al. 2012), problem-solving
(and other traditional behavioral couple therapy
strategies) is used in combination with techniques
from cognitive processing therapy for PTSD.
Through their application, this intervention aims
to reduce relationship distress and symptoms of
PTSD. Similarly, behavioral couple therapy
(BCT) for substance use disorders, as well as a
similar version developed for alcohol use disor-
ders, incorporates PST* and other BMT tech-
niques to reduce substance and alcohol use in
couples while simultaneously promoting positive
changes in their relationships. Within these inter-
ventions for a specific partner’s psychological
distress, the role of behavioral strategies,
Problem-Solving Skills Training in Couple and Family Therapy
including PST*, is to help improve relationship
functioning alongside therapeutic strategies for
the specific form of psychopathology. The theory
behind this approach is based on basic science that
suggests relationship distress can exacerbate or
prolong individual psychological distress (e.g.,
Whisman and Baucom 2012). Thus, although
PST* in its original form developed within BMT
is practiced less often, the core technique and
theoretical understanding of the strategy is still
present in many modern evidence-based couple
treatments.
Rationale for the Strategy or
Intervention
Problem-solving techniques were originally
developed as a component of behavioral couple
therapy. Problem-solving techniques were
included with other types of communication skills
training to help couples better navigate problems
or situations that evoked conflict. These were
paired with behavioral exchange strategies
designed to promote positive interactions within
the couple. In conjunction, these two strategies
(behavioral exchange and communication skills/
problem-solving training) were thought to rectify
behavioral skills deficits that distressed couples
possessed. In theory, unhappy couples were
experiencing significant relationship distress
because they engaged in fewer positive interac-
tions than satisfied couples and also lacked con-
flict resolution and problem-solving skills that
increased the frequency and duration of negative
interactions. Empirical research suggested that
both components were effective at reducing rela-
tionship distress (Jacobson 1977a, 1979). How-
ever, follow-up analyses that attempted to identify
which specific behavioral skills (including PST*)
learned in therapy contributed to maintenance of
relationship satisfaction over time were largely
unsuccessful. As a whole, empirical literature
and current manifestations of cognitive-
behavioral couple therapy suggest that PST* is
an important, but not wholly sufficient component
of couple therapy on its own (e.g., Jacobson 1984;
Hahlweg and Markman 1988).
2343
Description of the Technique
PST* consists of four steps or phases the couple
works through together. Ideally, these steps are
first presented and practiced in session with the
therapist prior to using them at home. They are
then rehearsed and reviewed in sessions over time
until the couple is comfortable using the technique
independently. These steps are (1) define problem,
(2) brainstorm solutions, (3) collaborate on a solu-
tion, and (4) reevaluate (Jacobson 1977b).
The couple must first define the problem to
which they wish to apply PST*. The problem
must be concrete and discrete, meaning that it is
behaviorally definable and small enough that pro-
gress can be observed (e.g., “Be a better parent” is
neither concrete nor small). Second, both partners
suggest possible solutions to the problem. It is
important that the therapist make it clear to the
couple that during the brainstorming period, any
and all solutions are accepted and written down.
Evaluation of the solutions occurs later in a sepa-
rate step to encourage couples to be as generative
as possible when coming up with possible solu-
tions. The therapist might also encourage the cou-
ple to include some implausible solutions to
promote creativity in finding solutions (e.g., prob-
lem, “We both need to spend more time with the
children”; possible solution, Husband and wife
quit their jobs to spend more time at home). P
Third, the couple evaluates each solution, with
each partner having the authority to negate solu-
tions until an achievable and mutually agreed-
upon solution is arrived at. The couple then
develops a plan to work toward that solution
(e.g., husband will try to come home early from
work twice per week to spend time at night with
the kids). Finally, the couple agrees to a date, time,
and location to have a reevaluation meeting to
assess progress on the plan. This step is critical
for insuring that progress on the plan is monitored
by both partners. At the reevaluation session, both
partners evaluate whether progress has been made
in enacting their agreed-upon plan.
It is important that the therapist emphasize for
the couple that PST* is a special type of commu-
nication training. PST* is very structured and
focused in its purpose. The intention is not to
2344 Problem-Solving Skills Training in Couple and Family Therapy
suggest to the couple that all discussions between
them should occur in such a manner. PST* is
reserved for a highly structured approach to solv-
ing a concrete problem for the couple. By
reviewing the appropriate use of the technique
through in-session practice combined with feed-
back, assignment for use at home, and then
in-session assessment of the couple’s use of the
skill at home, the therapist can both model the
process of PST* and monitor progress toward its
successful application for distressed couples. Ulti-
mately, the therapist will work with the couple to
reduce the therapist’s involvement in the couple’s
use of the skill and promote autonomy in the
couple using their own skills independently.
Case Example
Barbara and Ben were a couple who had been
married for 13 years. Both partners were White,
in their mid-30s, and this was the first marriage for
both husband and wife. Barbara and Ben had two
sons together, ages 5 and 7. They had briefly been
in couple therapy previously, approximately 1 year
before presenting to a departmental clinic special-
izing in IBCT. Relevant to the application of
problem-solving strategies with this couple, Ben
had been diagnosed with attention deficit hyperac-
tivity disorder (ADHD) roughly 3 years prior and
had been on stimulant medication (but not received
psychotherapy) for his ADHD since his diagnosis.
In their initial session, both husband and wife
described feeling disconnected from another emo-
tionally. In particular, Barbara noted that Ben had
difficulty following through on household tasks
and managing money well, which Barbara would
react to by trying to control these aspects of their
lives more closely. Both Barbara and Ben acknowl-
edged that some of Ben’s difficulty in
accomplishing these tasks was attributable to his
ADHD. Both partners articulated wanting to feel
closer to one another emotionally at the end of
couple therapy, and Barbara also articulated hoping
Ben would improve in managing household tasks
and money without her monitoring them so closely.
Ben and Barbara’s therapist conceptualized their
relationship distress by examining their individual
differences, emotional vulnerabilities, external
stressors, and their resulting pattern of interaction
around issues that caused distress or conflict. Espe-
cially relevant for the application of PST*
techniques for the couple, their therapist conceptu-
alized some of their relationship distress as a conse-
quence of Ben and Barbara’s individual differences
in their ability to mentally organize and plan (i.e., as
a function of Ben’s ADHD). In addition, Ben and
Barbara had developed emotional sensitivities
around these issues (e.g., Barbara having the belief
that if she mattered more to Ben, he would remem-
ber things he needed to do at home better; Ben
feeling condescended or inadequate when Barbara
did things for him). Stressors the couple experienced
(e.g., parenting, work-related stress) often exacer-
bated these issues. Finally, Ben and Barbara had
developed a pattern of interaction where Barbara
would ask Ben to complete a task at home and
then repeatedly ask Ben if it had been done. Ben,
in contrast, would try to avoid discussing the issue to
prevent feeling criticized when Barbara found out
he had not done the task.
Ben and Barbara’s therapist presented this con-
ceptualization to them. Their therapist first used
behavioral strategies to help the couple reduce
their relationship distress and feel more connected
around issues of daily household function given
both partner’s focus on feeling the need for behav-
ioral change. Ben and Barbara’s therapist pre-
sented the strategy of PST* to them in session.
First, the therapist explained the rationale
behind PST*, as it applied to the couple’s concep-
tualization of their relationship distress.
T I’m hearing that the specific problem you’re
wanting to focus on is how you get the household
organized for the week. It makes sense that this
issue would bring up a lot of conflict for you since
you both go about wanting to solve it in different
ways. Ben, you’d prefer to “go with the flow” and
take things day by day. Barbara, you’d prefer to
plan things out when in advance.
W That’s right.
T For these types of specific problems, we can use a
type of problem-solving that focuses on finding a
time you’ll both be in a good mindset for dealing
with it, come up with some possible solutions and
then select the one that makes the most sense
for you.
Problem-Solving Skills Training in Couple and Family Therapy
Next, the therapist outlined the concrete steps of
PST* for the couple so that they were clear in their
understanding of what the behavioral strategy
involved.
T To do this, you first want to pick a day and time
you can set aside for a problem-solving meeting.
This works best when you don’t have a lot of
other distractions, like kids or work. First, you’ll
want to decide on what the problem is very
specifically, like we did here.
H How we plan shopping and meals for the week.
T That’s right. That type of problem is very specific
and we can measure it. That way we know if
you’re meeting the goal or making good progress
toward it. After you both agree on the problem,
you can shift to coming up with possible
solutions. You both get to suggest solutions, and
no one gets to say no to any possible solutions
until you’re done coming up with them.
W So there are no bad ideas in brainstorming.
T Exactly! You’ll then go through each solution and
evaluate it. You both have veto power here. Once
you’ve agreed on a single solution, you can try it
out over the upcoming week. The important final
step is that you check-in about how that’s going
the following week and tweak the plan if
necessary.
The therapist then collaborated with the couple
on a specific issue they might apply the strategy
to, how they might apply it at home, and when
they planned to do so. The therapist aimed to help
the couple be as behaviorally specific as possible
and practice PST* in session. The therapist pro-
vided corrective feedback along the way.
T Let’s give this a try here today. Often these types
of skills are easier said than done. This way I can
provide some advice or help as you go along. We
can start with the first step.
H So the problem is how organized we both feel like
being.
T Let’s get really specific and zoom in on that.
W Ok, so one problem related to that is how we plan
our grocery shopping and meals for the week.
T Great, that’s very specific. What’s next?
H Solutions. So, we could sit down together every
Sunday night and write it out.
W That doesn’t seem very realistic.
T Remember, here we’re just coming up with
solutions.
W Right, ok. We could do that. Or keep a list on the
fridge.
T Sometimes it helps to come up with really out
there solutions to help you think outside the box.
2345
So, maybe you could each keep a meal plan and
grocery list and call one another at work every
time you change something on it.
H Hmmm. We could make the meal plan for the
week on Sunday morning after church and then
have it in our email that we could both see.
T So if you’re feeling like you have enough
solutions on your list of possibilities, you want to
shift to assessing each one.
W I think we want it to be convenient but also
reliable. I don’t think we’re ever going to
remember to check the fridge each morning.
I liked your email idea.
T So let’s just review together so we’re all on the
same page about what your plan is.
H We’re going to sit down together Sunday morning
after church and come up with a meal plan for the
week and a grocery list that goes with it. Then
we’ll e-mail it so we both have it handy separately
and can check it for whoever is covering dinner
that night.
T That sounds really clear. I know this process can
feel mechanical at first, but it did seem to help you
arrive at solution that might work well for you
both. I’ll be really curious to hear how that goes
when we meet next week.
Finally, the therapist reviewed the couple’s use
of the skill in a subsequent session to provide any
additional feedback and support.
T So I just wanted to check-in. How did your meal
planning and email solution end up going last
week?
W Really well actually. We made the list and both P
had it handy. Doing that every week seems hard
though. We might want to try and stretch it out to
last every two weeks.
T Well I’m glad you had some good success at the
start! It sounds like you’re using your check-in
time together to update the plan, which is great.
And if it turns out you don’t need to check-in as
much about the problem because the solution
starts to work, that’s perfectly ok.
References
Christensen, A., Doss, B. D., & Jacobson, N. S. (2014).
Reconcilable differences (2nd ed.). New York: The
Guilford Press.
Hahlweg, K., & Markman, H. J. (1988). Effectiveness of
behavioral marital therapy: Empirical status of behav-
ioral techniques in preventing and alleviating marital
distress. Journal of Consulting and Clinical Psychol-
ogy, 56, 44–447.
2346
Jacobson, N. S. (1977a). Problem solving and contin-
gency contracting in the treatment of marital discord.
Journal of Consulting and Clinical Psychology, 45,
92–100.
Jacobson, N. S. (1977b). Training couples to solve their
marital problems: A behavioral approach to relation-
ship discord: Part 1: Problem-solving skills. American
Journal of Family Therapy, 5, 22–31.
Jacobson, N. S. (1979). Increasing positive behavior in
severely distressed marital relationships: The effects
of problem-solving training. Behavior Therapy, 10,
311–326.
Jacobson, N. S. (1984). A component analysis of behav-
ioral marital therapy: The relative effectiveness of
behavior exchange and communication/problem-
solving training. Journal of Consulting and Clinical
Psychology, 52, 295–305.
Jacobson, N. S., & Christensen, A. (1996). Acceptance and
change in couple therapy: A therapist’s guide to trans-
forming relationships. New York: WW Norton & Co.
Jacobson, N. S., & Margolin, G. (1979). Marital therapy:
Strategies based on social learning and behavior
exchange principles. New York: Psychology Press.
Jacobson, N. S., Schmaling, K. B., & Holtzworth-
Munroe, A. (1987). Component analysis of behav-
ioral marital therapy: 2-year follow-up and prediction
of relapse. Journal of Marital and Family Therapy,
13, 187–195.
Monson, C. M., Fredman, S. J., Macdonald, A., Pukay-
Martin, N. D., Resick, P. A., & Schnurr, P. P. (2012).
Effect of cognitive-behavioral couple therapy for
PTSD: A randomized controlled trial. Journal of the
American Medical Association, 308, 700–709.
Whisman, M. A., & Baucom, D. H. (2012). Intimate rela-
tionships and psychopathology. Clinical Child and
Family Psychology Review, 15, 4–13.
Process Research in Couple
and Family Therapy
Myrna L. Friedlander and Hannah Muetzelfeld
University at Albany/State University of
New York, Albany, NY, USA
Name of Entry
Process Research
Synonyms
Change mechanisms; Change process research
Process Research in Couple and Family Therapy
Introduction
Over the past 20 years since researchers defini-
tively demonstrated the efficacy of various
approaches to couple and family therapy (CFT),
attention has turned to process research. That is,
aside from studying which therapeutic approaches
“work” best with different kinds of couples and
families, researchers are particularly interested in
studying specific factors that contribute to posi-
tive change.
Generally speaking, the term process research
refers to investigations of therapists’ and clients’
behaviors and perceptions during therapy. The
bulk of process studies in couple and family ther-
apy, like those in individual therapy, focus on
what takes place in therapy sessions themselves,
although some studies of behaviors occurring
between sessions are also considered to be process
research.
In large part, therapist behavior has been studied
in terms of techniques, such as confrontation and
interpretation, which are not tied to a single-therapy
approach, as well as techniques that are an integral
part of a specific type of therapy, such as
“reframing” in Attachment-Based Family Therapy.
Likewise, client behavior has been studied in the
context of a single theoretical approach, such as
partner “softening” in Emotion-Focused Therapy
for Couples, or across approaches, such as client
motivation or resistance. Research that is not spe-
cific to any one treatment approach is called com-
mon factors research (Sprenkle et al. 2009).
Similar to studies of individual psychother-
apy, the major questions addressed by early
process researchers in CFT were descriptive in
nature. Some of these descriptive studies had as
their objective simply to identify who speaks to
whom in a family session. Examples of other
questions posed in these early studies include
“Do family therapists work differently with par-
ents versus children?” and “To what extent do
different CFT techniques reflect the therapist’s
theoretical orientation?” Although quite basic,
these kinds of investigations established a sci-
ence of process research in the field.
In the late 1980s, authors began calling for
change process research*, or the study of specific
Process Research in Couple and Family Therapy
change mechanisms* that make a difference ther-
apeutically (e.g., Greenberg 1986). In other
words, rather than simply describing what hap-
pens in a therapy session or even whether certain
behaviors, when occurring frequently, predict the
ultimate success of therapy, researchers began
calling for more intensive analyses of behaviors
occurring within and across therapy sessions.
After all, it was argued, therapists need to know
what to do in the moment to bring about immedi-
ate change, such as when family members are
attacking one another or when members of a cou-
ple are bickering without listening to each other.
Studying how to intervene successfully in specific
instances, it was reasoned, is superior to counting
a particular behavior across sessions and then
correlating its frequency with a global outcome
like “improved marital satisfaction.”
Compared to the large body of process
research on individual psychotherapy, the process
literature in CFT is quite limited, which is likely
due to the challenge of studying the behavior and
perceptions of multiple clients in a family system
(Friedlander et al. 2016). Family members often
enter therapy with different perspectives on the
problem and varying motivation levels. More-
over, because they tend to be in conflict with one
another, the therapist needs to attend to each per-
son’s individual needs as well as the functioning
of the entire family system (Friedlander et al.
2006). All of these considerations make it imper-
ative for researchers to discover how and under
what conditions meaningful change takes place
over the course of couple and family therapy.
Description
Change process research can take many forms.
In-session behavior can be studied from live
observation of sessions (through a one-way mirror
or using closed circuit television) or, more often,
from video-recorded sessions. Typically, “judges”
who have been trained extensively to use a spe-
cific coding or rating system by observing ses-
sions (and/or reading written transcripts of the
sessions) make independent decisions about
what they observe and then confer with one
2347
another to negotiate any disagreements. To help
with difficult decisions, the judges refer to a train-
ing manual that provides definitions and examples
of the various behaviors under consideration.
Observer systems can be microanalytic, in which
the judges “code” or classify each speaking turn or
meaning unit within a speaking turn, or macro-
analytic, in which the judges make general ratings
of an entire therapy session or portion of the
session. Examples of codes include “therapist
confrontation” and “client resistance.” Examples
of rating scales include “the degree to which the
therapist joined with the family.” Software tech-
nologies are available to facilitate these observa-
tional analyses, which tend to be quite time-
consuming (cf. Escudero et al. 2011).
Process researchers are not uniquely focused
on observable behavior, however. Many studies
include assessments of clients’ and therapists’
perceptions of what is taking place, or what has
taken place, in the ongoing therapy. These assess-
ments most often take the form of self-report
questionnaires that the family members fill out
independently following a therapy session. Typi-
cally, the measures ask clients and/or the therapist
about the perceived impact of the session or their
perceptions of “improvement so far.” Some stud-
ies include pre-session questionnaires that ask
clients about the progress of the therapy (e.g.,
“How beneficial was your last session?”) or the P
current status of the presenting concern.
Some process research involves in-depth inter-
views with couples and/or family members. The
interviews can focus on clients’ perceptions after a
therapy session or upon termination of the entire
treatment. Most often, the focus of these interview
studies is the client’s perceptions of the therapist
or perceptions of the most and least helpful
aspects of the treatment. The interviews are
conducted, transcribed, and then analyzed using
various qualitative methods. Unlike research with
questionnaire data, qualitative studies result in
narrative themes that reflect the responses of mul-
tiple interviewees. As an example, themes from a
study on clients’ perceptions of their therapists
might include “the therapist offered us practical
suggestions” and “the therapist provided safety to
discuss difficult topics.”
2348
The bulk of the process literature in CFT has
focused on the working alliance, also called the
therapeutic alliance, a construct that refers to col-
laboration in therapy, i.e., an emotional bond
between client(s) and therapist and agreement on
the goals and tasks of the therapy. Due to the con-
joint nature of CFT, the working alliance has two
additional features that are unique to this treatment
modality, namely, (1) each client’s sense of safety
working in a therapeutic setting with his or her
family members and (2) family members’ working
cooperatively with each other toward shared goals
and valuing the time they spend together in therapy
(Friedlander et al. 2006). Of the various common
factors studied in CFT, the therapeutic alliance has
demonstrated the most consistent association with
the success of therapy.
Process research on the working alliance in
CFT includes group designs with multiple couples
and/or families, small sample studies of selected
sessions, and case studies. Studies of the thera-
peutic alliance have been published using all three
of these designs, as described below. The general
goal of these studies is to understand how the
alliance functions as a mechanism of change
in CFT.
Group Designs In contrast to small sample and
case studies, group designs require larger numbers
of participants. Process-outcome research with
group designs is generally used to explore a par-
ticular technique, treatment strategy, or common
factor in order to test if and how that aspect of
treatment operates to predict positive therapeutic
outcomes, on average, for the couples or families
in the sample. Although group designs are more
generalizable to a target population than small
sample designs, these designs are less likely to
explore change mechanisms in as much depth.
Since the samples are larger, it tends not to be
feasible to conduct in-depth analyses of sessions.
Rather, typically family members (and/or the ther-
apist) fill out self-report questionnaires to provide
their independent evaluations of change mecha-
nisms like the alliance and the value of the therapy
in general, such as satisfaction with the treatment
or perceptions of the couple’s or family’s
functioning.
Process Research in Couple and Family Therapy
Group designs can be either experimental
(comparing processes and outcomes in different
therapy approaches) or ex post facto (also called
naturalistic, descriptive, and nonexperimental).
In descriptive group designs, a process variable
like perceptions of the alliance is correlated with a
client characteristic (e.g., gender) or with clients’
perceptions of the therapist. A study of family
roles, for example, might ask whether adoles-
cents’ or parents’ perceptions of the alliance with
the therapist tend to be stronger in the first session
of family therapy. On the other hand, in experi-
mental group designs, couples and/or families are
randomly assigned to various therapy approaches
(e.g., manualized Brief Strategic Family Therapy
for adolescent drug use vs. non-manualized drug
counseling), and participants’ questionnaire
responses (the dependent variable) are compared
across groups. The outcomes (dependent vari-
ables) can be proximal (impact of a session) or
distal (success of the therapy as a whole). In this
way, the effectiveness of a particular therapy inter-
vention (e.g., reframing in Attachment-Based
Family Therapy) or common factor (e.g., alliance)
can be studied by comparing session or final out-
comes across two or more treatment approaches.
For example, a researcher could study whether the
therapeutic alliance with the adolescent tends to
be stronger in Brief Strategic Family Therapy or
in individual drug counseling.
Additionally, experimental group designs for
studying therapy processes can be used to deter-
mine how, why, when, and under what conditions
a particular approach “works.” To address these
questions, process indicators like the alliance are
studied as moderators and/or mediators of treat-
ment success. Moderator variables allow a
researcher to determine for whom a particular
therapeutic approach is most effective. When cli-
ents’ perceptions of the therapeutic alliance are
studied as a moderator of therapy effectiveness, a
research question might be, for example, whether
a strong within-family alliance early in therapy
strengthens the efficacy of Brief Strategic Family
Therapy for reducing adolescent drug use. In
other words, are families in which the members
collaborate well with each other on therapeutic
goals and tasks early in therapy more likely to
Process Research in Couple and Family Therapy
benefit from this approach than families that are
less collaborative?
Mediator variables, on the other hand, allow a
researcher to study a specific therapeutic process
as an ingredient that activates therapeutic change.
In other words, mediators are possible change
mechanisms in CFT. The therapeutic alliance has
most often been studied as a mediator of post-
treatment outcomes. In these studies, researchers
have asked whether clients’ perceptions of the
alliance at a specific point in therapy, such as in
Session 6, activate change by the end of therapy.
For example, is a strong within-family alliance,
observed in the midpoint of therapy, one mecha-
nism by which change occurs in Brief Strategy
Family Therapy? A substantial body of literature
has indeed found that a strong alliance is one
vehicle for positive change in conjoint therapy
with couples as well as families (Friedlander
et al. 2011).
More complex group designs have yielded
promising results. These designs include multiple
levels of data analysis, such as time, client, family,
and therapist, in order to tease apart how specific
therapeutic processes change over time and oper-
ate differently within and across families and
across different therapists. It seems reasonable to
assume that the question of whether a strong ther-
apeutic alliance is a mechanism of change
depends on (a) when in the therapy the alliance
is assessed, (b) whose perceptions are being
assessed (e.g., adolescent or parent), (c) to which
family the clients belong, and (d) which therapist
is working with the family. In other words, multi-
level designs take into account the fact that the
alliance tends to fluctuate over time, that within
any given family the clients’ perceptions tend to
differ, that families tend to differ from one another
in their experience of the alliance, and that some
therapists are more able than others to create
strong alliances with the clients in their caseload.
The actor-partner interdependence model
(APIM), a specific type of group design, examines
bidirectional influences in interpersonal relation-
ships, such as whether the parents’ view of alli-
ance predicts the adolescent’s view of therapy
success and vice versa. These reciprocal effects
can help researchers more fully understand the
2349
change mechanisms in CFT from a systemic
perspective.
As an example of the APIM, Anker et al.
(2010) examined the relationship between male
and female clients’ perceptions of the therapeutic
alliance, as indicated by questionnaire data, and
outcomes in couple therapy. Anker et al. reasoned
that since previous couple research had shown
that the relationship between alliance and out-
come differs for men and women, the alliance
rated by one member of the couple early in ther-
apy might predict the outcome of therapy as rated
by the other member of the couple.
In this study, 250 couples filled out self-report
measures on their perceptions of the therapeutic
alliance, their progress in therapy, and their mar-
ital functioning. These measures were adminis-
tered in each session, as well as 6 months after
the last session. Results showed that men’s alli-
ance scores were more predictive of outcomes
than women’s scores, a result that replicated ear-
lier findings. Reflecting the dynamic nature of
couple therapy, the APIM analysis showed that
regardless of gender, clients’ perceptions of ther-
apy outcomes were higher when their partners’
perceptions were also high.
Small Sample Designs With smaller samples
than are typically used in group designs, process
researchers can observe therapy sessions or epi- P
sodes within sessions in great detail by tracking
one or more change processes over time. The use
of sessions drawn from a handful of cases
(sometimes as few as three or four) allows
researchers to identify common, observable pat-
terns of behavior and/or to contrast change pro-
cesses that were or were not effective based on
some criterion like the clients’ evaluation of the
session’s value or depth. This process can uncover
intricate details related to multiple interacting
change processes, such as how effective therapists
react in the moment to client resistance and then
whether this reduction in resistance precedes the
softening of blame between family members and
accompanies an increase in alliance perceptions.
What this design sacrifices in terms of generaliz-
ability to a target population it gains in clinical
meaningfulness for practitioners.
2350
Observational coding of behaviors within ses-
sions can be used to study systemic behavior
using sequential analysis, which allows for the
exploration of directional effects. Using this meth-
odology, a researcher can detect meaningful pat-
terns in the interactions between partners, family
members, and/or the therapist. For example, a
researcher could examine if client behaviors
reflective of a strong therapeutic alliance (e.g., a
statement suggesting trust in the therapist) signif-
icantly follow certain kinds of therapist behaviors,
such as showing interest in the client’s life apart
from the therapy, within a 3-min time period. To
answer a question like this, the researcher would
first code all the alliance-related client and thera-
pist behaviors, noting the time they occur on the
video, and then construct a matrix across all ses-
sions in the sample in which the alliance-related
client behavior either followed or did not follow
the alliance-related therapist behavior within
3 min. A significance test of the matrix would
indicate whether the therapist’s behavior “acti-
vated” the client’s behavior in this sample,
which addresses the research question of how
therapists behave so as to build alliances with
their clients. Due to the time intensive nature of
observational coding, sequential analyses only
tend to be used with a small sample of cases or
therapy sessions within cases.
Task analysis, another common methodology
used in small sample studies, is more qualitative in
nature. This method involves first building a con-
ceptual model that explicates how change occurs
when a specific treatment task is being worked on
in therapy, such as when the therapist is
attempting to repair a rupture in the alliance. The
next step is to test the model with sessions drawn
from a few actual cases. The results of this initial
test are used to revise the original model for future
testing. The ultimate goal of this iterative
(theorizing, testing, theorizing, testing) methodol-
ogy is a refined model that closely resembles the
most effective steps for completing a specific
therapeutic task (Greenberg et al. 1996).
In CFT, task analyses have been undertaken
with cases drawn from a larger sample in which
a manualized treatment was used as well as from
samples of nonmanualized “treatment as usual.”
Process Research in Couple and Family Therapy
For example, a task analysis may have as its goal
to develop a model which demonstrates how
change occurs during an episode of client non-
compliance (behavior indicative of a poor alli-
ance) in manualized Emotion-Focused Couple
Therapy. In a treatment-as-usual sample, the task
analysis would involve studying how therapists
using different approaches address non-
compliance. In both kinds of studies, the initial
conceptual model is first tested with a small sam-
ple of cases in which the task of interest was or
was not successfully accomplished, i.e., the client
becomes more compliant before the session ends.
The steps of change observed in the successful
sessions are compared with those that are
observed in the unsuccessful sessions. The origi-
nal model is then adjusted based on the steps of
change that distinguish successful from unsuc-
cessful task resolution, in which the “resolution”
is a repair to the alliance.
The initial assessments in a task analysis usu-
ally involve qualitative analyses in order to dis-
cover the steps leading to within-session change.
Small sample designs like task analysis often rely
on qualitative analyses, which can involve exam-
ining the transcripts of interviews with clients to
discover, for example, how they viewed the ther-
apeutic process. The themes that emerge from
qualitative analyses are determined inductively.
Due to the intensive nature of qualitative research,
the sample sizes are generally small (i.e., fewer
than 20), which allows for a detailed analysis.
Qualitative analyses can be used to examine
behavior within cases, within particular sessions,
or even within moments. One type of qualitative
analysis, conversation analysis, focuses on verbal
interaction. As a methodology, the study of ther-
apeutic processes as conversation can illuminate
important change processes. For example, a
researcher might be interested in precisely how
therapists phrased their comments during sessions
that family members rated as “not valuable” on
post-session questionnaires. Did the therapists in
these sessions interrupt their clients too often? Did
the clients avoid answering questions directly?
Conversation analysis involves a highly detailed
analysis of speech, including tone of voice, length
of silences, and so on.
Process Research in Couple and Family Therapy
As one example, Shpigel and Diamond (2014)
used a small sample design to discover qualitative
themes that might distinguish cases with good ver-
sus poor therapeutic alliances in Attachment-Based
Family Therapy, an approach that emphasizes the
importance of alliance in the change process. Spe-
cifically, the researchers selected five high- and five
low-alliance cases based on observers’ ratings of an
early session and then qualitatively analyzed the
change processes in these cases from detailed ther-
apy notes and from transcripts of posttreatment
interviews with the parents. The sample included
sexual minority youth and their nonaccepting par-
ents, and the goal of the therapy was to improve
communication and build safety and trust in the
parent-child relationship.
The qualitative analysis of the therapists’ notes
resulted in a set of themes that distinguished the
five good from the five poor alliance cases.
Results suggested that in the good alliance cases,
the parents defined the goal of therapy as improve-
ment of the parent-child relationship, whereas the
parents in the poor alliance cases rejected this
goal. Other themes in the good alliance cases
included accepting the role of biology in the
development of sexual orientation, whereas
themes in the poor alliance cases included (a) the
parents being unwilling to identify themselves as
parents of a sexual minority child, (b) the therapist
confronting the parents about their attempt to
change their child’s sexual orientation, and
(c) parents blaming the therapist for validating
the child’s sexual orientation.
The qualitative themes that emerged from the
interview data suggest that parents who had good
alliances with the therapist typically described
themselves as important, active participants in cre-
ating change. Alternatively, parents with poor ther-
apeutic alliances described the goal of therapy in
external terms, placing the responsibility for
change on the youth. Another theme that distin-
guished good from poor alliance cases was the
extent to which the parents perceived the therapist
as empathic and the therapeutic environment as
safe. Finally, good and poor alliance cases were
differentiated by how much the parents felt they
could openly reveal their feelings of shame without
being judged by the therapist or made to feel guilty.
2351
Case Studies Case studies typically involve a
single family or couple, selected for analysis
either because the case is representative of a spe-
cific approach, the couple or family had a partic-
ularly good or poor outcome, or the therapist was
highly skilled and experienced. By limiting the
study to a single case, it is possible to conduct an
even more intensive analysis of the process of
change. In addition to self-report measures and
session observations, case studies often include
interviews with the participants. The multi-
method design allows for an uncovering of impor-
tant systemic processes between family members
and the therapist from various perspectives. That
is, an in-depth analysis of the therapy with one
family or couple can identify specific ways in
which change processes may worked or failed to
work, thereby contributing to theory building. As
in small sample designs, one drawback of case
studies is the lack of generalizability to other
therapy cases.
The term evidence-based case studies refer to
studies with multiple process and outcome mea-
sures, a detailed analysis of dialogue from session
transcripts, and a determination of the extent of
significant therapeutic change or outcome. Case
studies may analyze data from every session with
a couple or family, or they may singularly and
intensely focus on a few sessions that are represen- P
tative of the change process. As in small sample
designs, the cases might be drawn from larger
manualized or nonmanualized therapy samples.
Typically the process of change is evaluated multi-
ple times throughout the treatment in order to
obtain a comprehensive understanding of how ther-
apeutic change came about or failed to come about.
As an example, Friedlander et al. (2014)
conducted an evidence-based case study to exam-
ine the process of change in a successful case of
family treatment as usual at a not-for-profit com-
munity agency. The specific purpose of the study
was to discover, from multiple perspectives, how
a highly experienced family therapist managed to
work effectively with a family “at impasse”
(p. 41). The impasse referred to the parents’
opposing agendas and motivations, i.e., a poor
within-family alliance.
2352
The family included a mother, father, and
12-year-old daughter who were struggling with
the mother’s recent decision to leave the father
for another man. When the therapy began, the
daughter was expressing a great deal of anger
about the situation; the parents, who only agreed
to the therapy for her benefit, were not willing to
discuss their ambiguous marital relationship with
the therapist. Whereas the father’s agenda was to
encourage his wife to return to him, the mother
had no such intention or motivation.
Each family member completed self-report
measures on the alliance and session impact
before, during, and at the end of treatment. Videos
were analyzed to identify the alliance-related
behaviors of the therapist and family members in
selected sessions. The outcome data included the
clients’ distress over their presenting concerns,
their scores on a well-established outcome mea-
sure, and their satisfaction with treatment.
At the conclusion of therapy, the levels of
discomfort related to each client’s presenting con-
cerns decreased. The mother and daughter’s
reports of symptom distress also decreased a
great deal. While the father’s symptom distress
also decreased, it was not to the same extent as
the mother and daughter’s. All family members
reported high levels of satisfaction with treatment.
Throughout the therapy, each family member
rated his or her personal alliance with the therapist
and the family’s alliance with the therapist as strong
on two alliance questionnaires. The therapist’s ques-
tionnaire responses reflected this perception as well.
Notably, the observers rated the within-family
dimension of alliance as somewhat positive
throughout the therapy, but ratings of the safety
dimension of alliance for the mother notably
decreased in Session 6. An in-depth analysis of
the dialogue in this session showed precisely how
the therapist used alliance-related behavior to
address the mother’s lack of safety and the parents’
difficulties with problem-solving. In Session 6 the
therapist recommended that after the contracted ten
sessions with the daughter ended, the parents
should continue in treatment alone to discuss their
marital situation. They agreed to do so, and as a
result, they were reunited. The authors concluded
that by meeting the family with the only goal on
Process Research in Couple and Family Therapy
which everyone could agree, the therapist created a
strong alliance that eventually allowed the parents
to consider working toward resolving the marital
impasse (Friedlander et al. 2014).
In single-case studies as well as group and small
sample designs, the combined use of process and
outcome data can provide a clear picture of the
ways in which change can take place in CFT. As
shown in the three examples above, each investi-
gation approached the question of the alliance dif-
ferently, but taken together, this body of literature
demonstrates why and how the development of
strong, balanced family alliances is important for
promoting successful outcomes in CFT.
In sum, collecting self-report data, observing
sessions, and analyzing interviews with family
members allow researchers to develop an in-depth
understanding of what ”works” in psychotherapy.
That is, by administering questionnaires before
and/or after therapy sessions, researchers can dis-
cover how family members perceive the process of
change as it unfolds over time. By observing client
and therapist behavior in actual sessions,
researchers can identify precisely how moment-
to-moment interactions contribute to change. In a
program of research that uses case studies and
small sample designs along with larger group
designs, researchers can identify significant pat-
terns of change that culminate in successful therapy
outcomes for couples and families.
Cross-References
▶ Common Factors in Couple and Family
Therapy
References
Anker, M. G., Owen, J., Duncan, B. L., & Sparks, J. A.
(2010). The alliance in couple therapy: Partner influ-
ence, early change, and alliance patterns in a naturalis-
tic sample. Journal of Consulting and Clinical
Psychology, 78, 635–645.
Escudero, V., Friedlander, M. L., & Heatherington,
L. (2011). Using the e-SOFTA for video training and
research on alliance-related behavior. Psychotherapy,
48, 138–147.
Professions in Couple and Family Therapy
Friedlander, M. L., Escudero, V., & Heatherington,
L. (2006). Therapeutic alliances with couples and fam-
ilies: An empirically-informed guide to practice.
Washington, DC: American Psychological
Association.
Friedlander, M. L., Escudero, V., Heatherington, L., &
Diamond, G. M. (2011). Alliance in couple and family
therapy. Psychotherapy, 48, 25–33.
Friedlander, M. L., Lee, H. H., Shaffer, K. S., & Cabrera,
P. (2014). Negotiating therapeutic alliances with a fam-
ily at impasse: An evidence-based case study. Psycho-
therapy, 51, 41–52.
Friedlander, M. L., Heatherington, L., & Escudero,
V. (2016). Research on change mechanisms: Advances
in process research. In T. Sexton & J. Lebow (Eds.),
Handbook of family therapy (4th ed., pp. 454–467).
New York: Routledge.
Greenberg, L. S. (1986). Change process research. Journal
of Consulting and Clinical Psychology, 54, 4–9.
Greenberg, L. S., Heatherington, L., & Friedlander,
M. L. (1996). The events-based approach to couple
and family therapy research. In D. Sprenkle &
S. Moon (Eds.), Family therapy research:
A handbook of methods (pp. 411–428). New York:
Guilford Press.
Shpigel, M. S., & Diamond, G. M. (2014). Good versus
poor therapeutic alliances with non-accepting parents
of same-sex oriented adolescents and young adults:
A qualitative study. Psychotherapy Research, 24,
376–391.
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009).
Common factors in couple and family therapy: The
overlooked foundation for effective practice.
New York: Guilford Press.
Professions in Couple and
Family Therapy
Julie A. Peterson
The Family Institute at Northwestern University,
Evanston, IL, USA
Introduction
Marriage and family therapy (MFT) professions
can be considered one of the longest lasting and
most necessary professions. According to
Broderick and Schrader (1991), it is likely that
even our earliest of developed professions (e.g.,
physicians, priests, etc.) likely had to address
issues within family units. As the profession
2353
became more specialized within the twentieth
century following a vast increase in divorce and
juvenile delinquency (Broderick and Schrader
1991), the MFT rose to address the social needs
of the community. According to the Bureau of
Labor Statistics (BLS), it is predicted that by
2022, the profession of MFT will have grown
by 30.6% – the fastest growing average in com-
parison to other professions in the USA (BLS
2015). As a result, MFT is one of the most
essential specialized fields and can be seen
within a variety of treatment settings such as
private practice, outpatient clinics, community
mental health, and even hospitals.
Description
The American Association for Marriage and
Family Therapy (AAMFT) initiated one of the
first national data surveys in the mid-1990s to
better understand the profession of MFT.
Doherty and Simmons (1996) completed this
survey and found that, among the 526 MFTs
examined, many therapists had reported that
they treat a wide range of mental health and
relational issues. Even later surveys found that
MFT clinicians focus their work in couple diffi-
culties, depression, anxiety, and problems with
children and adolescents (Northey 2002). What P
makes MFT clinicians specialized and unique is
the use of systemic approaches when treating
these issues. MFT clinicians utilize modalities
such as individual, couple, or family work
(Doherty and Simmons 1996; Northey 2002)
to be able to conceptualize problems that
expand the focus of treatment beyond the indi-
vidual and instead into family and other systems
(Dallos and Draper 2010).
The use of systemic thinking allows families
and individual clients to feel less stigmatized
because labels utilized to describe problems often
are shifted from individual pathology to descrip-
tions of systems and interactions. National surveys
that included client reports found that those served
by MFTs often reported high satisfaction of ser-
vices and overall improvement in functioning
(Crane and Christenson 2012; Doherty and
2354
Simmons 1996; Northey 2002). These findings
appear to be consistent among MFT professions.
It was found overall that the profession of MFT is
one of the most cost-effective professions in com-
parison to individual work and also had the highest
success regarding services in comparison to other
professions other than physicians (Crane and
Christenson 2012; Crane and Payne 2011; Doherty
and Simmons 1996; Northey 2002). When com-
pared, practice patterns were found to be similar to
those trained in an MFT program versus those
initially trained from other professional back-
grounds, adding later training in MFT work
(Simmons and Doherty 1998).
MFT clinicians are also found to work with
clients for more short-term services than other
modalities (Doherty and Simmons 1996; Simmons
and Doherty 1995). Particularly, Simmons and
Doherty (1995) indicated that, on average, MFT
clinicians work with cases for about 11 sessions
over a 4-month period. Family sessions are com-
pleted within an average of eight sessions, and
couples work on average includes about ten ses-
sions (Simmons and Doherty 1995). When focus-
ing on individual sessions, MFT clinicians were
found to work with cases for about 14 sessions on
average (Simmons and Doherty 1995). This aver-
age of brief therapy services may be indicative of
effectiveness regarding services as outlined by
Crane and Christenson (2012).
MFT clinicians can use their training and skills
in other ways in addition to therapy. As systemic
thinkers, MFT clinicians focus their work on rela-
tional and contextual issues rather than difficulties
that reside only in an individual. This can assist
when addressing issues not only with couple or
family relationships but also within occupational
systems. MFT clinicians can work as consultants
at community agencies to provide perspective
regarding systemic issues and the impact they
have. MFT clinicians also qualify to function as
directors of academic or clinical programs that
wish to incorporate systemic perspectives. In
addition, MFT clinicians are well qualified to
also serve in administrative positions such as
supervision.
Professions in Couple and Family Therapy
There is a wide variety of opportunity for
MFT clinicians as it continues to be a growing
profession. It would be beneficial to continue to
explore how MFT clinicians can provide unique
perspectives in other professional areas within
psychology. As MFT clinicians are trained to
think systemically, it can allow for advance-
ments for both clinical and professional work
as a whole.
References
Broderick, C. B., & Schrader, S. S. (1991). The history
of professional marriage and family therapy. In A. S.
Gurman, & D. P. Kniskern, (Eds.), Handbook of
family therapy (Vol. II, pp. 3–40). New York:
Brunner/Mazel.
Bureau of Labor Statistics (BLS) (2015). Occupational and
employment: Marriage and family therapist.. Retrieved
from https://www.bls.gov/OES/current/oes211013.htm
Crane, D. R., & Christenson, J. D. (2012). A summary
report of the cost-effectiveness of the profession and
practice of marriage and family therapy. Contemporary
Family Therapy, 34(2), 204–216. https://doi.org/
10.1007/s10591-012-9187-5.
Crane, D. R., & Payne, S. H. (2011). Individual versus
family psychotherapy in managed care: Comparing the
costs of treatment by the mental health professions.
Journal of Marital and Family Therapy, 37(3),
272–289. https://doi.org/10.1111/j.1752-0606.2009.
00170.x.
Dallos, R., & Draper, R. (2010). An introduction to family
therapy: Systemic theory and practice (3rd ed.).
New York: Open University Press.
Doherty, W. J., & Simmons, D. S. (1996). Clinical practice
patterns of marriage and family therapists: A national
survey of therapists and their clients. Journal of Marital
and Family Therapy, 22(1), 9–25. https://doi.org/
10.1111/j.1752-0606.1996.tb00183.x.
Northey, W. F. (2002). Characteristics and clinical practices of
marriage and family therapists: A national survey. Journal
of Marital and Family Therapy, 28(4), 487–494. https://
doi.org/10.1111/j.1752-0606.2002.tb00373.x.
Simmons, D. S., & Doherty, W. J. (1995). Defining who we
are and what we do: Clinical practice patterns of mar-
riage and family therapists in Minnesota. Journal of
Marital and Family Therapy, 21(1), 3–16. https://doi.
org/10.1111/j.1752-0606.1995.tb00134.x.
Simmons, D. S., & Doherty, W. J. (1998). Does academic
training background make a difference among practic-
ing marriage and family therapists. Journal of Marital
and Family Therapy, 24(3), 321–336. https://doi.org/
10.1111/j.1752-0606.1998.tb01088.x.
Progress Research in Couple and Family Therapy
Progress Research in Couple
and Family Therapy
Jacqueline Sparks1 and Barry Duncan2
1
Department of Human Development and Family
Studies, University of Rhode Island, Kingston,
RI, USA
2
The Heart and Soul of Change Project, Jensen
Beach, FL, USA
Synonyms
Client feedback; Practice-based evidence; Pro-
gress monitoring; Progress research; Routine out-
come measurement; Systematic client feedback
Introduction
Progress feedback refers to the routine collection
of client feedback in psychotherapy services to
track client progress, identify at-risk clients, and
facilitate adjustment of therapy to prevent prema-
ture dropout or negative outcome (Lambert 2015).
While progress feedback systems have been
extensively tested in individual psychotherapy,
development of scientifically sound and viable
feedback systems for systemic work is still in its
early stages. This entry discusses the theoretical
underpinnings of progress feedback and its rele-
vance and applicability to couple and family
practice.
Theoretical Context for Concept
Close to 60% of clients in routine care have poor
outcomes compared with approximately 30–40%
of clients in clinical trials (Hansen et al. 2002).
Outcomes for children and youth appear more
concerning, with 40–60% dropout rates and effect
sizes near 0 in some studies (Nelson et al. 2013).
Making matter worse, clinicians tend to be overly
optimistic about their effectiveness and are unable
2355
to predict which clients are likely to fail (Hannan
et al. 2005). Progress feedback arose out of a
desire to improve outcomes in routine practice,
especially in light of these findings.
Progress feedback capitalizes on the
pioneering research of Ken Howard (Howard
et al. 1986) as well as more recent investiga-
tions that have found that most clients respond
to treatment early, within 6–8 sessions. These
findings support early and continuous monitor-
ing of client perceptions of progress to prevent
premature dropout. Many progress feedback
systems also monitor the therapeutic alliance,
an extensively researched variable predictive of
outcome (Norcross 2010). Typically, this
involves the collection of clients’ views of the
alliance during treatment to address current or
emerging ruptures that might undermine client
engagement.
Description
Determining whether a treatment is working
requires more than clinician intuition or adherence
to a preselected approach. Progress feedback aims
to identify treatment failures before they occur,
allowing time for clinicians to restore therapy to a
positive trajectory. Michael Lambert, the pioneer
of real-time progress feedback and creator of the P
most empirically validated method, the Outcome
Questionnaire (OQ) System, proposes that any
system should minimally include a reliable and
valid measure of client change, a signal for notifi-
cation of at-risk clients, and continuous monitor-
ing (Lambert 2015). Barry Duncan, developer of
the clinical process of the Partners for Change
Outcome Management System (PCOMS; Duncan
and Reese 2015), the first to include routine alli-
ance feedback, emphasizes feasibility for every
session implementation, client privilege, and col-
laborative interpretation of data with clients. Wil-
liam Pinsof developed the first progress feedback
system specifically designed to monitor change
and the alliance with couples and families from a
multisystemic perspective, the Systemic Therapy
2356
Inventory of Change (STIC; Pinsof 2017).
Despite variations in feedback protocols and
empirical support, effective progress feedback
systems facilitate the fit between the therapist’s
approach and a client’s unique circumstances and
preferences to increase the chance of a positive
outcome.
Application of Concept in Couple and
Family Therapy
Given its origins in psychology, progress feed-
back was developed with the individual client in
mind. Feedback protocols and research with cou-
ples and families, not surprisingly, have lagged
behind. While gathering, interpreting, and inte-
grating feedback with more than one client in the
room add complexity to the process, progress
feedback has the potential to clarify, or even
unify, the diverse views of multiple clients in
systemic practice. Moreover, clinicians increas-
ingly are interested in realizing the demonstrated
benefits of progress monitoring in systemic psy-
chotherapies (Sparks 2015).
To date, six empirically studied progress feed-
back systems are used in systemic therapy. The
following describes processes and modes of mea-
surement to assess and respond to client feedback
emphasized by each protocol and summarizes
relevant research for each.
STIC. The Systemic Therapy Inventory of
Change (STIC; Pinsof et al. 2009) measures pro-
gress by analyzing clients’ reports of individual,
partner/couple, and family change as well as how
change in one domain impacts others. STIC is
integrative in that it assesses behavioral, cogni-
tive, and emotional aspects of each systemic
dimension as well as clients’ reports on their fam-
ilies of origin. The system is designed to provide
an initial client assessment specific enough to
develop preliminary treatment strategies and to
assess targeted change during the course of
treatment.
The STIC System measures consist of (1) Ini-
tial STIC, (2) Intersession STIC, and (3) three
alliance scales: Individual Therapy Alliance
Scale, Couple Therapy Alliance Scale, and
Progress Research in Couple and Family Therapy
Family Therapy Alliance Scale. The Initial STIC
assesses clients’ beginning status along six
dimensions: individual problems and strengths,
family of origin, relationship with partner, fam-
ily/household, child problems and strengths, and
relationship with child. Each contains a number of
subscales.
Clients fill out the appropriate form (Initial
STIC at the first session; Intersession STIC, sec-
ond session and beyond) online approximately
24 hours prior to their session. Since STIC views
all therapy as multisystemic, clients fill out all
non-alliance scales regardless of whether they
are receiving individual, couple, or family treat-
ment. The appropriate alliance scale is attached to
the intersession scale and is also completed by
clients. Results from the scales generate a feed-
back report. The feedback report informs the pri-
mary targets, or foci, of the therapy. Just prior to
each session from the second session on, thera-
pists receive the Intersession Confirmation Report
which provides information on changes in client
functioning (improved or deteriorated and change
in relation to the clinical cutoff) and the alliance
(improved or deteriorated) since the last session.
A case report generates more specific subscale
information about change.
The feedback report was originally designed to
inform clinicians but gradually began to be shared
and discussed with clients. Throughout treatment,
online technology allows clients to view graphic
depictions (e.g., bars and graphs) of scored results
as well as those of others in treatment with them.
Given the access to all scores for clients in a
couple or family, members of the system are
made aware of differences in various relationship
domains that then can facilitate useful therapeutic
conversations.
With the exception of the family/household
domain, the Initial STIC scale was found to have
strong convergent validity with widely used, val-
idated measures (Pinsof et al. 2009). A confirma-
tory factor analysis supported construct and
factorial validity for the integrative alliance
scales. Research is underway to examine whether
the STIC can predict change trajectories on spe-
cific scales for certain types of clients (Pinsof
2017).
Progress Research in Couple and Family Therapy
PCOMS. The Partners for Change Outcome
Management System (PCOMS; Duncan 2014)
was designed to make available a valid and feasi-
ble option for routine practice settings, including
public behavioral health and multisystemic treat-
ment. PCOMS values client voice and the creation
of working partnerships with clients through col-
laborative interpretation of scores and construc-
tion of treatment goals and methods.
Four instruments comprise the basic PCOMS
measurement set: (1) the Outcome Rating Scale
(ORS), (2) the Session Rating Scale (SRS), (3) the
Child Outcome Rating Scale (CORS), and (4) the
Child Session Rating Scale (CSRS). The ORS and
SRS are used with adults and adolescents, aged
13–17. Children aged 6–12 use the CORS and
CSRS. Adult caregivers provide feedback for
their child or adolescent on either the CORS or
ORS, based on the child’s age. All PCOMS instru-
ments consist of four visual analog lines. Child
versions have “smiley faces” at either ends to aid
in comprehension.
The ORS and CORS, administered at the
beginning of each therapy meeting, measure client
perception of progress, while the SRS and CSRS,
given at the end of the meeting, measure client
perception of the therapeutic alliance. PCOMS
instruments are brief, generally requiring no
more than 3–5 min to administer, score, and dis-
cuss. The SRS and CSRS seek to ward off alliance
ruptures or identify them early. All expressions of
concern on the SRS or CSRS are welcomed as
they give clinicians a chance to acknowledge alli-
ance problems and communicate to clients their
intention to address them.
With PCOMS, client involvement is routine
and expected; scores are openly shared and
discussed immediately after they are collected.
This creates openings for therapeutic conversa-
tions and provides a common reference point for
what clients want to achieve, whether they believe
therapy is helping, and their preferences for help.
Open-ended visual analog scales allow clients to
rate their global levels of distress without the
constraints of specific theory or therapist-derived
content domains. Specifics of that distress unfold
as clinicians invite clients to give meaning to their
scores.
2357
PCOMS’ measures can be completed using
paper and pencil or on iPads or tablets linked to
a web-based system, Better Outcomes Now
(BON) (https://betteroutcomesnow.com/#/). BON
automatically displays graphs of clients’ scores
in relation to clinical cutoffs, expected treatment
response (ETR), and clients’ treatment trajectories
compared with the ETR. Customized dashboards
give clinicians and supervisors alerts for at-risk
clients and provide an array of reports at clinician,
program, and agency levels.
Despite its brevity, the ORS generates reliable
and valid scores, comparing favorably with the Out-
come Questionnaire 45.2 (OQ-45) as well as other
longer measures. The CORS and ORS with adoles-
cents also have demonstrated strong reliability and
moderate concurrent validity when compared with
the Youth Outcome Questionnaire (YOQ). Both the
ORS and CORS distinguish clinical from non-
clinical populations. Similarly, the SRS has demon-
strated strong reliability and moderate concurrent
validity with longer alliance instruments.
Five randomized controlled trials (see Duncan
and Reese 2015), conducted by the Heart and Soul
of Change Project (https://heartandsoulofchange.
com/), compared PCOMS with treatment as usual
(TAU). Notably, two randomized controlled trials
with couples indicate a significant advantage for
PCOMS clients over TAU clients (nearly four
times the rate of clinically significant change) and P
sustained improvement at 6-month follow-up for
feedback clients, double that for TAU clients. Feed-
back couples were 46% less likely than TAU cou-
ples to be separated or divorced at follow-up. These
findings are indicators of PCOMS efficacy in sys-
temic practice, at least with couples. A cohort study
involving youth in a primary school setting and their
caretakers found that 88.7% of the youth using
PCOMS during their school-based counseling
rated themselves improved; 77.6% of their care-
givers reported reliable change for their child.
When researchers compared the youth scores on
the Strengths and Difficulties Questionnaire (SDQ)
with those from school-based counseling in the UK
where PCOMS was not used, they found an almost
twofold advantage for youth using PCOMS based
on caretaker-completed SDQs, with a small but
significant advantage for teacher-completed SDQs.
2358
CFS. Contextualized Feedback Systems (CFS)
is a web-based application, continuous quality
improvement system designed for use in youth
mental health treatment (Bickman et al. 2011).
CFS provides computerized client, caregiver,
and clinician feedback reports to clinicians,
agency directors, supervisors, and administrators
and an alert for youth at risk of treatment failure.
CFS was designed to address the lack of an
evidence-based, psychometrically sound client
feedback systems for youth receiving routine men-
tal health services in office-, home-, and
community-based care (https://peabody.vander
bilt.edu/docs/pdf/cepi/ptpb_2nd_ed/PTPB_2010_
Chapter15_CFS_031212.pdf).
CFS collects and analyzes youth, caregivers, and
clinician feedback throughout treatment using the
Peabody Treatment Progress Battery (PTPB). The
PTPB consists of 11 measures that assess relevant
dimensions of mental health outcomes and pro-
cesses. In developing the PTPB, collaborators
included a large, social services agency delivering
counseling to youth and families in their homes.
Since the first PTPB manual, additional refinements
and testing were conducted, resulting in reductions
in the length of most measures. In its current form,
the PTPB is intended for use for youth aged 11–18
in varied service settings, including outpatient men-
tal health, home-based, and foster care.
The first six measures of the PTPB assess tradi-
tional outcome indices including systems function-
ing, life satisfaction, caregiver strain, hope, and
service satisfaction. The remaining five instruments
assess process dimensions, including the alliance,
treatment outcome expectations, youth counseling
impact, motivation, and session report. Measures of
the PTPB are administered with varying frequency
and at different points during treatment, either at
baseline, regularly during treatment, or at discharge;
CFS measures are given at the end of a session and
can be scored either electronically using iPads or
tablets or by paper and pencil with data entered at a
later time. Clinicians view all data on a dashboard,
with critical information (e.g., at-risk alerts)
highlighted. Quality of implementation is recorded
and is available to clinicians, supervisors, and
agency managers to assist with adherence and inte-
gration of data.
Progress Research in Couple and Family Therapy
All PTPB measures have undergone extensive
rounds of psychometric testing with findings of
validity and reliability for all respondent versions.
A large, multistate randomized controlled trial was
implemented to determine if weekly feedback to
practitioners in home-based mental health treatment
for youth improved outcomes (Bickman et al.
2011). According to clinician, caregiver, and youth
assessments, youth in the feedback group improved
faster than youth in the no-feedback group. Fre-
quency of clinician viewing of feedback was corre-
lated with significant increases in effect size, based
on clinician and youth assessment.
Another CFS randomized controlled trial was
conducted at two geographically separated outpa-
tient sites of the same agency in the USA
(Bickman et al. 2016). Higher implementation at
one site resulted in greater improvement by youth.
Implementation at the second site was extremely
low, though implementation rate at the first site
was only 34%. Researchers concluded that failure
to adequately use the system rather than the sys-
tem itself resulted in the lack of effect for that
location and even a modest attempt to incorporate
feedback can have positive results.
OQ System. The Outcome Questionnaire Sys-
tem (OQ System; Lambert and Shimokawa 2011)
consists of ongoing measurement of adult client
mental health functioning and additional assess-
ments for problem solving in instances of clients
not changing as expected. The primary instrument
administered for adults is the Outcome Question-
naire 45.2 (OQ-45.2; http://www.oqmeasures.
com/), a 45-item self-report measure designed to
assess three primary domains of client function-
ing: (1) symptoms of psychological distress,
(2) interpersonal difficulties, and (3) social role
functioning. The Youth Outcome Questionnaire
(YOQ) and its derivatives are modeled after the
adult OQ 45.2. These permit the identification of
not-on-track youth clients (Nelson et al. 2013) and
thus facilitate early identification of treatment fail-
ure in family systems practice.
The OQ is meant to be administered prior to the
first session and weekly thereafter but can be used
at specified midpoints and at treatment termina-
tion. OQ-Analyst is available as a software and
Internet-hosted application that allow clients to
Progress Research in Couple and Family Therapy
score the OQ from their homes via tablet, IPad,
smartphone, or paper and pencil scores entered on
these devices. Reports are generated for clinicians
within seconds. OQ and ASC feedback reports
include clients’ progress, current distress level,
and critical items, along with an alert for clients
not-on-track (NOT). NOT clients trigger assess-
ment (clinical support tools; CSTs) of the alliance,
social supports, motivation for change, diagnostic
formulation, and life events for not-on-track cli-
ents. The core of the CSTs, a 40-item self-report
questionnaire, Assessment for Signal Clients
(ASC), aids in problem solving with clients pre-
dicted to have a poor outcome.
The YOQ-30 is filled out by parents or guard-
ians. Youth ages 12–18 can self-report using the
YOQ-SR. The YOQ-30 consists of 30 Likert-type
items comprising six subscales: somatic, social
isolation, aggression, conduct problems, hyper-
activity/distractibility, and depression/anxiety;
the YOQ-SR maps the same domains. The instru-
ments are applicable not only for collection of pre-
and post-therapy data but routine assessment of
child and youth progress. Therapists identify
NOT children and youth via the OQ-Analyst,
giving the opportunity for therapists to speak
with child or youth and caregiver/s and adjust
the direction of treatment accordingly.
Research indicates that the OQ-45.2 is widely
considered the gold standard of sound psychomet-
rics. Both the OQ-45.2 and the shorter OQ-30
have been found to be effective in identifying
potential treatment failures (Lambert 2015). Stud-
ies indicate the YOQ has high levels of internal
consistency and test-retest reliability and corre-
lates highly with the well-known Child Behavior
Checklist, while the YOQ-30’s levels of reliability
are adequate. Both instruments distinguish
between clinical and nonclinical populations.
Studies indicate moderate to good validity and
reliability for the YOQ, and it has been found to
accurately predict youth deteriorating in natural-
istic services.
Regarding outcome research, a meta-analysis
of six RCTs of the OQ System found that 5.5% of
at-risk clients whose therapists received feedback
deteriorated compared with 20.1% of at-risk cli-
ents in the no-feedback group (Shimokawa et al.
2359
2010). Positive outcomes for the feedback group
were more than double that of the control group
(55.5% versus 22.3%). Since this meta-analysis,
six additional studies have been published
supporting previous findings and expanding the
evidence base for the OQ System across treatment
settings, client samples, and countries (Lambert
2015). In one large study examining change tra-
jectories for outpatient youth aged 4–17, more
frequent YOQ administrations resulted in faster
rates of change (Nelson et al. 2013). Another
study found that the YOQ-2.1 warning system
identified 69% of deteriorators in a community
mental health system and 61% in a managed
care setting (Warren et al. 2012).
CORE. Clinical Outcomes in Routine Evalu-
ation (CORE) is a client feedback system
designed to monitor change in psychological ser-
vices (http://www.coreims.co.uk/). CORE aggre-
gates feedback data at multiple levels – client,
therapist, sessions, episodes within sessions, and
overall treatment delivery. Multiple stakeholders,
including clients, therapists, managers,
policymakers, service designers, and researchers,
can benefit from client-generated data (Barkham
et al. 2015). CORE -PC and CORE-NET provide
software and cloud-based systems (respectively)
for administration and collation of CORE
measures data.
The original CORE measure, Clinical Out- P
comes in Routine Evaluation-Outcome Measure
(CORE-OM), is a pan-theoretical self-report
instrument tapping key psychological domains
of subjective well-being, problems, functioning,
and risks. The Young Person’s Clinical Outcomes
in Routine Evaluation (YP-CORE) expands appli-
cation of the CORE to youth and families (Twigg
et al. 2009). This ten-item instrument measures
psychological distress in young people aged
11–16. The YP-CORE was developed after exten-
sive involvement with practitioners and youth to
ensure its language and content fit its purposes
and were understandable to its intended client
age group.
Both full and shorter parallel versions of the
CORE-OM distinguish reliably between clinical
and nonclinical samples. The CORE-OM has high
levels of reliability and correlates highly with the
2360
Beck Depression Inventory and the Structured
Clinical Interview for the DSM, evidence of con-
vergent validity. Evaluation of the YP-CORE
indicated good psychometric properties and sen-
sitivity to change.
Two forms are completed by practitioners pre-
and post-therapy, the CORE Therapy Assessment
Form and the CORE End of Therapy Form,
respectively. The pre-therapy form includes client
demographic and referral information and thera-
pist assessment of the severity and duration of the
presenting problem. Therapists report on length of
treatment, whether termination was planned, and
types of interventions used in the post-therapy
form. YP-CORE and associated YP-Therapy
Assessment Forms and YP-End of Therapy
forms are available in the CORE Net system.
The client-report CORE System is completed
minimally prior to a first and last session, though it
can be used at every session. Some services
decide to keep therapists and clients unaware of
scores, whereas others choose to specifically use
CORE data in therapy conversations. The Y-P
Score similarly is used either for pre- or post-
therapy evaluation or more frequently for ongoing
therapy monitoring.
SCORE. SCORE (The Systemic CORE) mea-
sures (SCORE, 40; SCORE, 15; http://www.aft.
org.uk/view/score.html) were developed to
address the need for a valid means of evaluating
outcome in systemic family and couple therapy in
the UK (Stratton et al. 2010). Informed by theory,
clinical experience, and research, SCORE collects
and analyzes self-reports of various members of a
system regarding their views of family or couple
functioning. The cornerstone of SCORE is sys-
temic theory; it aims to document system health
and progress over the course of psychotherapy
treatment.
While inspired by the development of CORE,
SCORE creators set out to develop an entirely
new instrument capable of measuring system
functioning and indicating the types of changes
expected from family intervention. SCORE
attempts to balance sound psychometrics with
therapeutic and multicultural applicability.
SCORE-40, deemed too long to be viable in
everyday practice, spurred the creation of a
Progress Research in Couple and Family Therapy
shortened version, SCORE-15 (Stratton et al.
2014). SCORE-15 involves three primary factors:
(1) strengths and adaptability, (2) overwhelmed
by difficulties, and (3) disrupted communication.
SCORE-15 is used for family members ages
11 and over. Child SCORE, adapted for use in
the 8–11 age group, is modeled after the SCORE-
15 with modified language and color gradations
linked to the Likert scales to increase understand-
ing of the questions.
Studies indicate SCORE-15’s adequate to high
reliability and validity as well as sensitivity to
change in a clinical population (Stratton et al.
2014). Service users aged 12 or over were asked
to complete SCORE-15 at the start of the first and
fourth sessions. High rates of completion (87%
and 98% for each occasion, respectively) indi-
cated acceptability of the instrument in family
and couple clinical practice settings.
SCORE-15 is introduced at the beginning of
the first session and is completed privately by all
those age 12 and over. Children ages 8–11 com-
plete the Child SCORE. Family members are
instructed to decide who to include as “family.”
This respects that definitions of family vary
according to different cultural and familial con-
texts. The therapist informs the family that the
questionnaire is designed to help focus therapy
initially and will be revisited periodically to see
if change has occurred. Forms are done individu-
ally, but family members can then decide if they
would like to discuss their responses. At the sixth
meeting (or later), clients are asked to fill out the
SCORE-15 again to assess change. Family mem-
bers again decide if they want to keep their
answers private or share them with other members
of the family. At the final session, the same pro-
cedure is repeated.
Clinical Example
Progress feedback in systemic treatment has the
potential to facilitate fruitful conversations, espe-
cially in clarifying and negotiating different per-
ceptions of the problem, progress in resolving the
problem, or views of the alliance among multiple
members of a couple or family system (Sparks and
Progress Research in Couple and Family Therapy
Duncan 2018). The example below generalizes
this potential in one instance involving 10-year-
old Max, diagnosed with autism spectrum disor-
der, and his parents who sought counseling due to
Max’s unwillingness to sleep in his own bed and
anxious “meltdowns” at school.
Max’s parents, Elsie and Scott, sat on either side of
Max as the therapist logs in on her iPad at the start
of the fifth session. After each client scores how
they see Max doing, she shows the screen to each.
The scores indicate that Elsie believes Max is stuck
below his expected treatment response (ETR). Scott
places his son’s progress as exceeding the ETR by
two points. Max is in between, with the family
domain higher than the school domain. The coun-
selor invites each to explain their scores. Elsie states
that she is unhappy with the continuing bedtime
struggle and believes Max needs to learn greater
independence at school. Scott believes it is better to
give in to Max at bedtime so he gets the sleep he
needs to deal with his teachers’ inappropriate
expectations. Max says he sleeps fine and just
wants his teachers to “stop bugging him.”
Progress feedback in this example allowed the
precise and early depiction of family members’
positions related to their presenting concern. Fam-
ily members’ different views of progress reflect
such systemic variables as closeness/distance,
hierarchy, and coalitions. The counselor requested
a meeting with the parents for the next session
where she invited Elsie and Scott to talk about
their hopes and fears for their son. The ensuing
conversation led to a plan – both agreed to hold
firm with Max’s independent sleep for at least two
nights a week as a start and to encourage him to
wait alone outside after school for his pickup
rather than in the classroom. All agreed that, at
the next session, Max, his parents, and the coun-
selor would devise effective calming strategies for
Max and ways to involve school personnel to
support him with these.
Over several more sessions, family members’
scores reached greater convergence and indicated
an on-track trajectory. Family members were
empowered to see their progress and to know
that their voices mattered. Alliance scores
remained strong throughout treatment (except
when Max reminded the counselor that they had
not played his favorite game). Different views of
progress have implications for alliance scores, and
2361
knowing early the parents’ different levels of sat-
isfaction with progress allowed the counselor to
adjust her work, acknowledging and working with
those differences.
Routine client feedback that informs treatment
has been the rationale for creation of progress
monitoring systems. The goal has always been to
improve outcomes by facilitating clinician
decision-making in accord with regularly
obtained client feedback. Particularly pertinent
to multiclient treatment are concerns of feasibility.
New technologies have streamlined administra-
tion of feedback measures and interpretation of
data, enabling timely alerts for deteriorating cli-
ents. Still, considerable variation exists in feasi-
bility, frequency of feedback collection, and how
feedback informs treatment. Variation also exists
regarding the empirical support for each system
with only two of the above (OQ Systems and
PCOMS) designated as evidence-based practices.
Despite these differences, systemic progress feed-
back is gaining a solid presence in varied treat-
ment settings across the globe to ensure quality
and effective services to children, families, and
couples.
Cross-References
P
▶ Partners for Change Outcome Management
System, The
▶ SCORE
▶ Systemic Therapy Inventory of Change
References
Barkham, M., Mellor-Clark, J., & Stiles, W. B. (2015).
A CORE approach to progress monitoring and feed-
back enhancing evidence and improving practice. Psy-
chotherapy, 52(4), 402–411 https://doi.org/10.1037/
pst0000030.
Bickman, L., Kelley, S. D., Breda, C., de Andrade, A. R., &
Riemer, M. (2011). Effects of routine feedback to clini-
cians on mental health outcomes of youths: Results of a
randomized trial. Psychiatric Services, 62, 1423–1429.
https://doi.org/10.1176/appi.ps.002052011.
Bickman, L., Douglas, S. R., De Andrade, A. R. V.,
Tomlinson, M., Gleacher, A., Olin, S., & Hoagwood,
K. (2016). Implementing a measurement feedback
2362 Projective Identification in Psychoanalytic Couple and Family Therapy
system: A tale of two sites. Administration and Policy
in Mental Health and Mental Health Services
Research, 43(3), 410–425.
Duncan, B. L. (2014). On becoming a better therapist:
Evidence-based practice one client at a time.
Washington, DC: American Psychological Association.
Duncan, B. L., & Reese, R. J. (2015). The Partners for
Change Outcome Management System (PCOMS):
Revisiting the client’s frame of reference. Psychother-
apy, 52(4), 391–401. https://doi.org/10.1037/pst/
0000026.
Hannan, C., Lambert, M. J., Harmon, C., Nielsen, S. L.,
Smart, D. W., Shimokawa, K., & Sutton, W. (2005).
A lab test and algorithms for identifying clients at risk
for treatment failure. Journal of Clinical Psychology:
In Session, 61, 155–163.
Hansen, N., Lambert, M., & Forman, E. (2002). The psy-
chotherapy dose-effect and its implications for treat-
ment delivery services. Clinical Psychology: Science
and Practice, 9, 329–343.
Lambert, M. J. (2015). Progress feedback and the
OQ-system: The past and the future. Psychotherapy,
52(4), 381.
Nelson, P. L., Warren, J. S., Gleave, R. L., & Burlingame,
G. M. (2013). Youth psychotherapy change trajectories
and early warning system accuracy in a managed care
setting. Journal of Clinical Psychology, 69(9),
880–895.
Norcross, J. (2010). The therapeutic relationship. In
B. Duncan, S. Miller, B. Wampold, & M. Hubble
(Eds.), The heart and soul of change: Delivering what
works (2nd ed.). Washington, DC: American Psycho-
logical Association.
Pinsof, W. M. (2017). The systemic therapy inventory of
change – STIC: A multi-systemic and multi-
dimensional system to integrate science into psycho-
therapeutic practice. In T. Tilden & B. Wampold (Eds.),
Routine outcome monitoring in couple and family ther-
apy, European family therapy association series.
Cham: Springer.
Pinsof, W. M., Zinbarg, R. E., Lebow, J. L., Knobloch-
Fedders, L., Durbin, E., Chambers, A., . . ., & Fried-
man, G. (2009). Laying the foundation for progress
research in family, couple, and individual therapy:
The development and psychometric features of the
initial systemic therapy inventory of change. Psycho-
therapy Research, 19(2), 143–156.
Shimokawa, K., Lambert, M. J., & Smart, D. W. (2010).
Enhancing treatment outcome of patients at risk of
treatment failure: Meta-analytic and mega-analytic
review of a psychotherapy quality assurance system.
Journal of Consulting and Clinical Psychology, 78,
298–311 https://doi.org/10.1037/a0019247.
Sparks, J. (2015). The Norway couple project: Lessons
learned. Journal of Marital and Family Therapy,
41(4), 481–494. https://doi.org/10.1111/jmft.12099.
Sparks, J., & Duncan, B. (2018). The partners for change
outcome management system: A both/and system for
collaborative practice. Family Process.
Stratton, P., Bland, J., Janes, E., & Lask, J. (2010). Devel-
oping an indicator of family function and a practicable
outcome measure for systemic family and couple ther-
apy: The SCORE. Journal of Family Therapy, 32(3),
232–258.
Stratton, P., Lask, J., Bland, J., Nowotny, E., Evans, C.,
Singh, R., Janes, E., & Peppiatt, A. (2014). Detecting
therapeutic improvement early in therapy: Validation of
the SCORE-15 index of family functioning and change.
Journal of Family Therapy, 36, 3–19. https://doi.org/
10.1111/1467-6427.12022.
Twigg, E., Barkham, M., Bewick, B. M., Mulhern, B.,
Connell, J., & Cooper, M. (2009). The Young Person’s
CORE: Development of a brief outcome measure for
young people. Counselling and Psychotherapy
Research, 9(3), 160–168.
Warren, J. S., Nelson, P. L., Burlingame, G. M., &
Mondragon, S. A. (2012). Predicting patient deteriora-
tion in youth mental health services: Community men-
tal health vs. managed care settings. Journal of Clinical
Psychology, 68, 24–40.
Projective Identification in
Psychoanalytic Couple and
Family Therapy
Arthur C. Nielsen
The Family Institute at Northwestern University,
Chicago, IL, USA
Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA
The Chicago Institute for Psychoanalysis,
Chicago, IL, USA
Name of Concept
Projective Identification in Couple Therapy
Introduction
Projective identification (PI) offers a powerful
lens through which to view chronic marital con-
flict and unhappiness from a psychoanalytic per-
spective. Although PI was previously considered
solely a feature of serious personality disorders, it
is now recognized to be manifest in healthier
people, including distressed couples.
Projective Identification in Psychoanalytic Couple and Family Therapy
PI is a complex concept that originated in the
work of Melanie Klein (1946), whose early ideas
have been refined as applied to couples by
(in chronological order) Dicks (1967), Willi
(1984), Wachtel and Wachtel (1986), Scarf
(1987), Slipp (1988), Zinner (1989), Catherall
(1992), Siegel (1992, 2010), Berkowitz (1999),
Middelberg (2001), Donovan (2003), Stern
(2006), Lansky (2007), Gurman (2008), and
Ringstrom (2014).
PI is a form of interpersonal defense in which
people recruit others to help them tolerate their
own painful intrapsychic states of mind. This
contrasts with purely intrapsychic defenses
like repression, where others are not misused
in this fashion. In one common form of PI, an
internal conflict (“I want to buy a new car, but
I think I should save my money.”) becomes
interpersonalized as a debate between partners
(“I want a new car, but my wife thinks we should
save our money.”). Debates about one’s good-
ness or lovability can also be interpersonalized,
as in a client’s statement that “I feel better when
my husband hates me than when I hate myself”
(Scarf 1987, p. 180). In another common form
of projective identification, a disturbing self-
evaluation is externalized: “I worry that I’m
too needy” becomes “He won’t give me what
I deserve!” In both varieties, the projector is
unable to consciously maintain a complicated,
conflicted, or “good enough” view of the self
and the world and therefore splits complex facts
or feelings into black-and-white, all-or-nothing
terms. From this vantage point, adversarial cou-
ples can be seen to be battling to force each other
to accept the designation of “imperfect person,”
a shameful role both are trying hard to external-
ize as they toss it back and forth like a hot
potato.
Another form of PI is based on the observa-
tion that not only do people unconsciously mis-
perceive others based on their past experiences
and current needs, but they also unconsciously
attempt to actualize or enact specific role rela-
tionships based on those experiences and needs
(Sandler 1987; Stern 1994). To accomplish this,
they invite or induce others to play roles in their
real-life dramatic creations. This form of
2363
projective identification is somewhat different
from attempts to simply be rid of unacceptable
parts of the self since it involves actors in
dramas that move from uncertain beginnings to
hoped-for, positive conclusions. Anxiety and
hope blend together in an amalgam that may
be energizing and captivating in ways that differ
from scenarios that only seek to disown certain
states of mind while also “keeping them
around.” Much of “normal” life excitement
stems from such adventures, as when a moun-
tain climber, or, more prosaically, a weekend
golfer, seeks to prove his or her competence in
a challenging endeavor. However, when the
exciting script includes the wish to prove one’s
lovability to a distancing partner or to prove
one’s competence to a skeptical boss, therapists
will find it challenging to help clients give up
the powerful attraction of such enacted scenar-
ios and move on to more rewarding transactions
or partners.
In any of its forms, PI, by forcing partners into
prescribed roles, interferes with couple intimacy,
problem solving, and well-being.
Component Steps of PI
Projective identification begins with two theoret-
ically separable steps: (1) projection P
(transference) combined with (2) behavior likely
to induce behavior consistent with that projection
in others (here, the marital partner). In subsequent
steps, either or both partners may “identify” with
what has been projected and may then behave
accordingly.
Note that the process of projective identifica-
tion moves beyond transference (distorted percep-
tion) when the partner – “the recipient” – is not
only misperceived as some unacceptable part of
the self but actually comes to feel and behave
accordingly (to identify) because of pressure
from the spouse, “the inducer,” to do so (Sandler
1987). For instance, the previously relaxed spouse
who is repeatedly told that he is the socially anx-
ious one may begin to doubt himself, and this
uncertainty may engender anxious, socially awk-
ward behavior.
2364 Projective Identification in Psychoanalytic Couple and Family Therapy
PI Explains Induced Unpleasant
Outcomes
Therapists frequently observe that partners do not
just unrealistically fear certain outcomes; they
tend to elicit them. PI is one explanation, since
as clients disavow and induce unacceptable parts
of themselves; they then find them objectionably
present in their partners.
PI Explains Failures to Soften
PI also gives us an explanation for the failure of
some clients to “soften” after their partners have
exposed their vulnerabilities. Failures to empathize
can result from precisely the same forces that caused
a prior projective identification. Since projectors’
inability to contain a feeling in the first place has
led them to locate it in their partners, we should not
be surprised when they fail to welcome their part-
ners’ communicating it back to them.
Recipient Containment
PI begins when a person is unable to accept or
“contain” some way of feeling or thinking about
themselves and their world. We can classify sub-
sequent events by noticing how recipients manage
the projected/induced feelings or personal delin-
eations (“You’re the uncaring one!”). Since Bion
(1962), psychoanalysts have emphasized that if
the receiving therapist can “contain” the projec-
tion, “metabolize” it, and then feed it back to the
projecting client in a more manageable form, the
client may grow in his or her capacity to tolerate
the projected state of mind (Ogden 1982; Tansey
and Burke 1989). In the same way, spouses who
remain emotionally capable and empathic can
assist when their partners become overwhelmed
by inner states of distress (Catherall 1992).
Inductions Achieved via Inaction
One common critique of PI as a concept is that it
can seem mysterious, if not quite supernatural.
How, exactly, do people “put” or “locate” a part
of themselves in others or stir them to identify
with a disowned part of their own selves? How
are inductions actually accomplished? By telepa-
thy? No, in PI, much of the influencing force is
nonverbal – “written between the lines” – and
accomplished through inaction. This not only
makes it harder to see, but it also makes it easier
for inducers to deny. The absence of emotional
support tends to worsen insecurity, loneliness, or
narcissistic rage. A relative lack of worry in a
dangerous situation tends to increase anxiety in
others. To get this idea across to clients, I ask them
to consider the feelings of a passenger riding in a
car on a dark, winding road with a driver who is
speeding and acting utterly oblivious to danger.
Since nonresponsiveness, inaction, and psy-
chological blindness are often the mechanisms of
induction, inducers characteristically feel falsely
accused by recipients (noting, correctly, that they
haven’t done anything wrong) and think they
should not be held responsible for their partners’
reactions. This allows them to play the role of the
blameless victim of their partner’s psychopathol-
ogy. In addition, since they can see nothing that
they have done to cause their partner’s distress,
they grow even more convinced that their partners
“really are” the embodiment of what they fear.
Nonetheless, they are committing sins (i.e., induc-
tions) of omission.
The following case illustrates how one can
work with PI – and, more generally,
psychoanalytically – here, with a partner
defending against shame.
Working with PI: Rachel and Matt
Forty-year-old Rachel came for marital therapy
shortly after the failure of her business venture,
complaining, “My husband gives me a sick feel-
ing!” Rachel was ready to leave Matt, whom she
thought of as a disappointing provider and inade-
quate in bed. Her foremost complaint was that his
earning capacity – though well into six figures –
had never been what she had hoped for and was
less than that of many of her friends’ husbands.
Although she knew that Matt truly loved her, had
Projective Identification in Psychoanalytic Couple and Family Therapy
been very supportive when she had been addicted
to drugs, and had been a great help in squabbles
with her family, Rachel was now certain that she
should never have married him.
It was easy to see that Rachel’s contempt for
her husband was a projection of the shame she felt
after her own career failure. Indeed, this was so
easy to see that I had to work hard to contain my
initial negative countertransference to her as an
insensitive, entitled whiner! The contempt that
I was now trying hard to contain was partly
induced by Rachel’s failure to acknowledge the
obvious unfairness of her conclusions – an induc-
tion by inaction.
But Rachel’s contempt was not limited to a
defensive projection. Her vociferous attacks were
undermining Matt’s actual performance at work
and in bed, as they intensified his anxiety
concerning performance. Specifically, his growing
insecurity led him to avoid the risk of soliciting new
business because he feared a rejection similar to
what he experienced daily at home. He also
avoided approaching his wife for sex, since his
erections had begun to fail him. Rachel’s defense
against her shame and failed performance had
succeeded in inducing just those qualities in Matt.
As therapy began, Matt hardly moved or spoke
in our sessions, and his stooped body language
screamed “loser!” Matt felt ashamed and was
unable to defend himself when Rachel compared
him unfavorably to a self-confident military offi-
cer who had attracted her interest. As I sat
watching him, I tried to picture him soliciting
business; I could neither envision him mustering
the courage to make the necessary calls nor ima-
gine any clients trusting him with their business.
In all of this, Matt seemed to confirm his wife’s
(projected and induced) belief that he was “a poor
excuse for a man.”
The interventions that helped reverse this pro-
cess of projective identification involved helping
Rachel accept (i.e., own and contain) her shame
about the failure of the business venture she had
so hoped would transform her life and increase
their income. As she felt safer with me, we learned
that she also felt terribly ashamed of her contin-
ued, clandestine abuse of prescription drugs – a
defensive “home remedy,” separate from her use
2365
of PI, that had backfired and intensified the
shameful anxiety it was meant to conceal.
As she revealed her own disappointment and
shame over her business failure and her drug use,
Matt, who had previously been supportive of her,
provided a corrective experience beyond what I –
her paid therapist – could offer. As Rachel’s self-
esteem rose, she became more hopeful and pur-
sued a new line of work that eventually provided
companionship, self-esteem, and income. These
real benefits, coupled with her regained closeness
with Matt, helped her to see the positives in her
new job, even though it lacked the status and
cachet of the business that had flopped.
I also worked to help Rachel feel less ashamed
of Matt’s real limitations, most of which were the
flip side of his considerable strengths: While Matt
was not the competitive alpha male she thought
she would have preferred, he was extremely lov-
ing and patient as a husband and father. As
Rachel’s contempt lessened and her genuine grat-
itude emerged, Matt’s mood brightened and his
posture straightened. Feeling more confident, he
sought career counseling, which led to greater
professional success. Under less inductive pres-
sure to fail, he became more successful.
As the virtuous cycle continued, Matt’s grow-
ing self-confidence put him in a still better mood.
This allowed him to provide real emotional sup-
port to Rachel when she would develop doubts not P
only about her career, but about her physical
appearance and her functioning as a daughter
and a mother. Feeling more supported by Matt,
Rachel had less need to externalize her negative
self-image. Their sex life also improved, although
Rachel had to accept her role as initiator of most of
the action. The contemptuous, shame-inducing
cycle that had brought them to therapy not only
ceased, but was replaced by a positive, mutually
supportive cycle as each showed greater happi-
ness and pride in the other and growing trust in the
intimate contact that flowed from this sense of
safety, support, and well-being.
Fifteen years later, when Rachel consulted me
for help in coping with her aging parents, I learned
that these gains had withstood both the test of time
and some significant external challenges. I came
to see Rachel and Matt as one of my greatest
2366
successes: a couple that moved from contempt
and near divorce to high levels of mutual respect,
intimate connection, and loving appreciation.
Cross-References
▶ Idealization in Psychoanalytic Couple and
Family Therapy
▶ Object Relations Couple Therapy
▶ Psychoanalytic Couple and Family Therapy
▶ Psychodynamic Couple Therapy
References
Berkowitz, D. A. (1999). Reversing the negative cycle:
Interpreting the mutual influence of adaptive, self-
protective measures in the couple. Psychoanalytic
Quarterly, 68, 559–583.
Bion, W. R. (1962). Learning from experience. London:
Tavistock Publications.
Catherall, D. (1992). Working with projective identifica-
tion in couples. Family Process, 31, 355–367.
Dicks, H. (1967). Marital tensions. New York: Basic
Books.
Donovan, J. M. (2003). Short-term object relations couples
therapy. New York: Brunner-Routledge.
Gurman, A. S. (2008). Integrative couple therapy: A depth
psychological approach. In A. S. Gurman (Ed.), Clini-
cal handbook of couple therapy (4th ed., pp. 383–423).
New York: Guilford Press.
Klein, M. (1946). Some notes on some schizoid mecha-
nisms. International Journal of Psychoanalysis, 27,
99–110.
Lansky, M. R. (2007). Unbearable shame, splitting, and
forgiveness in the resolution of vengefulness. Journal
of the American Psychoanalytic Association, 55,
571–593.
Middelberg, C. V. (2001). Projective identification in com-
mon couple dances. Journal of Marital and Family
Therapy, 27, 341–352.
Ogden, T. (1982). Projective identification and therapeutic
technique. New York: Jason Aronson.
Ringstrom, P. A. (2014). A relational psychoanalytic
approach to couples psychotherapy. New York:
Routledge.
Sandler, J. (1987). The concept of projective identification.
In J. Sandler (Ed.), Projection, identification, projective
identification (pp. 13–26). Madison: International Uni-
versities Press.
Scarf, M. (1987). Intimate partners: Patterns in love and
marriage. New York: Random House.
Siegel, J. P. (1992). Repairing intimacy: An object rela-
tions approach to couples therapy. New York: Jason
Aronson.
Pseudohostility in Family Systems
Siegel, J. P. (2010). A good-enough therapy: An object
relations approach. In A. S. Gurman (Ed.), Clinical
handbook of couple therapy (4th ed., pp. 134–152).
New York: Guilford Press.
Slipp, S. (1988). The technique and practice of object
relations family therapy. Northvale: Jason Aronson.
Stern, S. (1994). Needed relationships and repeated rela-
tionships: An integrated relational perspective. Psycho-
analytic Dialogues, 4, 317–346.
Stern, D. B. (2006). Opening what has been closed,
relaxing what has been clenched: Dissociation and
enactment over time in committed relationships. Psy-
choanalytic Dialogues, 16, 747–761.
Tansey, M. J., & Burke, W. F. (1989). Understanding
countertransference: From projective identification to
empathy. Hillsdale: The Analytic Press.
Wachtel, E. F., & Wachtel, P. L. (1986). Family dynamics
in individual psychotherapy: A guide to clinical strat-
egies. New York: Guilford Press.
Willi, J. (1984). The concept of collusion: A theoretical
framework for martial therapy. Family Process, 23,
177–186.
Zinner, J. (1989). The implications of projective identifi-
cation for marital interaction. In J. Scharff (Ed.), Foun-
dations of object relations family therapy
(pp. 155–174). Northvale: Jason Aronson.
Pseudohostility in Family
Systems
Sara Moini1 and Matthew Jarvinen2
1
California School of Professional Psychology/
AIU-LA, Los Angeles, CA, USA
2
Fuller Theological Seminary; School of
Psychology, Pasadena, CA, USA
Name of Concept
Pseudohostility
Introduction
Families affected by schizophrenia have been
compared to unaffected families in order to learn
about how the emotional and relational dynamics
unique to these families may contribute to the
manifestation of schizophrenia. During the
mid-1950’s, research shifted its focus from schizo-
phrenic symptoms as an intrapsychic disorder, or
Pseudohostility in Family Systems
within an individual, to an interpersonal phenom-
enon shaped by family communication sequences
(Goldenberg and Goldenberg 2012). Lyman
Wynne and his colleagues (1958, 1963) investi-
gated the social organization and often blurred,
ambiguous, and confused communication pat-
terns in families with schizophrenic members.
Theoretical Context for Concept
One of the major contributions by Wynne and his
colleagues was that families affected by schizo-
phrenia deal with emotions, both positive and
negative, in inauthentic ways (Goldenberg and
Goldenberg 2012). Wynne believed that the dis-
tinct sequences of communication in families
could be described in terms of alignments and
splits between them. An alignment is defined as
“the perception or experience of two or more
persons that are joined together in a common
endeavor, interest, attitude, or set of values,”
thus, contributing to positive feelings toward one
another (Wynne 1961, p. 96). Splits are defined as
“an experience of opposition, difference, or
estrangement, with associated negative feelings”
(Wynne 1961, p. 96).
Description
Pseudohostility is a type of superficial split by
which families utilize bickering and turbulence
to buffer against anxiety-producing intimacy and
affection. That is, their need for tenderness and
affection is concealed due to their discomfort in
dealing with it directly. In addition, the same
strategy of turmoil may be employed to prevent
deeper hostility, which could lead to imagined,
permanent, destruction of relationships and hope-
lessness. By engaging in this process, families
rigidly maintain vulnerable relationships in a
fixed form, protecting themselves from anxiety-
provoking desires and impulses. However, this
distorted emotional process stifles the potential
for positive individual and relational development
(Wynne 1961).
2367
Application of Concept in Couple and
Family Therapy
Splits and alignments are phenomena observable
in all groups, including families. Some couples
and families spend most of treatment time
engaged in unruly arguments about seemingly
unimportant issues. In reference to the context
and timing of such events in family therapy,
Wynne (1961) noted the regularity of how conflict
often directly followed subtle signs of fondness or
alignment between members of a family. Whether
pseudohostility is interpreted as a fear of intimacy
or a fear of dealing with deeper conflicts, treat-
ment aims to help the family deal with the under-
lying issues, while the therapist provides a
protective context.
Clinical Example
Bob and Ellen are the parents of 15-year-old Joel.
Due to anxieties about emotional intimacy, they
settle for remaining connected through sarcasm
and criticism. Their relationship with their son is
built upon stern guidance and reinforcement. He
tries to succeed to win their approval, but such
approval is never offered. Joel often feels like a
third wheel, ignored, overlooked, and on the outside
of his relationship with his parents. While he wants P
to feel connected to his parents, anxiety about
dependency leads him to put on a facade of rugged
independence.
When reprimanded by his parents, Joel would
fire back, criticizing them for their failings on how
they raised him. The stress of these conflicts led Bob
and Ellen to fight with each other, criticizing each
other for different ways of dealing with Joel. In
response, Joel felt less on the outside of their rela-
tionship. Although he did not necessarily feel close
to either parent, he felt less threatened by abandon-
ment. His acting out and rebellion persisted and
increased, which led to further conflict between his
parents and corresponding increased feelings of
security for Joel. However, when his acting out
reached extreme levels (e.g., drug abuse, dropping
out of school), the stress nearly led his parents to
separate. The security that was previously afforded
2368
by his parents’ conflict with each other was now
replaced with fears of possibly losing connection
with one of his parents. In response, he berated
them for potentially leaving each other, indicating
that doing so would only make things worse for
him. In response, Bob and Ellen would begin to
repair their relationship and get back on the same
team. But this would arouse similar fears again for
all members of the family: fears of intimacy for Bob
and Ellen and fears of exclusion and emotional
abandonment for Joel. In response, Joel would
begin acting out again and find further ways to incite
conflict between his parents. And the cycle would
begin again, keeping the family locked in a kind of
conflict-laden, though inseparable, connection.
Eventually, these dysfunctional patterns led
Bob and Ellen to seek family therapy. The family
therapist, familiar with the concept of pseudo-
hostility, was able to see the negative surface
interactions in the family as well as the fears and
desires for connection underneath. The therapist
was able to guide the family into accessing these
underlying attachment feelings, communicating
directly about these feelings, and interacting in
emotionally responsive ways to bring security to
the family system. Once this new security was
established, the pseudohostile interactions and
their ways of providing secondary security were
no longer needed.
Cross-References
▶ Marital Fusion in Couples
▶ Pseudomutuality in Family Systems
▶ Psychodynamic Couple Therapy
▶ Separation-Individuation in Families
References
Goldenberg, I., & Goldenberg, H. (2012). Family therapy:
An overview (8th ed.). Belmont: Thomson Brooks/
Cole.
Wynne, L. (1961). The study of intrafamilial alignments
and splits in exploratory family therapy. In N. W.
Ackerman, F. L. Beatman, & S. N. Sherman (Eds.),
Exploring the base of family therapy (pp. 95–115).
New York: Family Services Association.
Pseudomutuality in Family Systems
Wynne, L. C., & Singer, M. T. (1963). Thought disorder
and family relations of schizophrenics, I and II.
Archives of General Psychiatry, 9, 191–206.
Wynne, L. C., Ryckoff, I. M., Day, L., & Hirsch, S. I.
(1958). Pseudomutuality in the family relationships of
schizophrenics. Psychiatry, 21, 205–220.
Pseudomutuality in Family
Systems
Sara Moini1 and Matthew Jarvinen2
1
California School of Professional Psychology/
AIU-LA, Los Angeles, CA, USA
2
Fuller Theological Seminary; School of
Psychology, Pasadena, CA, USA
Name of Concept
Pseudomutuality
Introduction
Lyman Wynne and his colleagues (1958, 1963)
have examined the contribution of family related-
ness and communication in the development of
schizophrenia. While they do not propose a single
theory to account for the many facets of schizophre-
nia, they offer a psychodynamic interpretation of
schizophrenia that considers the systemic organiza-
tion of the family. Their work has included the
comparison of families with members diagnosed
with schizophrenia to other families unaffected by
schizophrenia in order to delineate the communica-
tion patterns in these families, which are often
blurred, ambiguous, and confused.
Theoretical Context for Concept
Pseudomutuality concerns the issue of authenticity
in human relationships. Wynne and his colleagues
sought to understand the particular patterns of inau-
thenticity that seemed to be present in many families
affected by schizophrenia. During this investigation,
Pseudomutuality in Family Systems
they found that these families often deal with emo-
tions within the family, both positive and negative
emotions, in inauthentic ways (Goldenberg and
Goldenberg 2012). Relatedly, they discovered dis-
tinct patterns of communication with regard to how
the family responds to relational alignments and
splits. In this sense, Wynne (1961) defines an align-
ment as “the perception or experience of two or
more persons that they are joined together in a
common endeavor, interest, attitude, or set of
values,” thus, contributing to positive feelings
toward one another (p. 96). He defines splits as an
“experience of opposition, difference, or estrange-
ment, with associated negative feelings” (p. 96).
Description
A pseudomutual relationship often appears open,
understanding, and cohesive at face value. How-
ever, pseudomutuality is a type of superficial
alignment that defends against any conscious
splits and in doing so blurs the ability to experi-
ence both differences and deeper alignments
(Wynne 1961). The underlying dysfunctional
relational patterns are maintained in a fixed form
so that conflict, divergence, and greater intimacy
are avoided. Further exploration of these underly-
ing relational dynamics, including one’s feelings,
is threatening and is defensively excluded both
intrapsychically and interpersonally. The primary
theme of the pseudomutual family is about fitting
together, making it difficult for members to culti-
vate any form of individualism and therefore
engage in relationships outside of the system
(Goldenberg and Goldenberg 2012). As a result,
growth within the person and the relationship is
thwarted. Individuals who grow up in this emo-
tional climate fail to develop a strong sense of
self-identity, as any attempts to differentiate are
perceived as threats to the family unit.
Application of Concept in Couple and
Family Therapy
As a result of his research, Wynne (1961) con-
cludes that a focus on a family’s alignments and
2369
splits provides illuminating diagnostic informa-
tion about the health of the family. Paying atten-
tion to how a family organizes around and
responds to alignments and splits provides the
therapist with many possible avenues of fruitful
therapeutic intervention. For example, thera-
peutic work may be enhanced by helping family
members identify and face both the shared dread
surrounding intrafamilial conflict and the
resulting defenses against it (e.g., facade of har-
mony). When defenses become more dystonic
and their costs to the family are better under-
stood (i.e., rigid, stifled interactions which are
maintained by anxiety about separation), family
members can be helped to bear the anxiety and
other emotions related to those splits. In doing
so, it is expected that splits will give way to less
defensive alignments and more vital and
authentic relationships.
Clinical Example
Dan and Arika and their 20-year-old daughter,
Eve, came to family therapy following Eve’s diag-
nosis of schizophrenia. Dan and Arika described
their family as loving and could not comprehend
how their daughter could be struggling with her
mental health. Arika commented on how her
daughter was the most important person to her. P
Dan reacted to Arika’s comments with a sense of
agitation; he exclaimed that he never received the
attention she gave Eve. Immediately, Arika’s
frayed nerves became apparent. Uncomfortable
with this incipient conflict, he proceeded to affirm
his wife’s dedication to the family and their
daughter.
Initial interventions aimed at helping Dan
and Arika identify their feelings around family
conflict and providing a safe space for both
partners to express their personal vulnerabilities
regarding perceived separation during conflict.
As Dan and Arika engaged in authentic expres-
sions of their emotional experience, Eve
disclosed her sadness about the halt in her aca-
demic pursuits. She was in the first year of
college when she had her first psychotic epi-
sode. Leading up to her psychosis, Eve was in
2370
dispute with her mother. She dated a classmate
for a few months who was from a different
cultural background. Eve’s mother made it
very clear that she was not in favor of this
relationship and that continuing any relation
with him would be a sign of disrespect to her
mother. Arika explained that it was inappropri-
ate for her daughter to be dating someone whom
Arika knew nothing about.
Family therapy highlighted Eve’s attempt to
differentiate from her family of origin by dating
someone from a different cultural background
and whom she had selected herself and how this
threatened the apparent closeness of her family.
Over a few months, Dan and Arika developed
acceptance regarding their daughter’s desire to
date, while Eve acknowledged her parents’ anx-
iety over her spending less time with them.
Therapy facilitated open and authentic expres-
sions within the family, which contributed to a
deeper and less defensive sense of unity.
Cross-References
▶ Marital Fusion in Couples
▶ Pseudohostility in Family Systems
▶ Psychodynamic Couple Therapy
▶ Separation-Individuation in Families
References
Goldenberg, I., & Goldenberg, H. (2012). Family therapy:
An overview (8th ed.). Belmont: Thomson Brooks/
Cole.
Wynne, L. (1961). The study of intrafamilial alignments
and splits in exploratory family therapy. In N. W.
Ackerman, F. L. Beatman, & S. N. Sherman (Eds.),
Exploring the base of family therapy (pp. 95–115).
New York: Family Services Association.
Wynne, L. C., & Singer, M. T. (1963). Thought disorder
and family relations of schizophrenics, I and II.
Archives of General Psychiatry, 9, 191–206.
Wynne, L. C., Ryckoff, I. M., Day, L., & Hirsch, S. I.
(1958). Pseudomutuality in the family relationships of
schizophrenics. Psychiatry, 21, 205–220.
Psychoanalytic Couple and Family Therapy
Psychoanalytic Couple and
Family Therapy
Adrian K. Perkel
Bellevue Therapy Centre, Cape Town, Western
Cape, South Africa
Synonyms
Attachment theory; Containment; Defenses;
Depth psychology; Diphasic sexuality; Drive the-
ory; Emergent systems; Freudian psychology;
Mental apparatus; Object relations; Oedipal
enactments; Phantasy and fantasy; Projective
identification; Psychoanalytic systems; Relational
theory; Repetition compulsion; Transference-
counter-transference; Unconscious gridlocks
Introduction
Psychoanalytic couple and family therapy chal-
lenges the clinician to take a conceptual journey
through the core underlying precepts, research, and
theory which lies at the foundation of the richly
textured and complex field of psychoanalytical
thinking. Without some of the foundational theory,
contemporary methods would make little sense to
an informed reader. Accordingly, some of the core
theory and concepts that underpin psychoanalysis as
it has evolved to be incorporated into modern theory
of emergent couple and family systems are provided
in this entry. This theoretical and evidentiary
buildup will hopefully provide the reader with an
exciting insight into how depth psychology of the
unconscious has evolved though millions of hours
of clinical interventions and theoretical development
to provide a deeply textured and rich account of why
couples attract and why more often than not they
find themselves in states of disarray and dissolution.
It also enables a deeper capacity for informed inter-
vention, since without adequate formulation, inter-
vention in the clinical space will potentially suffer
from limited efficacy.
Psychoanalytic Couple and Family Therapy
Theoretical Framework
“Was man nicht erfliegen kann, muss man
erhinken” (Freud 1920, p. 338) – (“what we can-
not reach flying, we must reach limping”), Freud
wrote at the end of Beyond the Pleasure Principle,
his work bringing a more complete model to his
observations of the mental apparatus. In this state-
ment, Freud acknowledged that his giant corpus
of work remained, like any work, still in progress.
Nonetheless, these tenets of a comprehensive
model of mind have provided the foundation for
a better grasp of the psychological nature of
attachment and coupling. Freud’s work on Beyond
the Pleasure Principle paved the way for a dual-
istic model of mind, in which the dialectical ten-
sion between Eros (the life drive and it’s
derivatives) and the death drive, Thanatos, and
its derivatives (whose aim is homeostasis even
when its effects are aggressive), interact with,
and tension against each other. The model
remained to some extent incomplete at two levels:
firstly, in the paradoxical nature of what the
aggressive drive represents functionally in its
aims rather than effects, as a possible mental rep-
resentative of the immune system, and secondly,
although Freud wrote extensively on broader
social systems, his descriptions of the interper-
sonal, the nature of how psyches interact with
each other in relationship life, was not fully
developed.
However, a proper grasp of relationship and
couple theory relies on insight into the structure
of the mental apparatus itself and how an intimate
relationship manages to accomplish the complex
paradox of being simultaneously “I” and “we.”
A most remarkable essence of Freud’s insight of
mind is that it is an embodied mind that mental
systems and structures emerge from simpler pro-
totypes in development. Both the structure of the
mental apparatus itself and its internal processes
and defenses emerge from underlying prototypi-
cal experiences through which the infant experi-
ences the world. While the erotogenic foci vary
through different stages of development, deter-
mining how mental defenses emerge upon these
2371
somatic foci, the principle of simpler prototypical
experiences giving rise to emergent mental struc-
tures forms the foundation of Freudian theory.
This concept of emergent mental systems is mul-
tifold, like consciousness itself which “emerges
instead of a memory trace” (Freud 1920, p. 25),
enabling ego functioning to form as the interface
between the unconscious reservoir of memory
traces and the external world, like the crust of a
bread “baked through” (Freud 1920, p. 25) by the
external impingements of the environment. The
ego, being “first and foremost a bodily ego”
(Freud 1923, p. 6), therefore emerges as the rep-
resentative of the interface between the uncon-
scious and the external environment. Freud
(1923) further makes the point that “the ego is
ultimately derived from bodily sensations, chiefly
from those springing from the surface of the body.
It may thus be regarded as a mental projection of
the surface of the body” (p. 26), providing the
foundational understanding for the mental appa-
ratus of the individual. These insights were not
limited to the individual, however, and in the later
years of his work, Freud dealt extensively with
social structures that themselves are made up of
simpler “individual” ones. Groups of people coa-
lesce, under the pressures of the life drive, like
single somatic cells dividing into greater and
greater unities to form systems with their own
autonomous functions. Essentially, the character- P
istics of simpler systems permeate through to
emergent ones that then form a complexity with
a life of their own. Once hatched, the chicken
cannot be put back into the egg despite carrying
some of the structural and energetic qualities of its
more primitive origins. Structures emerge and
develop their own autonomy and complexity,
which, while carrying the essence of earlier pro-
totypes, develop a relative autonomy that is no
longer reducible. The emergence of mental struc-
tures, such as the systems consciousness and
unconscious, which are universal mental systems
in human development, is also accompanied by
individual experiences that in the intricacies and
minutiae of development influence how defensive
systems and experiences, through erotogenic foci,
2372
are navigated. These mental processes may be
fluidly navigated or in the presence of traumata
lead to their fixation, the over-cathexis of mental
energy into that particular part of the infant’s
development. This bloating of defensive cathexis
becomes, over time, the foundation of personality
and the character of the “imagos” from which later
relationship life and these systems emerge. One of
the groundbreaking insights that Freud brought to
his theory of mind was the recognition of the
diphasic nature of psychosexuality, the recurrence
of underlying experience from the first 5 years of
development in adolescence, and the templates
that form early in life which influence later attach-
ments. One of the most significant and important
of these for adult attachment is that at around
3 years of age, the child enters a universal phase
of oedipal development, already under the influ-
ence of preceding personality development, dur-
ing which sexual object choice, based on the
fantasized dynamics between the child and their
opposite sex parent, is formed. The nuances of the
longings and fantasies of this triadic dynamic and
their meeting with reality combine inner represen-
tations of the child’s objects with their libidinal
strivings to form unconscious templates from
which later adult object choices emerge. While
libidinal strivings pressure the desire for attach-
ment and the child’s wish to desire or be desired
by the opposite sex parent, disappointments and
hurts may be defended against under the influence
of the aggressive drive, whose aim is the removal
of the source of pain and the restoration of stasis.
Injury, or its perception, may lead to rage or hate
being generated that must find some pathway
within the mental apparatus. The individual com-
bination of libidinal and aggressive strivings, and
their cathexis with internal object representations,
or imagos, creates the foundation for later adult
attachments. The psychoanalytic view would
strongly hold to the influence on these internal
representations, even if they are largely uncon-
scious, that through development form the tem-
plates of individual adult life and its attachments.
The force that drives these recreations relies on
what Freud termed the “repetition compulsion,” the
tendency to return to the familiar. This repetition is,
paradoxically, based on the aggressive drive, which
Psychoanalytic Couple and Family Therapy
aims for restoration of earlier (or older) states of
being/equilibrium. This process has a link to mem-
ory, which function of encoding experience facili-
tates survival, particularly because noxious events
become neuroanatomically encoded. This mecha-
nism may be viewed as the mental representative
of the immune system of the body, which aims to
encode noxious pathogens and mount an aggressive
response to them to restore somatic equilibrium.
Aggression may often have destructive effects but
its aim is benign – the restoration of the equilibrium
that pertained prior to the impingement. The repeti-
tion compulsion serves to return the individual to
earlier introjects, mental representations of early
objects that are meaningfully cathected with libidi-
nal and aggressive energies. These intrapsychic rep-
resentations form the foundation for later object
choice. Injuries of personal history may be defended
against, creating fixated instinctual and affective
energy that has become attached to ideation/ideas
representing internalization of parental objects.
These form the prototypes, or “imagos,” of later
object choices (to use Freud’s term for the prototype
of parental objects – Freud 1921, p. 171, see also,
1924, p. 423). Although authors such as Fisher
(1999) distinguish between objects that are “internal
to the self” (pp. 140–141), being both subjective
(they are my internal objects), and the internal
objects (unconscious) which constitute the self as a
totality and which provide the substance for couple
exchange, psychoanalytic consensus from Freud
onward would agree that adult choice of objects
will be deeply influenced by infantile ones. “These
new objects,” Freud (1912) argued, referring to
adult object choice, “will still be chosen on the
model (imago) of the infantile ones. . .” (p. 249).
The unconscious has the distinct capacity of being
filled with internal representations of past objects,
the “replacement of external by psychic reality”
(Freud 1915, p. 191). Unconscious objects are dom-
inated by parental representations because these
objects are cathected with enormous quantities of
raw emotional and instinctual energy, the result of
intense affects becoming associated with mental
representations of parental figures.
Building on these core concepts, many con-
temporary relationship theorists in the psychoan-
alytic paradigm, originally pioneered 65 years ago
Psychoanalytic Couple and Family Therapy
by clinicians in the precursor body to the modern
Tavistock Centre for Couple Relationships
(TCCR), have grappled with the mechanisms
through which these unconscious imagos, repre-
sentations infused with large quota of affect, can
be placed in the emergent system, or third psyche,
which represents the combining of two individual
psyches in an intimate embrace. The challenge
was to determine how the one-person psychology
of traditional Freudian psychoanalysis translates
into the two-person psychology of systems. While
there is large consensus that early childhood
objects form the foundation for later adult inti-
macy and attachment, and most theorists would
agree that there is an emergent system that is more
than the sum of its parts, as discussed earlier, the
mechanism of exchange in this interpsychic gap
remains contentious. This emergent space is one
in which unconscious projections, usually
repressed, can manifest to restore psychic com-
pletion of what Klein would call the “lost parts of
self.” The implication that “thought projectiles”
can metaphysically find their way into an inter-
personal space via projection or projective identi-
fication (the concept Klein 1946 introduced to
describe the forceful intrusion into another per-
son’s mind) has puzzled clinicians. However, clin-
ical evidence shows consistently, in both the
transference relationship of psychotherapy and
in intimate coupling, that people seek others who
offer a repository for their repressed unconscious
parts, in a mutual interpsychic exchange. This
mechanism is assisted by the concept of uncon-
scious phantasy, a system which structures the
couple system and partner choice and enables
shared unconscious phantasies to thrive, through
being enacted and/or defended against. The flesh
is under the command, as it were, of such phan-
tasy. These phantasies trend toward congruence
and complementarity in the early stages of mating
but lead to conflict as they change and the sym-
metry shifts of the unconscious phantasy of both
what a couple is and individual projections into
that imago. Shared unconscious phantasy has
many layers which act interpersonally through
the intrapsychic matrix. Shared defenses and
shared anxieties, as well as shared injuries that
are defended against, inhabit this projective
2373
matrix. This interpersonal psyche carries elements
of the transferring internal object representations
and hence also recreates these in a therapeutic
space in which the intervention of the therapist
can produce transference and counter-
transference experience, useful in the process of
“working through.”
Attraction has the characteristic that as the old
adage goes, “opposites attract,” at least on the
surface. This essentially refers to the outer
defenses that couples who exhibit opposite defen-
sive systems will likely attract. The sadist, for
example, would likely be attracted to someone
masochistic for a fit to be possible. However, the
“opposites attract” concept represents the mani-
festation of the defenses used against a deeper
underlying conflict or anxiety, and in this respect
it appears that similar injuries accompanied by
different defenses form one of the foundational
pillars of attraction. As a relationship evolves, it
appears that a general rule of relationship dynam-
ics is that what initially attracts later repels. As
underlying elements that remain unintegrated in
the personality find their form through the
interpsychic lacuna, the manifestation of exposure
to unwanted parts of self becomes increasingly
visible in the partner and, rather than being com-
plementary and compensatory as in the initial
attraction, becomes the source of discontent.
That is, the underlying projective elements start P
to flounder under the pressures of development
and the inherent tendency of any system to want to
return to stasis under the pressures of the death
drive and its aggressive derivatives. The couple
system itself suffers the pressure of homeostasis, a
return to a state of nonbeing, as it were, against
which the libidinal and creative elements must
compete. This emergent interpsychic system
becomes a living entity with its own developmen-
tal pressures, not dissimilar to the developmental
stages that Margaret Mahler refers to for the indi-
vidual infant, from an initial autistic merger to a
gradual separation and individuation.
Part of the natural fulfillment of the emergent
couple, under the strong pressures of the life drive
and libidinal energy, is a creative and procreative
one, to produce offspring through which an exis-
tential and psychological fulfillment and elevation
2374
can be achieved. This accomplishment, the pinna-
cle of the (pro)creative process, is unfortunately
most often also the source of marital conflict and
breakdown. Pressures on the mother, through the
psychically boundary-less state with her infant,
leave her exposed to provocations and demands
against which she has no filter in her infant’s
(parasitic) relationship with her. States of disequi-
librium do, by definition, provoke the immune
response of the mind that is aggression, which,
as Winnicott points out, cannot be enacted against
the infant. Normal ambivalence and hostility,
even hate, may tend to build up and be introjected
(hence postpartum depression) or displaced into
what has been termed the “phallic container,” that
is, directed at the father as the source of frustra-
tion. Marital breakdown through narcissistic
injury may well follow these internal assaults on
the couple, since, as Freud suggested, neurotic
acts of revenge can be directed at the wrong peo-
ple since “punishment must be exacted, even
when it does not fall upon the guilty” (Freud
1923, p. 45).
How projections of unconscious parts of the
self may find their way into their partner, or into a
third emergent entity, may appear somewhat
metaphysical. Freud made the point that internal
“unpleasure” or unwanted parts that are repressed
can be treated by the psyche as if they were acting
not from the inside but from the outside, as if parts
of the ego do not belong to oneself and are instead
ascribed to the external world. In the process of
coupling, these parts are projected into a partner
willing to unconsciously take them on or through
projective identification, take them in, not so
much to be rid of them, like a concrete object,
but to find psychic completion through this
exchange. Projective and introjective identifica-
tions form, thereby, a mutual psychic exchange.
But transference phenomena, through projections
and projective identification, have been well
documented in the psychoanalytic process as
interpersonal dynamics invariably contain ele-
ments of ideation and affect associated with inter-
nal unconscious processes and the internal
representation of historical objects. Old traumas,
hurts, disappointments, and simply the texture of
internal imagos form the templates through which
Psychoanalytic Couple and Family Therapy
later objects are experienced. Under the influence
of the repetition compulsion, such experiences
seek reenactment through later attachments,
beginning under the influence of puberty and the
onset of the second wave of psychosexuality. The
first 5 years of development will have been turned
latent during the latency phase of development,
only to recur in adolescence. Sexual and aggres-
sive drives, tensioned against each other and inter-
weaving with each other, foreground into devel-
opment. Anxieties and envies that may have been
part of oedipal development can, depending on
their earlier resolution, lead to a complicated ten-
sion between what Freud referred to as the affec-
tional versus sensual currents. It must be noted
that one of the important overlays of both devel-
opment and the couple remains the different expe-
riences for men and women, built on a
fundamental tenet of psychoanalytical theory,
that the mind is an embodied mind and that psy-
chic development is rooted in and routed through
somatic experience. Given the different experi-
ences of embodiment for boys and girls indicates
that psychic development will be subject to these
filters. The manner in which men and women are
affected through life by these layers leads to com-
plex interplays between sensual and affectional
currents – those subject to emotional versus erotic
elements. For men, repression of oedipal associa-
tions remains crucial for a healthy erotic life to be
possible, idealization and devaluation tendencies
being part of their Madonna-whore split, in the
survival of a free-flowing erotic life. For women,
Freud brings out the more accessible oedipal asso-
ciation which enables both a greater access to their
bisexuality and a forbidden component that seems
to thrive within the erotic life of women, leading
to a dad-cad, or good father, versus bad-lad split,
in which the erotic charge in attraction may be
affected by the advent of the good guy who makes
a good father. The point of these distinctions is to
recognize that embodiment leads to significantly
different mental life and sexual experience that
affects how the marital dyad will be constructed.
Political correctness aside, psychoanalysis holds
that exchanges around embodiment needs impli-
cate both anatomy and neurobiology in the psy-
chic emergence of the marital dyad. Hurts that
Psychoanalytic Couple and Family Therapy
derive from a natural waning of sexual ascen-
dance over time itself bring narcissistic injury to
the fore, and such developmental pressures create
hurts that trigger an immune response – that is,
anger and hate. While its aim is the restoration of
equilibrium pertaining to the self, the effects can
emerge in malignant forms within and for the
couple.
The couple is subject to all the intrinsic and
extrinsic vagaries indicated above. Freudian and
neo-Freudian psychoanalysts, including object-
relations theorists, agree that external objects are
subject to the projections of internal objects.
Freud’s later works on social functioning were
supplemented by later neo-Freudians such as
Klein, Winnicott, and the intersubjectivists like
Kohut and Fairburn, who tried to address the
minutiae of the dynamics that make up the inter-
personal third. The concept of a “relational third”
has become integrated into relationship theory
and, with it, the understanding that projective
exchanges can lead to projective gridlocks. Cou-
ples become quagmired in projective exchanges
which, because of their unconscious origins, grid-
lock the system into malignant conflicts as the
ascendance of the death drive, replacing the prom-
inence of the Eros in the early stages of the couple
entity, facilitates the breakdown of the sense of
completion that derives from the engagements
with repressed/lost parts of self through the
other. This compensatory exchange falters as
development creates a trend toward homeostasis
again and the projective exchange takes on the
appearance of the unwanted. What initially
attracted, it might be formulated as a law of cou-
pling, later repels. The relatively autonomous
functioning of the emergent system does not eas-
ily lend itself to an integration of projected parts,
and invariably this threatens the integrity of the
couple system.
Family systems, and subsystems, emerge from
this dyadic system and also give rise to autono-
mous psychological systems that are more than
the sum of their parts. Freud’s insight into how
innate drives as well as psychological systems
emerge from their underlying biological and
somatic foundations indicates that it is not simply
a reductionism of “anatomy is destiny” but that
2375
the nuances of somatic experience form the con-
duit through which higher mental structures can
form and experience both inner and outer life.
Defenses and personality emerge on this founda-
tion and in turn give rise to psychological systems
in which minds merge. This emergent entity is
built not only on somatic experience but on pro-
jections of repressed and unresolved inner uncon-
scious experience, all of which contain
subjectivity in such experience. There is an “I”
doing the perceiving and experiencing, even when
this “I” is deeply affected by unconscious pro-
cesses and memories. These fixations form the
material for an imperative to repeat the familiar
in an attempt to resolve them and find compensa-
tion for the incompletion that derives from the
lack of psychological integration. Bion’s notion
of the container-contained provides some theoret-
ical assistance for Klein’s (1946) view that pro-
jections and projective identification, in which
unconscious phantasies form the basis of projec-
tive processes between the infant and its mother,
are held in a mental space in which they are kept
alive and psychologically metabolized.
The containment of projective elements in a
couple relationship is not necessarily for therapeu-
tic reasons, but this mechanism does provide the
prototype for the therapeutic processes and its
transference phenomena. Intervention with the
struggling couple depends, in the psychoanalytic P
view, on providing a container in which projective
processes can be identified within the couple
dynamic and in which insight into unconscious
gridlocks can be explored – gridlocks that have
been described as “mutual projective identifica-
tion” (Fisher, p. 139). While projective processes
are the foundation of intimacy, these may repre-
sent or evolve to represent malignant forms of
relating. In these, a pattern of disturbing
interlocking retaliatory impulses in response to
intrusive projections locks the couple into
destructive emotional enactments. As attachment
theorists would identify, affect dysregulation pre-
dominates in these gridlocked exchanges, corrod-
ing the well-being and sense of vitality that comes
from a harmonious, shared system of projective
exchange. Restoring affect tone and regulation
becomes a vital therapeutic component. But
2376
more than that, the therapeutic container provides,
like the mother to her infant, a space that provides
a metabolic function, through which affects can be
expressed and metabolized. Part of this is accom-
plished through creation of a safe predictable
frame in which thinking is facilitated and enabled.
The couple therapy container is also subject to
transference phenomena, or a “transference
field,” in which projections from individual
patients and the couple are enacted according to
the repetition compulsion. Rather than engaging
in the projective gridlock through enactment, the
therapist is able to identify and name these pro-
cesses, subjecting compulsive elements to scru-
tiny, nonreactive interpretations, and a “working
through.” Linking early experience and its psy-
chic matrix to current enactments in the transfer-
ence field becomes the therapeutic sine qua non of
the psychoanalytic approach. Mourning of losses
and lost parts (that is, repressed) creates the
ground for reintegration of these “lost” parts of
the self-alienated in projective identification. The
emergent system within the transference relation-
ship with the therapist enables these lost parts to
reemerge into consciousness, dealing with the
original traumas that led to their fixation. Integra-
tion gradually replaces evacuation, intended orig-
inally as a maneuver for psychic preservation
through, according to Klein, evacuation of parts
of inner experience that in early life may have felt
poisonous to the infant. Their evacuation into the
mother, and, later, into the intimate other in the
couple, provides a relief from this internal threat.
Invariably, these processes are accompanied by
internal hostility and aggression that disrupt equi-
librium to such a threatening extent and that
expelling these into the (m)other may actually be
adaptive in these early stages of experience.
Enacted though adult relationships, however,
these projective processes often become maladap-
tive as the compulsive elements to their repetitive
nature create again and again problems in relating
where the unconscious elements rule from the
history and do not allow growth and elasticity in
emotional challenges.
Much of the psychoanalytic literature points to
the difficulty in resolution, while projective phe-
nomena remain deeply unconscious and active in
Psychoanalytic Couple and Family Therapy
the couple gridlock. Of course, loss may also be
reality based, as in the narcissistic injury of having
a child, the attacks on the mother and her unfil-
tered absorption of these, as well as the demotion
of the husband to an outsider to the intimacy of the
mother-infant dyad, and the displacement onto
him of unmanageable hostile affects by the
mother, may lead to states of rage and hate borne
of the disequilibrium created by these intrusions.
No matter how loved and wanted, the disequilib-
rium of childbirth and child-rearing often shatters
the peace of the couple intimacy and, through this
tectonic shift, exposes the underlying parts of the
self that remain unintegrated, even when initially
compensated for through the engagement with the
other. In the landmark text “Marital Tensions,”
Dicks (1967) theorized how the engagements of
psychic structures affect each other, interacting at
both conscious and unconscious levels through
projective processes and projective identification
to form a “joint marital personality.” This form of
an emergent third has a different quality, a system
that is different from and greater than the individ-
ual personalities from which it emerges. In this
exchange, individuals regain lost parts of the self
both in and through the other. This wonderful
sense of completion, of sensual and affective cur-
rents combining in a projective exchange, leads to
the pinnacle experience of being in love. How-
ever, as the unintegrated projections are not
resolved in this exchange means that a therapeutic
unlocking of the unconscious gridlock may
enable growth and developmental traction to be
regained where it has become fixated. The exten-
sion of this projective process within a broader
family system may be normal where projective
processes rotate within family systems and
between members. Sometimes, however, one
member, the “index patient,” carries the
disavowed parts of the family system or of the
other members and carries these disavowed and
unconscious projections in a fixed and fixated
way, identifying with them through projective
identification, which renders the system patholog-
ical. Often missed in systems theory but which
psychoanalytic theory of the system recognizes is
that sometimes this projective process is reversed.
A child can become disturbed through birthing or
Psychoanalytic Couple and Family Therapy
postpartum challenges, often medical ones that
impact the developing mind negatively. These
impingements, even when originating from inside
the infant’s body (such as reflux, colic, and so on),
may create mental disturbance based on the mind
emerging through a challenged somatic system.
Such a dysregulated infant can forcibly project
their dysregulation into the mother, couple, and
family, turning these subsystems into the index
patient. The couple or family has to absorb these
intrusive and dysregulating affects and projec-
tions. At times, these may be beyond the capacity
of the couple or family system, inducing distur-
bances that take a psychological toll on the marital
dyad, siblings, and the family as a whole.
Psychoanalytic intervention to unfix, as it
were, projective gridlocks requires attention to
various components. These include the complex
and multilayered interplay between the two peo-
ple that make up the couple psyche, their internal
object relations, unconscious phantasies, con-
flicts, anxieties, and defenses and how these inter-
act. Addressing these components requires
attention to a holding, predictable container in
which projective and transference phenomena
can be processed. This frame enables the under-
lying unconscious material to surface in the
knowledge that it can be safely expressed and
processed. The attitude of impartiality in the ther-
apist creates an environment of acceptance with-
out judgment within which the darkest material
can be accessed. Interpretation is a primary tool in
which links can be made through therapist obser-
vation and unconscious material brought into con-
sciousness through insight and interpretation.
Transference and counter-transference attunement
is at the core of developing insights and working
through unconscious processes, as affect is
tracked and emotional expression contained and
metabolized. Understanding the initial attraction
remains an important element of diagnosis, for-
mulation, and intervention, since it is this that
indicates both conscious and unconscious ele-
ments that enabled the psychic mix of mutual
projection that created the couple fit. In this way,
early object imagos and phantasies can be brought
into awareness. However, already in his early
work on hysteria, Breuer and Freud (1893)
2377
recognized that insight without the abreactive pro-
cess would be limited in its healing efficacy.
While the unconscious is a reservoir of ideation,
the “working through” of underlying affects is
crucial in proper resolution, and so tracking of
underlying affects and facilitating their catharsis
and connection are important parts of the psycho-
analytic process. This is particularly so with
aggression – which aims to restore equilibrium
from the impingements of life that hurt and
threaten it and which often create, through the
individual’s perception, narcissistic injuries,
hurts, and retaliation. But aggression and its deriv-
atives (cold or hot forms such as hate and rage), in
reacting to associations from unconscious history,
may intend to restore equilibrium but can also be
destructive in its effects and often impact the
couple negatively. The therapeutic space can
allow links to be made through interpretation
while controlling the abreactive process and
release of emotion and affect. Through such inte-
gration, consciousness, and relief from emotional
fixations, triggers are removed from the fixated
patterns, enabling the couple to find healthier,
integrated ways of relating. Enabling growth in
this way facilitates the couple’s resuming a devel-
opment path of growth. It may be noted that much
of what is involved in both coupling and its strug-
gles is narcissism, the internally cohering aspect
of the self in which identity and subjectivity, the “I P
am” experience, can emerge. When under threat,
hurt in some way, this self-integrity is threatened,
and narcissistic retaliation is likely to manifest
under the protective watch of the aggressive
drive. Hence, cycles of aggressive retaliation
emerge whenever hurt presents itself through sub-
jective filters, leading to malignant cycles of con-
flict in the couple system. The aim of this
destructiveness is actually benign, the restoration
of an earlier state of equilibrium that existed prior
to the impingement or hurt. But its effects are
often malignant, setting up cycles of retaliation
that quagmires the couple into mutual projective
gridlock in which the system is driven toward its
own state of stasis, or as with the aim of the death
drive, according to Freud, a state of nonbeing that
existed prior to emergent coupling under the pres-
sures of the life drive or Eros. The aim of the
2378
therapist is to facilitate a mutual disengagement of
these projective cycles and retaliatory destructive-
ness so that the couple can, ultimately, find a
normal and healthy path toward timely quies-
cence. This quest for the couple to navigate its
way through the vicissitudes of internal and exter-
nal life, along a developmental path that survives
these impingements and challenges, aims to main-
tain a creative elasticity under the influence of
libidinal elements while keeping the aggressive
ones in check. This becomes, ultimately, the
often long, complicated, and circuitous path of
psychotherapy with a couple. The psychoanalytic
view of intervention is a humble one, denying the
possibility of magical or quick solutions to prob-
lems in the couple or family. The outcome can
never be idealized, for an end state of happiness or
health does not seem to exist in either physical or
mental life, but it can assist in a normal path
toward an eventual, natural quiescent state of
health and warmth where love remains ascendant
and hate sufficiently integrated to keep the couple
out of a state of quagmire and projective gridlock.
The relationship can be potentially containing for
the couple, providing an opportunity for working
through and development. If the projective system
is flexible enough, parts of the self are not lost, but
held by the other and within the safety of the
couple space. Over time projected parts can be,
at least to some extent, re-introjected and hence
integrated. Ideally, individual growth can con-
tinue in the context of this couple container, and
development replaces defense where the latter has
become dominant and stagnant. The therapeutic
container, with its capacity to enable a “thinking
space,” in which, to borrow Bion’s concept, beta
elements can be transformed into alpha ones, the
chaotic un-metabolized into coherent thinking,
enables coherence to form out of unconscious
emotional chaos, facilitating resolution that
unbinds fixated ideation and affect, leading to
renewed growth and development. The compul-
sion to repeat can be compelling, fueled by real-
life provocation. But unlike the marital container,
the therapeutic container can metabolize the inter-
face between transference projection and reality,
enabling enactments to find different outcomes
from previously. If such containment is affective,
Psychoanalytic Couple and Family Therapy
there is a greater likelihood that pattern repetitions
will tilt toward being active and constructive. The
ascendance of development remerges in place of
the regressive pull of defense.
To paraphrase Freud, if psychoanalytic inter-
vention for couples and families cannot reach this
noble goal flying, it can at least, in humility, reach
it limping.
Case Example
Brett (47) and Sandra (43) presented for couple
therapy approximately 18 years into their mar-
riage in a state of crisis and overload. Severe stress
seemed to disable their ability to relate. Sandra
was struggling to contain her heightened emo-
tional arousal and feelings of being overwhelmed.
It was as if she was in a state of perpetual break-
down internally but masked externally by her
persona of a super-coping housewife and mother
to her two children. The older daughter, high
functioning, then in late adolescence, presented
with a tendency to introject her aggression and
hence suffered depression for which she was on
medication and had been hospitalized. The youn-
gest child, who was then an early pubescent, had
been born with a genetic abnormality, a syndrome
that entirely consumed the family’s emotional
resources and especially that of the mother, who
devoted virtually all her time and energy to keep-
ing the sickly child alive. For the first 4–5 years of
her life, the child needed constant attention and
interventions from numerous medical specialists
and beyond this period constant emotional care
and monitoring.
Sandra was initially attracted to Brett’s appar-
ent calmness, even-keeled and solid temperament
and apparent lack of any aggressive tendencies.
He, in turn, found her energy and emotional sen-
sitivity and intensity intriguing and energizing.
She felt safe and secure in his presence. He felt
energized and alive in hers, as if the emptiness in
his life vaporized in her presence. Soon after
marriage, however, this couple found themselves
consumed by a life hijacked by their newly born
special-needs child. Their dedication significantly
tested their resources – sleep deprivation, high
anxiety, serious family disruption, raw fear of
her dying, and a dedication consumed them.
Psychoanalytic Couple and Family Therapy
However, the flip side of their parental heroism
was a severe testing and breakdown of their
relationship.
Underpinning these challenges, however, like
all couples, was that what initially attracted them
later became a source of breakdown. Sandra came
from a family with its own psychological prob-
lems, characterized by chaos, volatility, and neg-
ativity. She developed highly attuned radar,
bordering on paranoia, as a protection against
her father’s violent and unpredictable nature, as
well as strong reaction formations – anal defenses
fixated due to her father’s harsh intolerance of any
aggressive displays during her anal phase and
subsequent years. This also complicated her oedi-
pal feelings to him and her ambivalent relation-
ship to what she felt was her unprotecting mother.
Sandra’s martyrdom belied her deeper volca-
nic destructive inner world that phantasized
about annihilation. Ambivalence and a tendency
to desexualize, a collateral effect of her tendency
to repress primary drives, seemed to become
familiar repetitions with her later attachments.
With the advent of her troubled child, the respite
and safety she had found in her unreactive if
emotionally distant husband, and their shared
defenses against affect and emotion, unraveled.
The repressed rage she carried from her child-
hood threatened to emerge as her defenses
became increasingly overwhelmed by the chal-
lenges and demands of her child. Her husband’s
soft retreat into his familiar affectless state, more
accurately his passive-aggressive state, so attrac-
tive to her initially, added fuel to the fire and
stoked violent unconscious impulses of rage
and murder, provoked by the child’s incessant
demands but in her mind originating from her
neglectful husband.
Brett’s own family of origin tended to cut off
from emotional problems, and he felt that he was
never really “held in mind” by his parents. His
injury of being unseen led to his creating for
himself a retreat into being the outsider, a dynamic
he repeated in their relationship and family. It is
noteworthy that their initial defenses against
aggressive impulses, both in the form of reaction
formations, through martyrdom and passive
aggression, respectively, defended them against
2379
their common early experiences of mis-
attunement and the narcissistic injuries of neglect.
But while initially adaptive, these aggressive pro-
mptings struggled to find safe expression in adult-
hood, especially for Sandra, whose provocations
from her maternal role accumulated, as her normal
capacity to metabolize her rage remained
impaired. As the therapy progressed, she feared
at times that her defenses might succumb to the
breakthrough of her rage, so intense and frighten-
ing that she imagined it could actually “kill” Brett
(and myself in the transference when I failed to
understand her) if it were released.
Initially, connecting this rage to the constant
provocations of her children was impossible – a
link fully repressed in the early stages of the work.
Sandra “loved” her handicapped child and pro-
tected her with utmost devotion which rendered
unconscious her murderous hate. What could not
be defended against was displaced into her hus-
band, who remained removed and relatively unaf-
fected by the emotional barrages that hammered
their way through the household. He worked hard,
and seldom retaliated at Sandra’s virulent and
constant attacks, though reportedly became short
and irritable around the children. While she had
initially found such comfort in his stable and
constant emotional states, she now felt increas-
ingly provoked by the same qualities, his non-
reactive capacity for withdrawal, often causing P
ructions to escalate in the family constellation.
He soldiered on, always diligently providing for
the family and uncomplaining about the multiple
medical expenses associated with the daughter’s
demands, instead displacing his hatred at both his
wife and their daughter into sport. In this context,
Sandra would sometimes feel murderous to him –
especially when she experienced him as “non-
human,” as she called him, and “not present” in
the family.
This case represents a number of the concepts
discussed above: early infantile and childhood
experiences layered to form internal representa-
tions repeating later in life; a psychological
exchange of unconscious parts of self-split-off
and projected outward into each other in an
interpsychic exchange; similar childhood injuries
but different mechanisms of defense – especially
2380
her increasingly active and highly expressed hos-
tility and his increasing passive aggression in
response to narcissistic injury; and the impact of
normal developmental challenges, such as having
a baby, that provokes disequilibrium in the mother
without a mechanism of retaliation to the source.
Instead, the marriage became the casualty of both
intrapsychic and developmental assaults and
displacements.
In this case, separation from the child and any
negative feelings toward her had been unthinkable
through the early years. The tragic and tortured
state of their little girl evoked tremendous sympa-
thy and sadness, but was also intensely provoca-
tive and frustrating. Her demands could evoke
murderous fury, albeit at an unconscious level,
that flowed into the mother’s somatic and psycho-
logical saturation and into her marriage. Despite
the intensity of their conflicts, their psychological
fit was well designed given their histories, person-
alities, and circumstances. Aggression in her his-
tory had been negative – a volatile father and a
family “cocktail of violence” leaving her with a
deep fear of both external aggression and her own
internal retaliatory impulses.
Since no part of the psychological system can
be simply dispensed with, she began to repress
her own aggressive responses, projecting them
into the environment in the form of paranoid
ideation. In addition to her activated and satu-
rated state, they could find no outlet except
through utilizing her husband as an auxiliary
container and a repository for her violent and
fearsome affects who absorbed them through
his ability to remain passive and unreactive.
Although this further infuriated her and failed
to facilitate the metabolizing of her unrelenting
assaults from her internal and external world, it
did assist to maintain a form of pathological
homeostasis and gridlock that kept the family
constellation from disintegrating.
Treatment was long term, spanning several
years of weekly intervention, which both enabled
containment of uncontainable and threatening
feelings, normalized the mother’s hostility to her
children, and eased her defensive reaction forma-
tions aimed at neutralizing unmanageable affects.
Deeper work was also done, aimed at integrating
Psychoanalytic Couple and Family Therapy
both partners’ internal object representations and
defensive maneuvers, through making conscious
that which governed from the unconscious. By
loosening the compulsive nature of their repetitive
patterns, conflicts gradually eased and emotional
states normalized. The couple remained married
in a more balanced state as interpretations facili-
tated their ability to “work through” that which
had remained repressed and defended against
throughout much of their lives.
Cross-References
▶ Object Relations Couple Therapy
▶ Object Relations Family Therapy
▶ Psychodynamic Couple Therapy
References
Breuer, J., & Freud, S. (1893). Studies on hysteria.
London: Penguin, 1974.
Dicks, H. (1967). Marital tensions. Clinical studies
towards a theory of interaction. London: Routledge.
Fisher, J. V. (1999). The uninvited guest: Emerging from
narcissism to marriage. London: Karnac.
Freud, S. (1912). On the universal tendency to debasement
in the sphere of love (Contributions to the psychology
of love II). In J. Strachey (Ed. and Trans.), The Stan-
dard Edition of the Complete Psychological Works of
Sigmund Freud (Vol. 11, pp. 177–190). London: The
Hogarth Press.
Freud, S. (1915). The unconscious. In J. Strachey (Ed.), On
metapsychology. The Penguin Library, 11. London:
Penguin, 1991.
Freud, S. (1920). Beyond the pleasure principle. In
J. Strachey (Ed. and Trans.), The Standard Edition of
the Complete Psychological Works of Sigmund Freud
(Vol. 18, pp. 7–64). London: The Hogarth Press.
Freud, S. (1921). Group psychology and the analysis of the
ego. In J. Strachey (Ed. and Trans.), The Standard
Edition of the Complete Psychological Works of
Sigmund Freud (Vol. 18, pp. 67–143). London: The
Hogarth Press.
Freud, S. (1923). The ego and the id. In J. Strachey
(Ed. and Trans.), The Standard Edition of the Complete
Psychological Works of Sigmund Freud (Vol.
19, pp. 1–66). London: The Hogarth Press.
Freud, S. (1924). The economic problem of masochism. In
J. Strachey (Ed.), On metapsychology. The Penguin
Library, 11. London. 1991.
Klein, M. (1946). Notes on some schizoid mechanisms.
International Journal of Psychoanalysis, 27, 99–110.
Psychodrama in Family Therapy
Psychodrama in Family
Therapy
Diana J. Semmelhack
Midwestern University, Downers Grove, IL, USA
Synonyms
Family sculpturing; J. Moreno; Psychodrama
Introduction
Several writers have suggested that Jacob
Moreno’s work in psychodrama has not received
the recognition that it deserves for contributing to
systems and family therapy (Perrot 1986).
Compernolle (1981) states that, “Moreno is. . . a
much overlooked pioneer in the field of family
therapy” (p. 1). Many family therapists such as
Nichols (1984) and Satir (1964) perceive there to
be a direct relationship between psychodrama and
family therapy. According to Perrot (1986), both
family therapy and psychodrama recognize the
reality and significance of a person’s social con-
text. Both therapy systems have as their goal the
changing of interpersonal relationships in a
system.
Psychodrama was developed by Jacob Moreno
more than 80 years ago (Siu Fung Chung 2013).
Psychodrama is considered to be a form of therapy
that brings about positive change in its partici-
pants through dramatization. Psychodrama offers
a creative way for an individual or group to
explore and solve personal problems much like
family therapy offers innovative ways for families
to explore their problems. In Psychodrama, clients
use spontaneous dramatization, role playing, and
dramatic self-presentation to investigate and gain
insight into their lives. Psychodrama includes ele-
ments of theatre often conducted on a stage where
props can be used. A psychodrama therapy group,
under the direction of a licensed psychodramatist,
reenacts real-life, past situations (or inner mental
processes) by acting them out in present time –
similarly to family therapy.
2381
Participants then have the opportunity to evalu-
ate their behavior, reflect on how the past incident is
getting played out in the present, and more deeply
understand particular situations in their lives.
Theoretical Framework
Moreno’s psychodrama, similar to family ther-
apy, uses the concept of the “social atom” which
refers to the smallest meaningful formulations
of social relationships to an individual (Perrott
1986). “Collective social atoms comprise link-
ages that one has through personal or associa-
tive connection with a number of formal or
informal structures within society” [including
the family] (Guldner 1983, p. 44). In other
words, those individuals who surround the per-
son in their daily life (including their family)
consist of their cast or collective social atom
(Guldner 1983). Both family therapy and psy-
chodrama focus on reformulating interpersonal
systems so they function most effectively
(by working with the social and collective social
atom of the individual). The modality’s focus on
the cathartic nature of the reenactment of expe-
rience gives it psychodynamic leanings.
P
Rational for the Strategy or Intervention
Like the family therapist who enters the family,
the drama therapist (joins the group as the psy-
chodrama director) who is positively connected
with most group members and therefore creates
or modifies the group’s structure through “dra-
matic” reenactments on the stage that hopefully
lead to individual transformations – changes in
social relationships. During the action phase of
psychodrama, the intentions and actions of the
psychodrama “director” parallel those of the
family therapist. Like the family therapist, the
psychodrama “director” identifies problems and
formulates hypotheses about what actions are
required within the social/collective atoms
being explored to facilitate change in the
system.
2382
Description of Strategy or Intervention
Specifically, Duhl et al. (1973) point to family
sculpturing and choreography to be clearly
related to Moreno’s work. Family sculpting is
the visual representation, as envisioned by one
individual person (referred to as the identified
client), of their present family situation as they
experience it. KANTOR and Lahk Distance and
other spatial factors are used to sculpt a three-
dimensional representation of the family as the
client arranges and places members in relation
to their own unique position within the family
system. The arrangement and placement of
others will reveal emotional themes, alliances,
conflicts, distancing and alienation, as well as
other valuable assessment information. “The
family structure can quickly and dramatically
become visible” (Hartman and Laird, p. 281)
through the use of family sculpting (Duhl
et al. 1973).
In family choreography (another technique in
alignment with drama therapy), arrangements go
beyond initial sculpting; family members are
asked to position themselves as to how they see
the family and then to show how they would like
the family situation to be. Family members may
be asked to reenact a family scene and possibly
resculpture it to a preferred scenario. This tech-
nique can help a stuck family and create a lively
situation in which spontaneity and change are
possible.
Case Example
An example of a psychodrama technique that
(as stated earlier) is used in family therapy is
sculpturing. A case study highlighting this tech-
nique follows. In this example, a family is in
therapy with a female adolescent who is acting
out. The father, mother, older brother, and
female adolescent are part of the session. The
adolescent girl is triangulated between a father
who is absent much of the time for business and
a controlling mother who takes out her rage
towards her husband for his multiple absences
by being overcontrolling of the adolescent girl.
Psychodrama in Family Therapy
In turn, the adolescent resists/acts out against
the controlling mother by being frequently tru-
ant from school. The therapist might use family
sculpturing by asking the adolescent girl to
physically arrange the family members to show
how she perceives her family in the here and
now. The girl places her father on the other side
of the room near the door with his back toward
the family (to emphasize his physical absence
from the family) and her brother between her
and her mother who are in an extremely close
arrangement (facing each other). After
discussing this family arrangement and its
seemly imbalance, the therapist may ask the
adolescent girl to place the members of the fam-
ily in a more idyllic arrangement. In this case,
the girl might place her father and mother closer
together (facing each other) with her and her
brother next to each other facing the parents.
All members of the family appear to be an
appropriate distance from each other. This dra-
matization of the family through sculpturing
provides a picture of the pathology as well as a
way of reaching a more homogeneous arrange-
ment which could result in a reduction in
symptoms.
Conclusion
Moreno actually proposed family therapy in his
earlier works without naming it that Perrot (1986).
When discussing an approach to a marital prob-
lem in 1970, he said, “The more I went on with the
work, the more I realized that I was not treating
one person or the other, but an ‘interpersonal,’
relationship, of what one might call an interper-
sonal neurosis;” (p. 236). He also went on to talk
about triangulation in his work when describing
clinical dynamics with couples and families much
as a family therapist would.
Compermolle (1981) suggested two hypothe-
ses for why Moreno did not receive the recogni-
tion he deserved in the field of family and marital
therapy: (1) he often alienated professional audi-
ences with his sometimes provocative style and
(2) he published almost exclusively in a journal he
started titled The Journal of Sociometry. Whatever
Psychodynamic Couple Therapy
the reason, there is solid evidence that he has been
overlooked as an important inspiration for the
field of family therapy.
Cross-References
▶ Sculpting in Couple and Family Therapy
References
Compernolle, T. (1981). J.L. Moreno: An unrecognized pio-
neer of family therapy. Family Process, 20, 331–335.
Duhl, F., Kantor, D., & Duhl, B. (1973). Learning, space,
and action in family therapy: A primer of sculpture. In
D. A. Bloch (Ed.), Techniques of family therapy
(pp. 47–63). New York: Grune & Stratton.
Guldner, C. A. (1983). Structuring and staging: A comparison
of Minuchin’s structural family therapy and Moreno’s
psychodramatic theory. The Journal of Group Psycho-
therapy Psychodrama and Sociometry, 35(4), 141–154.
Kantor, D., & Lehr, W. (1975). Inside the family. San
Francisco: Jossey-Bass.
Moreno, J. L. (1970). Psychodrama (Vol. I). Beacon:
Beacon House.
Nichols, M.P. (1984). Family therapy: Concepts and
methods. New York: Garden Press.
Perrot, L. (1986). Using psychodramatic techniques in struc-
tural family therapy. Contemporary Family Therapy, 8,
279–290.
Satir, V. (1964). Conjoint family therapy. Palo Alto:
Science and Behavior Books.
Siu Fung Chung, Y. (2013). A review of psychodrama and
group process. International Journal of Social Work
and Human Services Practice, 2, 105–114.
Psychodynamic Couple
Therapy
Arthur C. Nielsen
The Family Institute at Northwestern University,
Chicago, IL, USA
Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA
The Chicago Institute for Psychoanalysis,
Chicago, IL, USA
Name of Intervention
Psychodynamic couple therapy
2383
Introduction
This essay reviews what I believe are the most
important psychodynamic contributions to the
field of couple therapy. It is a whirlwind tour
condensing material covered in six chapters and
more than 100 pages in my earlier book (Nielsen
2016), which, itself, distills the work of many
clinicians and researchers. I will discuss four cen-
tral psychoanalytic domains – underlying issues,
divergent subjective experiences, transference
hopes and fears, and self and partner acceptance –
and apply them to couple problems and therapy.
The additional, important, topic of projective
identification as applied to couple therapy is cov-
ered in a separate article in this encyclopedia.
Specific schools of psychoanalysis – modern
ego psychology, object relations theory, self-
psychology, relational psychoanalysis,
mentalization, or attachment-based treatment –
have genuine differences and emphases, but this
essay is not an exercise in compare and contrast.
Rather, it is an attempt to extract the best elements
from each approach and integrate them into a
workable whole that will not trigger brain freeze
in the practicing clinician. This is consistent with
my larger project of integrating the three main
approaches to couple therapy – systemic, psycho-
dynamic, and behavioral/educational – into a prac-
tical guide for conducting therapy (Nielsen 2016). P
The most important contributors to this field
include Bergler (1949), Berkowitz (1999), Dicks
(1967), Donovan (2003), Gerson (2010), Hazlett
(2010), Leone (2008), Livingston (1995),
Ringstrom (1994, 2014), Sager (1994), Scharff
and Scharff (2008), Shaddock (1998, 2000), Siegel
(1992, 2010), Slipp (1988), D. Stern (2006),
Wachtel and Wachtel (1986), Willi (1984), Zeitner
(2012), and Zinner (1989), as well as therapists
who are not psychoanalysts and do not describe
themselves as writing from this perspective, but
who have, nonetheless, made important contribu-
tions to a depth psychological perspective:
Catherall (1992), Greenberg (Greenberg and
Johnson 1988; Greenberg and Goldman 2008),
Goldman (Greenberg and Goldman 2008),
Gurman (2008), Johnson (1996, 2008), Mid-
dleberg (2001), Real (2007, 2011), Scarf (1987),
2384
Scheinkman (2008), Scheinkman and Fishbane
(2004), and Wile (1981, 1993, 2002, 2013).
These individuals believe, as I do, that to
understand and remediate negative couple inter-
actions, it is usually necessary to uncover individ-
ual psychological issues that do not simply follow
from system-level concepts. All adhere to modern
psychoanalytic thinking and research by positing
unconscious schemas of self and others in inter-
action (Westen 1999). All emphasize that abnor-
mal, maladaptive behavior makes sense when
examined through the lens of important, often
unconscious, motives, fears, and defenses. To
varying degrees, they all focus on common
human concerns and conflicts over trust, depen-
dency, autonomy, shame, guilt, envy, identity,
honesty, and intimacy. Sex, aggression, love, and
hate – as highly charged forms of human
interaction – get special attention. All emphasize
the formative influence of both childhood and
adult experiences in intimate relationships in lay-
ing down the structure of personality, including by
shaping expectations, motives, and methods of
adapting. All believe that underlying issues and
concerns can be defensively concealed and may
reveal themselves indirectly in seemingly random
thoughts or casual remarks (associations), in
dreams, in symptomatic behavior, and in patterns
of interaction with others (transferences). All see
therapists’ emotional responses to clients
(countertransferences) as potentially valuable in
assessing those relational patterns and as possible
sources of interference. All subscribe to the belief
that what is curative in therapy consists of a com-
bination of growing self-awareness (insight) and
new experiences of more positive ways of relat-
ing. All see the “real” relationship with the thera-
pist as crucial for providing a safe environment for
self-discovery and as a setting for new transfor-
mative experiences, some centered around the
therapist–client relationship itself.
Just as the model T is no longer a fair represen-
tation of a modern automobile, psychoanalytic psy-
chology has moved on, building on Freud’s basic
foundations, while jettisoning some of his earlier
ideas that have proven to be untenable. Contrary to
some misunderstandings of the field that present
psychoanalysis as unscientific or passé (see Park
Psychodynamic Couple Therapy
and Auchincloss 2006), most contemporary psy-
choanalytic ideas, like those just presented, will
appear sensible and useful to the couple therapist.
Underlying Issues
To help couples exit their pathological dances,
their “vulnerability cycles” (Scheinkman and
Fishbane 2004), we must focus not only on the
process per se (that when one person nags, the
other withdraws, which elicits more nagging and
then more distancing), but on what drives this
maladaptive process, namely, the underlying sen-
sitivities, hopes, and fears of the partners. The
more I have worked with couples whose conflicts
seem endless, the more I have found it critical to
focus less on their current, specific complaints
(e.g., who will take the dog out) and more on
their basic human concerns: their hopes for love,
concern, appreciation, closeness, and understand-
ing and their fears and experiences of disapproval,
abandonment, domination, incompetence, and
other varieties of emotional suffering.
In doing so, I find myself in the company of
those who have sought to make “emotion” the
central focus of couple therapy, especially Les
Greenberg and Sue Johnson and their colleagues
(Greenberg and Johnson 1988; Johnson 1996;
Greenberg and Goldman 2008). In my work, how-
ever, I have found it preferable to speak of “hopes
and fears,” “meanings,” and “transferences,”
rather than “emotions” to cover the amalgam of
motives, feelings, and self-and-other schemas that
we therapists refer to when we look below the
surface of couple interactions.
Intimate relationships can evoke some of our
most basic fears. The most important are fears of
abandonment/rejection/loss of love, shame and
humiliation, jealousy, guilt, being “controlled”
by being told what to do or how to think, losing
control of one’s emotions or mind, being over-
whelmed or overburdened by one’s partner’s
needs, and revisiting past traumas. Many fears
that emerge in therapy are best seen as specific
amalgams of dreaded states of mind. For instance,
we may discover that a spouse’s excessive worry
about credit card debt is powered by a fear of the
Psychodynamic Couple Therapy
return of a number of childhood traumas that
followed her father losing his job: not only the
dread of poverty itself, but anxiety about parental
discord, paternal alcoholism, inordinate self-
blame for parental strife, and shame at school
when she was unable to keep up with peer group
fashion trends.
Negative interaction cycles are also powered
by unmet or poorly articulated hopes, needs, and
desires (Leone 2008). One central goal when
exploring underlying issues is to help couples
articulate just what they are really fighting about,
including what they need from each other. To
some extent, fears and desires are simply mirror
images of each other. People who desire attach-
ment and empathy will be distressed when these
are not available, so that their feared “danger
situation” is one in which these are lacking. All
of us seek affirmation rather than shame and guilt,
and we all prefer a certain amount of autonomy to
feeling excessively controlled. More generally, all
of us desire to feel “safe” and “secure,” which
amounts to the absence of all the feared danger
situations just listed.
Some hopes and desires, however, are dis-
tinct from this complementarity of desires and
fears. This is especially true of needs for joint,
coordinated, or co-constructed activity: for
sharing and building a life together, for having
sex with a beloved partner, for raising children
together, for watching sunsets, and for sharing
thoughts. Such wishes contain the crucial ingre-
dients of affect sharing and “co-constructed
meaning” (Weingarten 1991). These sources of
pleasure all depend on the presence of a partner,
often a particular partner, but their nature is not
fully characterized by the simple presence or
absence of that partner. A partner may be phys-
ically present, but the desires will remain
unsatisfied if he or she is not involved or
invested in the joint effort. Understanding peo-
ple’s frustration in attaining these shared,
co-constructed ends will help us empathize not
only with the content of some complaints (the
lack of shared pleasurable time, fears of losing a
shared life via divorce) but also with how much
it hurts to feel out of step and stepping on each
other’s toes during painful arguments.
2385
Most of us also want others to know how we feel,
what we like, what we hope for, and how we are
doing. Success feels better when it’s shared; defeat
is less distressing when someone can commiserate.
These wishes play a part in what we call our needs
for empathy and intimacy. Successfully meeting
these needs also counters negative projections and
allows us to accurately meet our partner’s needs.
The desire for empathy extends to hoping that
our partners will understand our distress even in
cases when they fail to meet our needs, a desire
that is frequently a casualty of the partner’s defen-
siveness. Much of the intensity of client distress
during negative interaction cycles can be
explained by the failure of such secondary
empathic containment. And much of the restor-
ative power of “softening” derives from the part-
ner providing it. We also find ourselves
uncovering desires for unencumbered time
alone, for revenge when hurt, and for uncondi-
tional love from a flawless, all-giving partner.
Divergent Subjective Experiences
When we look for underlying issues as the source
of couple problems, we commonly discover idio-
syncratic or person-specific meanings of events
that evoke conflict between the partners. Because
such meanings are often incompletely known to P
the people themselves (because they are uncon-
scious) or are assumed to be universal (because
they are learned in childhood or are embedded in
cultural givens), they frequently cause puzzling
discord.
The Rob Reiner film, The Story of Us (2000),
shows a couple on the verge of marital separation
rushing to get their kids to the bus that will take
them to camp. The family car is slowed when it
gets trapped behind the unlikely impediment of a
house being towed down the road. The mother
reacts anxiously, seeing the house as an obstacle,
something that must not deter them from their
mission. The father, however, sees it as a possible
source of fun and family bonding, noting how its
zip code keeps changing and wondering what
would happen if someone flushed a toilet. Both
are right. And both are hurt and deflated into
2386
silence when their partner fails to acknowledge
the merit of their alternative perspective. This
particular polarity – the wife all work and the
husband all fun – plagues them in other situations
and is central to their marital troubles.
My experience with couples in conflict over
divergent subjectivities inspired what I came to
call the “You’re both right” intervention: The
therapist points out that while the partners seem
to assume that there can be only one correct way
to see a situation, in fact, both can be simulta-
neously correct. When making this postmodern
point, I mention a situation, familiar to all, of
two people reacting very differently to the iden-
tical movie. A more memorable way to make
this point is by showing couples the Rubin vase,
shown below, which can be seen simultaneously
as a vase and as two faces in profile.
Sometimes, I term this challenge of differing
subjectivities the “Life Doesn’t Come with
Labels” problem. More than most people realize,
our daily lives are a continuous Rorschach inkblot
test, with our perceptions and assessments best
seen as mental events that are influenced by inter-
nal concerns and templates. Many arguments
between couples are prolonged needlessly by
semantic wrangles that can never be resolved
objectively. Whether a man’s working late
makes him a “good provider” or a “neglectful
husband” cannot be determined by the objective
Psychodynamic Couple Therapy
time he arrives home. The husband and wife will
have to work out their divergent preferences with-
out reference to absolutes.
Transferences
Another way to dig deeper into the psychology of
a couple’s problematic interactions is to examine
their transferences. The fundamental concept of
transference in psychoanalytic theory is that one’s
experience of others may be a function of his or
her current (often unconscious) wishes and fears,
and not so much the result of objective criteria that
would shape the perception of a hypothetical
transference-free person. These wishes and fears
may derive from a combination of inborn motiva-
tions, past experiences, and current emotional
needs. Important past experiences include those
with childhood caretakers, with siblings, with
one’s peer group (especially in adolescence), and
with prior intimate partners.
Transference Hopes and Fears
It is useful to divide transferences into transfer-
ence hopes and transference fears. These corre-
spond to the relationship hopes and fears
I mentioned above. The rather obvious point that
I am adding now is that although everyone has
powerful hopes and fears concerning relation-
ships, each of us experiences certain hopes as
more pressing and certain fears as more worri-
some. In many cases, the sources of this variabil-
ity can be found in a person’s history.
Some transference wishes in intimate relation-
ships are universal, some are attempts to master
childhood traumas or to make up for personal
deficiencies, and some become intensified
because they are not being met. Since many such
wishes derive from unmet needs and are thus
linked to memories of their disappointment, trans-
ference wishes often arrive in the company of
transference fears (Stolorow et al. 1987; Stern
1994). In all cases, the therapist’s initial role is to
help clients make these wishes and their attendant
fears more explicit and to give them a more sym-
pathetic, articulate voice.
Psychodynamic Couple Therapy
Varieties of Transference Distortion
As with projective tests, some transferences rely
less on the simple distortion of facts and more on
selective focus, which then distorts or narrows the
overall picture. (“I focus on my partner’s failings,
because I fear being fully aware of how dependent
I might otherwise feel.”) Again, as with projective
tests, some transferences result not simply from
generalizations about past experiences (“I was dis-
appointed when I asked my mother for help, so I’m
almost certain I will be disappointed if I ask my
wife for help.”) as from a present need to distort
current events. (“I see my spouse as blameworthy,
because I can’t stand to feel guilty.”) Many trans-
ferences serve as self-protective defenses. Finally,
transferences always imply some view of the self
in relation to the other, with this view of the self
also subject to potential distortion. (“Seeing
myself as [falsely, unconsciously] responsible for
my parents’ divorce, I now feel unable to ask them
for a loan to help me purchase a home.”)
Transference Allergies, Core Negative Images,
and Default Settings
When speaking to clients about transference fears,
I find it helpful to describe these as “psychological
allergies” or “transference allergies.” Just as a
person who had a prior exposure to a bee sting
may have a severe reaction to a subsequent bee
sting, so a person who experienced early parental
abandonment may have an excessive emotional
reaction to a spouse’s business trips. With trans-
ference allergies, people smell psychological
smoke and expect an emotional forest fire. Our
job as therapists is to help clients tell the differ-
ence between their early warning systems and the
approach of a real catastrophe:
Terrence Real’s “core negative image” is another
good way to put the negative transference concept
into lay language. According to Real (2007), the
CNI is that vision of him [your partner] that you feel
most hopeless and frightened about. You say to
yourself, in those furious, or resigned, or terrified
moments, “Oh my god! What if he really is a
vicious person?...What is she really is a coldhearted
witch?...A betrayer? An incompetent? Constricted?
Selfish? Your CNI is your worst nightmare. It is
who your partner becomes to you in those most
difficult, irrational, least-loving moments. (p. 83)
2387
To communicate the idea that transference
fears and dispositions operate unconsciously in
the background, I compare them to default set-
tings on a computer, the options or preferences
preloaded at the factory. Often, we may not even
know we have choices concerning how our appli-
cations function until we want to change some-
thing and then go looking for the other options. In
a similar way, we adults come with “settings” or
preferences that operate in the background that
were not consciously chosen by us, and are often
not experienced as options, but seem to be the
only way to compute the world. Such “settings”
include not only views of the self and others
interacting in traumatic scenarios but also beliefs
about how amenable they are to change. This last
element helps explain why our CNIs are so feared:
because of an attendant belief (“setting”) that we
are helpless to do much about them.
Interlocking Simultaneous Transferences
When people seek couple therapy, it is almost
universally true that both partners are experienc-
ing transference allergies, so that neither can
soothe nor empathize with the other during epi-
sodes of emotional distress. And it is not only that
the two partners are experiencing their personal
CNIs simultaneously, but their dysfunctional
defensive reactions to each other further confirm
P
the validity of their fears (Wachtel 2014). This
confirmation helps explain the ensuing tenacity
and escalation of the cycle. I use the term
“interlocking transferences” to portray this fitting
together of (neurotic) transference fears of one
partner with confirming behavior from the other.
Working with Underlying Issues,
Divergent Subjective Experiences, and
Transferences
When working with underlying issues, divergent
subjectivities, and client transferences, our goals
are to simultaneously foster insight and to repair
and strengthen the couple bond. As concerns
insight, we aim to assist partners in recognizing
their hidden fears and desires and those of their
partner – sooner and more clearly. This will help
2388
them to meet those needs more effectively and to
repair the relationship when (inevitably) those
needs are not fully met. Clients then develop a
better map of their relationship, one that replaces
previous, hurtfully simplistic representations.
This improved map will help the couple discuss
and interrupt their pathological dances, which
have now become more comprehensible.
Useful methods for fostering insight are well
known to therapists schooled in individual psy-
choanalytic psychotherapy. They include
empathic immersion, reducing resistance,
accepting ambivalence, interpreting (reframing)
behaviors, and exploring the past.
Useful methods for strengthening the couple
bond include (1) helping clients voice their hopes
and fears more effectively to each other, (2) explor-
ing and countering partner reluctance to “soften”
and to alter their responses, and (3) helping couples
use their new insights and strengthened bond to
develop a plan to prevent and rein in future negative
cycles. Interested readers can consult my book
(Nielsen 2016) for detailed recommendations
concerning how to achieve these ends.
Acceptance
Stimulated by the writings and research of
Christensen and Jacobson (1998), couple therapists
have come to see working to achieve acceptance as a
new and important therapeutic target, so much so
that Sprenkle et al. (2009) have recognized “appre-
ciating one’s partner’s differences” as a “common
finish line” for most current schools of couple
therapy.
A New Tool for Insoluble Problems
Acceptance is a welcome new tool in the thera-
peutic toolbox. Interventions aimed at acceptance
lead therapists in a very different direction from
assisting couples to negotiate differences by help-
ing them state their needs more clearly and less
offensively. Instead, therapists help partners to
accept or contain differences and chronic disputes
that may never change, termed “unsolvable” or
“perpetual problems” by Gottman (2010) and
“irreconcilable differences” by Christensen and
Psychodynamic Couple Therapy
Jacobson (1998). Helping clients to abandon
their efforts to change what seems unchangeable
sometimes leads (paradoxically) to the desired
changes as partners stop reacting passive-
aggressively to insistent demands to change, but
even when changes are not forthcoming, accep-
tance helps diminish what has commonly become
the most toxic characteristic of a couple’s mar-
riage: not so much the unchanging problems, but
the incessant wrangling over changing them.
Conversations about how to contain insoluble
problems also offer opportunities for marital inti-
macy and bonding. While couples may never
come to total agreement on how much to socialize
or on what counts as “being late,” their conversa-
tions about these enduring problems will feel inti-
mate as they share their struggles and views on
their differences. To be sure, this is working
toward a form of “change” for the couple, but it
is a very different sort of change.
Facilitating Acceptance
Many interventions can facilitate acceptance; only
a few can be mentioned here. The most important
will be helping clients know and accept them-
selves as a way to stop blaming their partners for
their disappointment. Interpreting projective iden-
tification is especially helpful, as it focuses spe-
cifically on helping clients to re-own unacceptable
parts of themselves. More generally, all of our
psychodynamically informed efforts to help cli-
ents know themselves and each other better, to
uncover their underlying issues, and to truly
empathize can be seen as efforts to facilitate
acceptance of what is, while facilitating mourning
for what might have been.
Clients who are aware of psychological hot
buttons (transference fears) in themselves and
their partners will prove more accepting of them-
selves and their partners. Spouses who acknowl-
edge their own psychological allergies will be less
insistent that their partners never throw them “the
pitch they can’t hit” and, instead, will take per-
sonal responsibility and work internally to calm
their idiographic distress. Insightful partners of
those spouses will try not to trigger their spouses’
allergies and will be less surprised and intolerant
when they do so inadvertently.
Psychodynamic Couple Therapy
We can also help clients give up the exces-
sively romantic expectations they may have
about marriage. We can help them acknowledge
that what they find dissatisfying in their partners is
often simultaneously valuable: The hardworking
husband who disappoints by coming home late is
also the husband who helps fund college tuition.
The wife who seems persnickety about how to
parent the children is the same mother who iden-
tifies, and gets, the best teachers for them. More
generally, the problem will be to help clients
accept both that any character trait will have plus-
ses and minuses and that any partner will come
with plusses and minuses.
Throughout this essay on psychodynamics,
the emphasis has been on facilitating intimacy,
bonding, and conflict resolution by assisting cli-
ents to voice their deeper needs and injuries. As
this occurs, couples’ negative interaction cycles
become less negative and more supportive and
collaborative. When this happens, the resulting
improved interpersonal connection (selfobject
bonding) helps couples to mourn the desires
(surfacing in their persistent problems) that
may never be met. Matt may never become the
wealthy alpha male that Rachel thought she
needed, but feeling his real support and connec-
tion makes her less insistent on those concrete
satisfactions. Further, improved connection in
pursuer–distancer couples routinely enables
both partners to tolerate less-than-perfect out-
comes: Pursuers, now getting more intimate con-
nection, come to accept less than they had hoped
for, partly because they no longer take their part-
ners’ distancing so personally. Distancers, hav-
ing learned how to be better listeners, become
more comfortable with the demands of intimacy,
including responding to their partners’ overtures
for closeness at times when they might have
preferred some alone time.
As this whirlwind tour of psychodynamic con-
tributions to couple therapy concludes, I hope that
readers can better appreciate the value of the ther-
apeutic targets I have reviewed: underlying issues,
divergent subjective experiences, transferences,
and acceptance. I cover the additional important
topic of projective identification elsewhere in this
encyclopedia.
2389
Cross-References
▶ Interpretation in Couple and Family Therapy
▶ Object Relations Couple Therapy
▶ Projective Identification in Psychoanalytic
Couple and Family Therapy
▶ Psychoanalytic Couple and Family Therapy
▶ Selfobject in Psychoanalytic Couple and Fam-
ily Therapy
▶ Transference Interpretation in Couple and Fam-
ily Therapy
References
Bergler, E. (1949). Conflict in marriage: The unhappy
undivorced. Madison: International Universities Press.
Berkowitz, D. A. (1999). Reversing the negative cycle:
Interpreting the mutual influence of adaptive, self-
protective measures in the couple. Psychoanalytic Quar-
terly, 68, 559–583.
Catherall, D. (1992). Working with projective identifica-
tion in couples. Family Process, 31, 355–367.
Christensen, A., & Jacobson, N. S. (1998). Acceptance and
change in couple therapy: A therapist’s guide to trans-
forming relationships. New York: W.W. Norton.
Dicks, H. (1967). Marital tensions. New York: Basic Books.
Donovan, J. M. (2003). Short-term object relations couples
therapy. New York: Brunner-Routledge.
Gerson, M.-J. (2010). The embedded self: An integrative
psychodynamic and systemic perspective on couples
and family therapy (2nd ed.). New York: Routledge.
Gottman, J. M., & Gottman, J. S. (2010). Gottman method P
couple therapy. In A. S. Gurman (Ed.), Clinical hand-
book of couple therapy (4th ed., pp. 138–164).
New York: Guilford Press.
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-
focused couples therapy: The dynamics of emotion,
love, and power. Washington, DC: American Psycho-
logical Association.
Greenberg, L. S., & Johnson, S. M. (1988). Emotionally
focused therapy for couples. New York: Guilford Press.
Gurman, A. S. (2008). Integrative couple therapy: A depth
psychological approach. In A. S. Gurman (Ed.), Clini-
cal handbook of couple therapy (4th ed., pp. 383–423).
New York: Guilford Press.
Hazlett, P. S. (2010). Attunement, disruption, and repair: The
dance of self and other in emotionally focused couple
therapy. In A. S. Gurman (Ed.), Clinical casebook of
couple therapy (4th ed., pp. 21–43). New York: Guilford
Press.
Johnson, S. M. (1996). The practice of emotionally focused
marital therapy. Florence: Brunner/Mazel.
Johnson, S. M. (2008). Emotionally focused couple therapy.
In A. S. Gurman (Ed.), Clinical handbook of couple
therapy (4th ed., pp. 107–137). New York: Guilford Press.
2390
Leone, C. (2008). Couple therapy from the perspective of
self psychology and intersubjectivity theory. Psycho-
analytic Psychology, 25, 79–98.
Livingston, M. S. (1995). A self psychologist in
Couplesland: Multisubjective approach to transference
and countertransference-like phenomena in marital
relationships. Family Process, 34, 427–439.
Middleberg, C. V. (2001). Projective identification in com-
mon couple dances. Journal of Marital and Family
Therapy, 27, 341–352.
Nielsen, A. C. (2016). A roadmap for couple therapy:
Integrating systemic, psychodynamic, and behavioral
approaches. New York: Routledge.
Park, S. W., & Auchincloss, E. L. (2006). Psychoanalysis
in textbooks of introductory psychology: A review.
Journal of the American Psychoanalytic Association,
54, 1361–1380.
Real, T. (2007). The new rules of marriage. New York:
Ballantine Books.
Ringstrom, P. A. (1994). An intersubjective approach to
conjoint therapy. In A. Goldberg (Ed.), Progress in self
psychology (Vol. 10, pp. 159–182). Hillsdale: The Ana-
lytic Press.
Ringstrom, P. A. (2014). A relational psychoanalytic
approach to couples psychotherapy. New York:
Routledge.
Sager, C. J. (1994). Marriage contracts and couple ther-
apy: Hidden forces in intimate relationships.
Northvale: Jason Aronson.
Scarf, M. (1987). Intimate partners: Patterns in love and
marriage. New York: Random House.
Scharff, J. S., & Scharff, D. E. (2008). Object relations
couple therapy. In A. S. Gurman (Ed.), Clinical hand-
book of couple therapy (4th ed., pp. 167–195).
New York: Guilford Press.
Scheinkman, M. (2008). The multi-level approach: A road
map for couples therapy. Family Process, 47, 197–213.
Scheinkman, M., & Fishbane, M. (2004). The vulnerability
cycle: Working with impasses in couple therapy. Fam-
ily Process, 43, 279–299.
Shaddock, D. (1998). From impasse to intimacy: How
understanding unconscious needs can transform rela-
tionships. Northvale: Jason Aronson.
Shaddock, D. (2000). Contexts and connections: An inter-
subjective systems approach to couples therapy.
New York: Basic Books.
Siegel, J. P. (1992). Repairing intimacy: An object relations
approach to couples therapy. New York: Jason Aronson.
Siegel, J. P. (2010). A good-enough therapy: An object
relations approach. In A. S. Gurman (Ed.), Clinical
casebook of couple therapy (4th ed., pp. 134–152).
New York: Guilford Press.
Slipp, S. (1988). The technique and practice of object
relations family therapy. Northvale: Jason Aronson.
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009).
Common factors in couple and family therapy: The
overlooked foundation for effective practice.
New York: Guilford Press.
Stern, S. (1994). Needed relationships and repeated rela-
tionships: An integrated relational perspective. Psycho-
analytic Dialogues, 4, 317–346.
Psychoeducation in Couple and Family Therapy
Stern, D. B. (2006). Opening what has been closed,
relaxing what has been clenched: Dissociation and
enactment over time in committed relationships. Psy-
choanalytic Dialogues, 16, 747–761.
Stolorow, R., Brandshaft, B., & Atwood, G. (1987). Psy-
choanalytic treatment: An intersubjective approach.
Hillsdale: The Analytic Press.
Wachtel, P. L. (2014). Cyclical psychodynamics and the
contextual self: The inner world, the intimate world,
and the world of culture and society. New York:
Routledge.
Wachtel, E. F., & Wachtel, P. L. (1986). Family dynamics
in individual psychotherapy: A guide to clinical strat-
egies. New York: Guilford Press.
Weingarten, K. (1991). The discourses of intimacy:
Adding a social constructionist and feminist view.
Family Process, 30, 285–305.
Westen, D. (1999). The scientific status of unconscious
processes: Is Freud really dead? Journal of the Ameri-
can Psychoanalytic Association, 47, 1061–1106.
Wile, D. B. (1981). Couples therapy: A nontraditional
approach. New York: Wiley.
Wile, D. B. (1993). After the fight: Using your disagree-
ments to build a stronger relationship. New York:
Guilford Press.
Wile, D. B. (2002). Collaborative couple therapy. In A. S.
Gurman & N. S. Jacobson (Eds.), Clinical handbook of
couple therapy (3rd ed., pp. 281–307). New York:
Guilford Press.
Wile, D. B. (2013). Opening the circle of pursuit and
distance. Family Process, 52, 19–32.
Willi, J. (1984). The concept of collusion: A theoretical
framework for marital therapy. Family Process, 23,
177–186.
Zeitner, R. M. (2012). Self within marriage: The founda-
tion for lasting relationships. New York: Routledge.
Zinner, J. (1989). The implications of projective identifi-
cation for marital interaction. In J. Scharff (Ed.), Foun-
dations of object relations family therapy
(pp. 155–174). Northvale: Jason Aronson.
Psychoeducation in Couple
and Family Therapy
Ellen P. Lukens
Columbia School of Social Work, New York, NY,
USA
Introduction
Psychoeducation is a treatment model that focuses
on strengths, the development of insight and self-
efficacy for the participants, and collaboration and
Psychoeducation in Couple and Family Therapy
parity between the practitioner and person or
group. The model draws on theories that encom-
pass health and mental health literacy and educa-
tion as well as individual, family, group, and
community practice in a social justice context
(Nutbeam 2006). Psychoeducational approaches
are flexible enough to be adapted for individuals,
couples, and families confronting challenges
ranging from mental illness and trauma to physi-
cal illness and restorative justice (Lukens 2015;
Walsh 2010). When most effective, the model
builds on the synergy between education and psy-
chotherapy as an avenue for increased awareness
and healing. The overarching goal is to promote
understanding, hope, and possibility among par-
ticipants and a knowledge exchange among prac-
titioners and participants.
The term “psychoeducation” has been used
somewhat indiscriminately in the applied practice
and academic literature to refer to interventions as
simple as the distribution of an informational bro-
chure in a medical clinic that outlines the key
symptoms of a disorder or as complex as a care-
fully designed multisession group intervention
model that follows a prescribed curriculum.
Access to even the most basic information regard-
ing a particular illness or procedure can serve to
allay fear and support recovery (May and Pfäfflin
2005). However, in this overview
psychoeducation will be considered as a full clin-
ical intervention guided by theory, practice prin-
ciples, and curriculum. The aim is to allow the
reader to consider its rich potential to mitigate a
range of health, mental health, and life challenges
for individuals, couples, and families through
strategies that involve both prevention and
intervention.
Psychoeducational multiple family group and
single-family interventions have been well tested
with persons with schizophrenia and their fami-
lies. As such, the model is evidence-based when
implemented with fidelity (Lyman et al. 2014;
McFarlane 2002). Psychoeducation has been
applied for many other personal, interpersonal,
and family challenges as well, suggesting the
flexibility and potential for adaptation (Lukens
2015). When these models draw on the principles
identified in the evidence-based applications, they
can be considered evidence-informed.
2391
Theoretical Framework
Psychoeducational models draw on a range of
theories and models that complement and enhance
each other. These include (1) ecological systems,
(2) applied practice, and (3) learning theories.
Ecological systems theory provides the overarch-
ing structure in that it offers a cross systems and
intersectional perspective on the needs and assets
of individuals and groups. It emphasizes the
importance of context that people are influenced
and affected by systems that change and interact
in unique ways over the life span. These systems
include individual, family, and community (e.g.,
school, work place, house of worship) as well as
cultural, social structural, and political. Within
and among these systems are multiple factors
that facilitate or hinder personal development,
growth, and quality of life. These factors can
serve as a platform for psychoeducational curric-
ulum development regardless of the particular life
challenges involved.
The intersecting practice theories that inform
psychoeducational approaches include trauma
and recovery, narrative approaches, and group
practice theory. Trauma and recovery theory
involves several core components that build on
each other (Herman 2015) and that serve to
ground the psychoeducational approach. They
include the creation of a safe environment or P
space, attention to identification, and management
of affect, including grieving and loss, and an effort
to move toward transformative learning that
allows room for meaning making (i.e., to under-
stand and integrate challenging experiences in a
productive fashion), attention to personal care,
and a return to self-efficacy. For persons who
confront trauma or major stress of any form, the
work on grief is particularly important – for those
with mental health challenges the grief may focus
on loss of self; for their parents, it may be a loss of
“what could have been.”
Narrative practice models celebrate the value
of stories and bearing witness to these stories
(White 2007). Central to this practice is the
attention to the “story” rather than the “prob-
lem” as a path towards understanding and mean-
ing making (i.e., coming to terms, personal
resolution) for participants. Through the
2392
exchange of stories people gain perspective on
their own experiences and are able to reflect in
ways that help them process grief and other
challenging emotions. The narratives provide a
framework that allows participants to reconsider
their own reactions and experiences and to learn
vicariously through the stories of others. For the
facilitators, stories offer rich opportunity to
identify strengths and personal resources and
to reframe response.
Although psychoeducational interventions can
be implemented one-on-one, couple, family, and
group models promote healing by creating a struc-
ture for co-learning, exchange of ideas, and
opportunity for relating shared experiences
(McFarlane 2002). Social support theory posits
that various forms of encouragement and involve-
ment from family and friends promote health,
self-esteem, and self-regulation in the face of
daily and cumulative stress (Chen and Greenberg
2004). In an ongoing psychoeducational group,
the participants can offer and receive needed
social support that may be missing in external
settings.
Social learning theory suggests that people
gain insight and knowledge through common
experience; in the context of group
psychoeducation, the potential for participants to
share and reflect on experiences and reactions is
greatly enhanced. This helps participants gain
perspective and reflect on their own lives in
ways that would be limited by a two-way
exchange. The exchange is further enhanced by
the professional knowledge offered by the facili-
tators and the lived or “everyday” perspective of
the participants (Borkman 1990).
Rationale
Individuals, couples, or families are typically
invited to participate in a clinically oriented
psychoeducation intervention when they are over-
whelmed and stressed by life circumstances.
These stressors can lead to difficulty coping with
symptoms, processing information, moving for-
ward, making decisions, or simply unraveling and
navigating the complex challenges in their daily
Psychoeducation in Couple and Family Therapy
lives. As an educational intervention,
psychoeducation offers sequenced, structured,
and user-friendly information and care strategies
regarding general and particular aspects of health
and illness. As a therapeutic intervention, it offers
a safe environment, predictable structure, and
time for participants to process information that
may trigger unexpected emotions. Together the
components provide participants with a frame of
reference for their experience. The facilitators are
responsible for creating synergy and balance
between the therapeutic and educational aspects
of the work. They encourage participants to share
stories, recognize their own symptoms and trig-
gers, and gain perspective on reactions and emo-
tions. Identifying common experiences tends to
promote insight, decrease stress, and build com-
munity within the group. This in turn fosters resil-
ience and promotes hope and improved quality
of life.
Description
Psychoeducation is principle based and curric-
ulum driven. The model is appropriate for indi-
viduals, couples, families, groups, or groups of
families and can be easily adapted as a train-the-
trainers model (Lukens et al. 2004). Because it
can be fast-paced when implemented with fam-
ilies, groups, or group of families,
co-facilitation can be highly effective, allowing
the clinicians to model productive feedback and
exchange, graceful conflict resolution, problem
solving strategies, and varying perspectives on
curriculum content.
Key Principles Psychoeducation is strengths
based and present focused. The curriculum
grounds the intervention and a series of principles
drive the model. These include a focus on resil-
ience, well-being, and quality of life through
increased knowledge and awareness, time allotted
for process, attention to cultural context, and
building an expanded circle of support (Lukens
2015; Pescosolido et al. 1995; Williams 2008).
Participants learn to recognize past successes
and then to draw on these as they incorporate
Psychoeducation in Couple and Family Therapy
new knowledge to address current and future
challenges. In group settings, this is reinforced
through the collaboration between participants
and facilitators – all parties serve as educator,
student, advocate, translator (of cultural context,
of ideas), advocate, and monitor. The facilitators
draw on their professional knowledge regarding
general patterns and response to illness, stress and
crisis management, and typical patterns of
response. The participants bring the lived experi-
ences of confronting symptoms, illness, and deal-
ing with multiple providers over time. Once
immersed in a psychoeducational frame of refer-
ence, participants can begin to recognize subtle
changes in personal patterns and identify trigger
responses that interfere with functioning or sug-
gest increased symptoms. As these insights grow,
they can begin to identify ways to decrease or
manage negative response and heighten coping
strategies.
Curriculum Content The curriculum grounds
the intervention, guiding the facilitators and pro-
viding structure for the participants. It can cover
topics relevant to many situations and systems,
including coping skills, stress management,
stigma, effective communication and problem
solving, self-efficacy, and self-advocacy. It also
delineates key information related to the particular
illness or life challenge at hand (i.e., symptoms,
potential treatments, medications and side effects,
prognosis, early signs of relapse). Offering a bal-
ance of illness- and wellness-related topics pro-
motes hope and perspective among participants
(Lukens 2015). Wellness-related topics might
include modules related to building successful
relationships, self-esteem, or caregiving and
care-receiving.
Content, sequencing, timing, and approach
are adjusted based on cultural context, educa-
tional level, and sophistication of participants
and language. This involves attention to
“pitch”; how, when, and how much information
is presented so that participants can understand
and successfully process ideas. The overall
number of sessions, frequency and duration of
each, and number of participants must be deter-
mined as well (Lyman et al. 2014).
2393
Structure If psychoeducation is delivered with
couples, families, or groups, allotting time for
initial one-on-one “joining” sessions enhances
the process (McFarlane 2002). These sessions
allow a facilitator to serve as an initial point per-
son and advocate, explain the unique qualities of
the psychoeducational approach (including atten-
tion to both professional and everyday knowl-
edge), assess readiness and willingness to
participate, troubleshoot, and address generalized
anger, frustration, or fear (i.e., regarding the health
or mental health system), and field questions.
Once the psychoeducational sessions begin, the
structure can include a brief period of informal
exchange, review of group guidelines, a presenta-
tion/discussion focused on a topical curriculum
module, time for planning, role play, extended
discussion or other group exchange, and sum-
mary/closure. A predictable structure contributes
to the establishment of a safe environment. To
promote safety and equilibrium, group guidelines
are created and reviewed at the beginning of each
session; these serve as a point of reference and
reprieve for the facilitators if anger or discord
emerges.
Applied Practice Many of the clinical techniques
involved in psychoeducation are also common to
narrative therapy, motivational interviewing, and
cognitive behavioral therapy (CBT). These include P
reflective listening, amplification, reframing, goal-
setting, and problem-solving. The “learning
exchange” between clinician and participant builds
emotional and relational modulation, self-
awareness, personal agency, and decision-making.
A “culture of participation and citizenship” with
attention to social justice is expected and modeled
by the facilitators (Bloom et al. 2003).
Facilitators attend to affect and body language
and can use gentle humor, metaphor, and discrete
self-disclosure as appropriate for the task at hand.
They solicit perspectives and experiences regard-
ing curriculum content and teach participants how
to listen to and provide feedback to each other.
They identify “understandable responses” to dif-
ficult circumstances and help to translate cultural
and linguistic barriers that occur as participants
attempt to process new information. They
2394
encourage cross-participant exchange as a way to
build support, empathy, and personal efficacy.
Flexibility is critical – the facilitators adhere to
the curriculum when possible while allowing
room for unexpected exchanges and narratives
that increase awareness and insight. They titrate
the presentation of the curriculum modules in an
effort to balance a presentation of information that
is neither too complex nor too simple and that is
timed so that participants are calm enough to hear
and process content.
Challenges Psychoeducation has tremendous
potential as an applied practice intervention and
is flexible enough to be adapted for many circum-
stances and contexts. However, a curriculum
requires thoughtful consideration as to design,
content and the needs of the particular population
served. Once implemented, the approach requires
careful attention to planning and ongoing decon-
struction of process. The facilitators must be will-
ing to plan sessions initially and debrief and
recalibrate as they proceed (i.e., through peer or
other forms of supervision), to ensure that timing,
structure, and sequencing are appropriate for the
particular set of group members. Potential partic-
ipants need to be receptive to the approach and
structure – one hostile participant can quickly
derail the process and spook the facilitators. Sup-
port and investment from administrators regard-
ing the investment in time required is essential
(McFarlane 2002).
Case Study
Juan carried a diagnosis of schizophrenia, first
diagnosed during his junior year in college when
he became unfocussed, angry, and paranoid
regarding his professor’s assessment of him.
Prior to that time, he had had a relatively close
relationship with his parents. After dropping out
of college, Juan had floundered for 10 years or
more. Because of his angry outbursts and threat-
ened violence towards his mother, and once
towards a co-worker, he had been hospitalized
multiple times. Still he had had brief periods
when he seemed to be doing well. Early on he
Psychoeducation in Couple and Family Therapy
was able to work part-time as a grocery clerk and
focus on activities that interested him, particularly
playing the guitar and watching old Ginger Roger
movies. During these periods, he showed great
empathy for his fellow employees and seemed to
enjoy his job. However, he lost focus and his
symptoms increased rapidly when he stopped his
medicine, which led to increasing anger and inev-
itably hospitalization. Initially his employer was
willing to work with his treatment team, but after a
second extended absence Juan permanently lost
his position.
After Juan’s sixth hospitalization, a bi-lingual/
bi-cultural social worker/psychologist team at the
local day program decided to offer a psychoedu-
cational multiple family group to be conducted in
Spanish for adults diagnosed with schizophrenia
and related illness. They planned to co-facilitate
12 two-hour sessions to be conducted bi-weekly
over a 6-month period. As a first step they met
individually with the persons with illness and
separately with the potential family participants
to address concerns and ascertain interest and
commitment (i.e., the “joining” sessions). Juan
was hesitant; however, after some discussion he
agreed “to try it out.” His parents, in contrast,
were quite responsive, expressing their relief that
they could talk about their challenged relationship
with Juan in their native language. The mom cried
and the dad teared up as they described their love
for Juan and how they felt they had “lost” the
high-functioning adolescent who had become the
first family member to attend college.
Five families committed to the sessions,
including four couples and one single mother,
and five individuals with schizophrenia, all in
their twenties and thirties. Early on, Juan
remained quiet, even hostile and agitated during
the session. Still he attended and listened as the
participants shared stories and discussed topics
relating to both to illness (such as medicines,
early warning signs of decompensation, stigma,
and anger) and wellness (such as social support
and building relationships).
By the end of the second month, Juan began to
form an alliance with another participant, Angel
C. and Angel’s father, Mr. C., an older gentleman
who spoke no English at all. Mr. C. seemed to
Psychoeducation in Couple and Family Therapy
have a gift for gently reinforcing the feedback that
Juan and other young group members received
from the facilitators. And Juan seemed to be able
to accept comments from Angel and Mr. C. that he
rejected from his own father. At first this seemed
to bother Juan’s parents, but as the sessions pro-
gressed, they seemed relieved and to even regard
Juan’s responses to Mr. C. with some humor.
During a session early in the third month that
focused on antipsychotic medicines and their side
effects, Juan listened intently. A facilitator intro-
duced the concept of shared decision making
between psychiatrist and person with illness
(Deegan and Drake 2006) and suggested that
together everyone prepare a list of questions they
might ask a psychiatrist during a medication
review. Angel commented that it never occurred
to him to ask questions or even try to understand
what he was taking and how it might affect him.
Another group member stated that she became so
stressed when she had to speak to a mental health
professional that her English deteriorated; there-
fore, she never really understood the medicines or
how they worked. This comment triggered much
nodding in recognition and discussion among the
group as they prepared their list. Juan’s mom
offered to compile and organize the questions for
everyone and another parent suggested that they
try role-playing an interview with a psychiatrist
during the next session.
During the fourth month when the facilitators
offered a module on stigma, the discussion
became lively. The adult children talked about
how they felt labeled – almost always seen as a
“mental patient” first, rather than simply a person.
Juan became vocal for the first time. He admitted
that he felt horribly shamed by his unsuccessful
work history. He acknowledged that had never
really understood stigma before the facilitators
introduced the topic – and how much it had
gripped him and thwarted his progress over the
years. One facilitator noted that he too had been
stigmatized by losing a job once and that it had
blocked his progress as well. This disclosure
clearly meant a lot to Juan; he seemed almost
stunned that the clinician has shared this. The
ensuing discussion prompted someone to suggest
role playing a job interview, with feedback to be
2395
offered by all. Together the facilitators and the
group members laid out guidelines for the role
plays, and everyone became invested. Juan
seemed to revel in the experience, offering insight
on his own performance and kind feedback for
others. The other participants noticed,
commenting that Juan’s feedback was helping
them. The role plays and subsequent exchange
seemed to be a turning point for Juan; he began
to apply for part-time jobs, a process that as he put
it, would offer some “structure in my life.” He
managed to land a position as a clerk in a book
store, starting out with only a few hours on
Saturday mornings. When the group ended, he
maintained an ongoing friendship with Mr. C
and Angel and talked about teaching Angel
some chords on the guitar. His relationship with
his parents improved, and in the last group session
he admitted that it helped to have another dad to
talk to. At a 6-month follow-up meeting with one
of the facilitators, Juan reported that he had con-
tinued to work part-time, was taking his medica-
tion, and was watching movies again. In a separate
follow-up session, his parents reflected on the
group process, what they had learned from the
other families, and how much the work involved
had calmed them down and allowed them to
appreciate Juan for what he could accomplish in
the face of his illness.
P
Cross-References
▶ Acceptance in Couple and Family Therapy
▶ Forgiveness in Couple and Family Therapy
▶ Mediation in Couple and Family Therapy
▶ Stages of Change in Couple and Family
Therapy
References
Bloom, S. L., Bennington-Davis, M., Farragher, B.,
McCorkle, D., Nice-Martini, K., & Wellbank,
K. (2003). Multiple opportunities for creating sanctu-
ary. Psychiatric Quarterly, 74, 173–190.
Borkman, T. J. (1990). Experiential, professional, and lay
frames of reference. In T. J. Powell (Ed.), Working with
self-help. Washington, DC: NASW Press.
2396
Chen, F. P., & Greenberg, J. S. (2004). A positive aspect of
caregiving: The influence of social support on caregiv-
ing gains for family members of relatives with schizo-
phrenia. Community Mental Health Journal, 40(5),
423–435.
Deegan, P., & Drake, R. E. (2006). Shared decision making
and medication management in the recovery process.
Psychiatric Services, 57, 1636–1639.
Herman, J. (2015). Trauma and recovery: The aftermath of
violence—From domestic abuse to political terror.
New York: Basic Books.
Lukens, E. (2015). Psychoeducation: An annotated bibli-
ography. New York: Oxford Bibliographies.
Lukens, E. P., O’Neill, P., Thorning, H., Waterman-
Cecutti, J., Gubiseh-Ayala, D., Abu-Ras, W.,
Batista, M., & Chen, T. (2004). Building resiliency
and cultural collaboration post September 11th:
A group model of brief integrative psychoeducation
for diverse communities. Traumatology, 10,
103–123.
Lyman, D. R., Braude, L., George, P., Dougherty, R. H.,
Daniels, A. S., Ghose, S. S., & Delphin-Rittmon, M. E.
(2014). Consumer and family psychoeducation:
Assessing the evidence. Psychiatric Services, 65(4),
416–428.
May, T. W., & Pfäfflin, M. (2005). Psychoeducational pro-
grams for patients with epilepsy. Disease Management
and Health Outcomes, 13, 185–199.
McFarlane, W. R. (2002). Multiple family groups in the
treatment of severe psychiatric disorders. New York:
Guilford Publications, Inc.
Nutbeam, D. (2006). The evolving concept of health liter-
acy. Social Science and Medicine, 67, 2072–2078.
Pescosolido, B. A., Wright, E. R., & Sullivan, W. P. (1995).
Communities of care: A theoretical perspective on case
management models in mental health. Advances in
Medical Sociology, 6, 37–79.
Walsh, J. (2010). Psychoeducation in mental health. Chi-
cago: Lyceum Books.
White, M. (2007). Maps of narrative practice. New York:
W.W. Norton.
Williams, C. (2008). Insight, stigma, and post-diagnosis
identities in schizophrenia. Psychiatry, 71(3), 246–256.
Psychopharmacology in
Couple and Family Therapy
John Sargent
Tufts Medical Center, Boston, MA, USA
Name of Intervention
Psychopharmacology.
Psychopharmacology in Couple and Family Therapy
Synonyms
Psychiatric medication meds
Introduction
Often a family member engaged in couples or
family therapy will also be treated with psychiat-
ric medication or might raise the question of a
need for medication. At times, the therapist may
notice or learn about problematic behavior of a
family member and wonder if medication might
be helpful in addressing that concern. At times
also discussions about medication may be a
source of conflict in couples or family treatment.
This entry will review indications for using psy-
chiatric medications and approaches for
responding to discussion about medications. Cou-
ples and family therapy may be conducted by
psychiatrists or licensed nurse practitioners who
are able to prescribe medication. This entry will be
directed primarily to nonphysicians conducting
couples and family therapy, and will not address
situations where the same professional both con-
ducts couples or family therapy and prescribes
medication. However, the principles presented
here will apply to those professionals also.
Theoretical Framework
The use of psychopharmacology is based upon a
central premise – that all individual behavior is a
reflection of chemical and electrical activity in
that individual’s central nervous system.
A further premise of the practice of Neuropsychi-
atry and Psychopharmacology is that individual
cognition, behavior, and emotional experience
can be altered by the use of pharmaceuticals
with consistent, expectable effects on brain func-
tion. This effect can raise or lower mood, reduce
delusions and hallucinations, decrease anxiety, or
enhance focus and concentration. For the couples
and family therapist, these effects can enable them
to more directly decrease isolation, enhance rela-
tional negotiation and collaboration, build the
possibility of collaboration toward relational
Psychopharmacology in Couple and Family Therapy
satisfaction, and enhance the family’s ability to
support both connection and individual auton-
omy. Since change in any one person’s function-
ing always affects family interactions and family
life, the use of psychopharmacology when indi-
cated offers the couples and family therapist
greater flexibility in helping families achieve
their goals.
Rationale for Psychopharmacology
Relational Situations Where Medication Can
Be Helpful
Several clinical situations may warrant consider-
ation of an evaluation of an individual for medi-
cation. A couple may be caught in an impasse of
irritability, criticism, and stress. Excessive alcohol
use, job loss, and problems with children and
grandparents may be present. The therapist could
discuss with the family if antidepressants could
help with the stress. In another situation, a couple
may describe conflict in the family centered on a
child’s poor school performance and defiant
behavior at home. The therapist could suggest a
child and adolescent evaluation with consider-
ation of medication for attention deficit hyperac-
tivity disorder. Other discussions that may occur
in couples and family include concerns about
elderly parents, especially depression, bizarre
behavior or excessive drug use in late adolescents
and young adults, and suicidality in adolescents.
These all warrant treatment specifically directed
toward these challenges. Treatment should
include consideration of pharmacology.
Description of Using
Psychopharmacology
Uses of Psychopharmacology
Medication use can be organized by diagnosis to
be treated or by target symptoms to be affected.
These can be conflated because symptoms can be
put together to create diagnoses. For the family
and the systemic therapist, it is easier to focus on
target symptoms which can be monitored as a way
of evaluating the effectiveness of the
2397
psychopharmacology. (A list of commonly used
medications and common side effects is in the
Appendix of this entry.) Some examples of target
symptoms and medications used to improve or
reduce them are below.
(a) Hyperactivity, poor concentration, and
impulsivity – stimulants and adrenergic
agonists
(b) Anxiety and fearfulness – selective serotonin
reuptake inhibiters (SSRIs)
(c) Low mood, irritability, and low motivation –
selective serotonin reuptake inhibitors, tricy-
clic antidepressants
(d) Hallucinations, delusions, bizarre behavior,
atypical and typical antipsychotics
(e) Flight of ideas, grandiosity, elated mood
cycling with low mood and low motivation –
mood stabilizers and atypical antipsychotics
(f) Emotion dysregulation – adrenergic agonists
and atypical antipsychotics
(g) Insomnia – Melatonin, Benadryl, Remeron,
Trazodone, and at times Seroquel
(h) Aggressiveness – can be difficult to control
with medication and requires a comprehen-
sive evaluation, but atypical antipsychotics
and mood stabilizers are sometimes
prescribed
(i) Other problems that medication may be an
element of the treatment plan for – aggression P
in autism spectrum – atypical antipsychotics,
obsessive compulsive disorder – SSRIs,
panic – benzodiazepines, opiate withdrawal –
Naltrexone and subozone, alcohol
withdrawal – benzodiazepines
Process of Using Medication
Several guidelines are very helpful in using
medication:
1. Clear definition of roles and responsibilities.
Medication decisions and concerns about med-
ication effectiveness and side effects should
always be directed to the prescribing
professional
2. The individual and family should decide with
the professional to use medication
2398
3. The goals of medication use should be clearly
defined with a method of measurement of
response specified
4. If possible only one medication change should
be done at a time
5. Plans for increase and discontinuation of any
medication should be outlined
6. Interactions among psychiatric medication and
with other medications should be clarified
7. A follow-up plan for monitoring the medica-
tion should be specified
As much as possible the couples or family
therapist should be aware of the plan and the
medications used and should engage in enough
communication so that a treatment partnership is
developed.
Using psychopharmacology can be confusing
for systemic therapists. Their focus is in the relation-
ships and interactions between individuals while
psychopharmacology is directed at the thoughts,
feelings, and behavior of an individual. Discussions
about individual concerns can appear to be
scapegoating that person, so the therapist needs to
develop a framework to understand the discussion
and to frame the decision to support requests for
medication. Specific symptoms and consistent func-
tional problems across contexts and circumstances
strengthen the decision to use medication. A trusted
and known physician, psychiatrist, or nurse practi-
tioner can be asked to provide a consultation about
both diagnosis and the potential of medication to
address important thought, emotion, and behavioral
problems. The importance of frequent, open, and
direct conversation between the therapist and the
prescribing clinician cannot be understated. This
communication can include:
1. If medication will be used
2. Discussion of the individual and relational
expectations from using medication
3. Follow-up plan for both clinicians
4. Reasons for changing or stopping medication
5. How each professional can promote both indi-
vidual and systematic effectiveness of using
medication
Psychopharmacology in Couple and Family Therapy
6. Discussion of circumstances that might war-
rant revision of treatment or reconsideration of
the use of medication
Systemic Effects of Using Medication
Usually a family is organized to respond to behav-
iors that may be the targets of medication. Hyperac-
tivity, mood fluctuations, anxiety, compulsions, or
the withdrawal and irritability associated with
depression may be the focus of significant reactions
from family members. Futile attempts at control,
conflictual interactions, and excessive accommoda-
tion of problematic behaviors may be common,
distressing but unavoidable. Once the family and
therapist have agreed that an individual family
member might seek a medication and that medica-
tion is prescribed and noted to be helpful the family
may need to be helped by the therapist to focus
attention on other issues and concerns. The family
may persist in focusing on that symptomatic mem-
ber through reminders about medication or argu-
ments about adherence to the prescribed regimen.
The therapist will need to be aware of these chal-
lenges and skillfully resolve how the medication is
used, how responsibility for taking the medication is
decided upon, and how attention in family interac-
tions can be refocused or redirected. As this happens
the therapist will notice that concerns about medi-
cation and the symptoms it addresses diminish.
Conclusion
Integrated treatment, including psychopharmacol-
ogy and couples and family therapy, is frequently
helpful and necessary. Collaboration and regular
communication between therapist and prescribing
professional is essential. Opportunities for these
clinicians to support and potentiate each other’s
work with the couple or family are present
throughout treatment. Combining systemic and
pharmacologic therapies can resolve chronic con-
flicts and significantly improve outcomes for indi-
viduals and families. Challenges in maintaining
consistent medication use and challenges based
on conflicting belief systems within the family can
be addressed and resolved in relational therapy.
Psychopharmacology in Couple and Family Therapy 2399

Appendix: List of Commonly Used Common side

Psychiatric Medications Stimulants Generic name Use effects
Luvox Fluvoxamine Depression and “........”
anxiety
Common side Wellbutrin Bupropion Depression and Seizures in
Stimulants Generic name Use effects anxiety overdose
Concerta Methylphenidate ADHD Appetite Antianxiety
suppression, (in addition to
irritability SSRI’s)
occasionally Ativan Lorazepam Acute panic Can be
Focalin Methylphenidate ADHD Irritability severe anxiety addictive
occasionally Klonopin Clonazepam Acute panic “........”
Ritalin Methylphenidate ADHD “........” severe anxiety
Metadate Methylphenidate ADHD “........” Xanax Alprazolam Generally not “........”
Methylin Methylphenidate ADHD “........” used

Adderall Dextroamphetamine ADHD “........” Alpha agonists

Vyvanse Dextroamphetamine ADHD “........” Tenex Guanfacine Aggressiveness Sedation

ADHD
Strattera Atomoxetine ADHD Less effective/
sedation Catapres Clonidine Aggressiveness “........”
insomnia
Atypical
antipsychotics Mood stabilizers

Risperdal Risperidone Psychosis Appetite Lithium Lithium Bipolar disorder Kidney and
emotion increase, CNS toxicity/
dysregulation metabolic tremor
changes, Depakote Divalproex Bipolar disorder Weight gain,
muscle rash
stiffness Trileptal Oxcarbazepine Bipolar disorder Sedation
Seroquel Quetiapine Aggressiveness “........” Topomax Topiramate Bipolar disorder “........”
(at times)
Neurontin Gabapentin Bipolar disorder, “........”
Geodon Ziprasidone Aggressiveness “........” pain
(at times)
Lamictal Lamotrigine Bipolar disorder, Rash
Zyprexa Olanzapine Aggressiveness “........” depression
(at times)
Insomnia
Abilify Aripiprazole Aggressiveness “........”
Melatonin Sleep induction
(at times)
Trazodone Trazodone Sleep induction Some
Clozaril Clozapine Aggressiveness Appetite
sleepiness in
(at times) increase,
AM
metabolic
Remeron Mirtazapine Sleep induction “........”
changes,
muscle
P
stiffness, and
blood
abnormalities
Antidepressants
(SSRI’s)
Prozac Fluoxetine Depression and Suicidal
References
anxiety ideation (very
occasionally) Findling, R. L. (2008). Clinical manual of child and ado-
Lexapro Escitalopram Depression and “........” lescent psychopharmacology. Arlingotn: Amreican
anxiety Psychiatc Publishing.
Celexa Citalopram Depression and “........” Martin, A., Scahill, L., & Kratochvil, C. (Eds.). (2011).
anxiety Pediatric psychopharmacology (2nd ed.). Oxford:
Zoloft Sertraline Depression and “........” Oxford University Press.
anxiety (and
Pies, R. W. (2005). Handbook of essential pharmacology
OCD)
(2nd ed.). Arlington: American Psychiatric
Paxil Paroxetine Depression and Not used for
anxiety children and
Publishing.
adolescents Schatzberg, A. F., & Nemeroff, C. B. (Eds.). (2017). The
Other American Psychiatric Association Publishing textbook
antidepressants of psychopharmacology (5th ed.). Arlington: American
Effexor Venlafaxine Depression and Suicidal Psychiatric Publishing.
anxiety ideation (very Yudofsky, S. C., & Hales, R. E. (Eds.). (2012). Clinical
occasionally) manual of neuropsychiatry. Arlington: American Psy-
(continued) chiatric Publishing.
2400
Psychotherapy Networker
Chris Lyford
Psychotherapy Networker, Washington,
DC, USA
Name of Organization/Institution
Psychotherapy Networker
Synonyms
Formerly known as “The Family Therapy
Networker”
Introduction
Psychotherapy Networker is a nonprofit educa-
tional organization dedicated to offering practi-
cal guidance, creative inspiration, and
community support to therapists around the
world. Since its creation in 1978, Psychother-
apy Networker magazine has earned a world-
wide readership for its incisive, tough-minded
coverage of the everyday challenges of clinical
practice and the therapeutic innovations shaping
the direction of the profession. Written with the
practical needs of clinicians in mind, the Net-
worker is the most topical, timely, and widely
read publication in the psychotherapy commu-
nity today. Celebrated for its engaging style, it is
also a recipient of the National Magazine
Award.
Psychotherapy Networker joined the PESI
family in 2015, and PESI began providing sup-
port services for Psychotherapy Networker in
February 2016. PESI offers live seminars and
online learning opportunities in the form of live
video webcasts, online courses, and digital sem-
inars, as well as educational products such as
audio CDs, books, and DVD videos.
Psychotherapy Networker
Location
Psychotherapy Networker
5135 MacArthur Boulevard N.W.
Washington, DC, 20016
USA
Prominent Associated Figures
Richard Simon (owner and editor)
Mary Pipher (features writer)
Marian Sandmaier (features editor)
Mary Jo Barrett (contributing writer and Sympo-
sium presenter)
Judith Beck (Symposium presenter)
William Doherty (contributing writer and Sympo-
sium presenter)
Patrick Dougherty (contributing writer and Sym-
posium presenter)
Lisa Ferentz (contributing writer and Symposium
presenter)
Janina Fisher (contributing writer and Sympo-
sium presenter)
James Gordon (contributing writer and Sympo-
sium presenter)
John Gottman (contributing writer and Sympo-
sium presenter)
Julie Gottman (contributing writer and Sympo-
sium presenter)
Kenneth Hardy (contributing writer and Sympo-
sium presenter)
Susan Johnson (contributing writer and Sympo-
sium presenter)
David Kessler (contributing writer and Sympo-
sium presenter)
Jack Kornfield (Symposium presenter)
Joe Kort (contributing writer and Symposium
presenter)
Harriet Lerner (contributing writer and Sympo-
sium presenter)
Peter Levine (Symposium presenter).
Lynn Lyons (contributing writer and Symposium
presenter)
Tammy Nelson (contributing writer and Sympo-
sium presenter)
Psychotherapy Networker
Margaret Nichols (contributing writer and Sym-
posium presenter)
Esther Perel (contributing writer and Symposium
presenter)
Terry Real (contributing writer and Symposium
presenter)
Richard Schwartz (contributing writer and Sym-
posium presenter)
Marta Straus (contributing writer and Symposium
presenter)
Ron Taffel (contributing writer and Symposium
presenter)
Margaret Wehrenberg (contributing writer and
Symposium presenter)
Michele Weiner-Davis (contributing writer and
Symposium presenter)
Amy Weintraub (Symposium presenter)
Contributions
With one of the largest offerings of distance-learning
programs in the field, the Networker offers continu-
ing education (CE) credits to clinicians through a
number of venues. Learning options include our
popular video interviews with the field’s most cele-
brated practitioners, audio programs on a vast range
of clinical topics, reading courses featuring the work
of therapy’s finest writers, magazine quizzes, and
our annual Networker Symposium.
Since 1978, the Networker Symposium has
hosted a unique annual conference highlighting
the latest developments in psychotherapy. With a
teaching faculty of over 100 of the field’s best and
brightest, the Symposium draws an average of
more than 3000 mental health professionals to
Washington, DC, each year to take part in an
array of learning opportunities. The Symposium
offers workshops and events designed to tap cre-
ativity, sharpen clinical skills, and deepen mental
health professionals’ understanding of their craft.
Continuing education credits are also available for
the Psychotherapy Networker Symposium.
Psychotherapy Networker has featured the early
writing of a number of now-prominent couples’
therapists, including Esther Perel, Susan Johnson,
and John and Julie Gottman. Regular contributors in
2401
the field of couples and family therapy include Betty
Carter, William Doherty, Terry Real, Tammy Nel-
son, Michele Weiner-Davis, Joe Kort, Rick Miller,
Molly Layton, Ellen Wachtel, W. Robert Nay, Jon
Carlson, Margaret Nichols, David Schnarch,
George Faller, Maria Isaacs, Gay Hendricks,
David Treadway, Shirley Glass, Jeri Hepworth,
Karen Kissell Wegela, Michael Metz, Barry McCar-
thy, B. Janet Hibbs, Jeff Levy, Helen Fisher, and
Steven Stosny. Our annual Symposium includes an
average of nearly two dozen workshops that focus
on couples and family issues. Topics covered have
included healing from infidelity, expanding sexual
comfort zones, the power of emotion in couples
therapy, working with domestic violence issues,
divorce counseling, the evolution of sex therapy,
working with cross-cultural couples, couples ther-
apy for traumatized clients, monogamy and poly-
amory, creating secure connections in couples
therapy, working with LGBTQ couples, and how
to make couples therapy gains stick.
Cross-References
▶ Doherty, William
▶ Gottman, John
▶ Gottman, Julie
▶ Hardy, Kenneth V.
▶ Hookup Culture P
▶ Johnson, Susan
▶ Perel, Esther
▶ Real, Terrence
▶ Schwartz, Richard C.
▶ Simon, Richard
▶ Weiner-Davis, Michele
References
Gottman, J. M., & Gottman, J. S. (2018). The new science of
couples therapy. Psychotherapy Networker, 42(3), 36–37.
Johnson, S. (2016). The dance of sex. Psychotherapy
Networker, 40(1), 19–20, 42.
Perel, E. (2018). Our myths about sexuality.
Psychotherapy Networker, 42(3), 34–35.
Real, T. (2017). The long shadow of patriarchy.
Psychotherapy Networker, 41(5), 35–41, 58.
Solomon, A. (2016). Inside hookup culture. Psychotherapy
Networker, 40(1), 30–33, 46–47.
2402
Punctuation in Family
Systems Theory
J. Gregory Briggs and Chris J. Gonzalez
Department of Psychology, Counseling, and
Family Science, Lipscomb University, Nashville,
TN, USA
Name of Intervention
Punctuation
Synonyms
Reframing
Introduction
Punctuation is a method of reconceptualizing a
series of events in a linear manner (i.e., one
event causes another) when the events are in fact
arranged in a circular manner (i.e., events mutu-
ally influence one another). Watzlawick et al.
(1967) saw punctuation as a vital tool for organiz-
ing ongoing interactions. In this way, punctuation
simplifies a complex web of interactions. Punctu-
ation can be useful in therapy when a therapist
utilizes it to examine individual steps in a conflict
cycle (e.g., “Tell me what happens after you get
angry”). Yet, it can also create conflict when cli-
ents punctuate a series of events at different
points, allowing them to blame one another for
the struggles they are facing. For example, when a
couple argues about who started a fight, it is often
because each partner has punctuated a series of
events at different places.
Theoretical Framework
As an intervention, punctuation has its theoretical
foundation in general systems theory and is a com-
ponent of structural, strategic, and systemic family
therapy models. Additionally, punctuation, and its
Punctuation in Family Systems Theory
emphasis on how perspective shapes reality, is also
congruent with aspects of postmodern theory.
Punctuation is particularly useful when thera-
pists and clients attempt to make sense of interac-
tions that are the result of circular causality.
Consider a repeated series of two events, A and
B (i.e., A ! B ! A ! B ! A ! B, etc.).
Punctuation forces a start and end point to the
interaction, allowing A and B to be organized in
one of two ways: A ! B or B ! A. Bateson and
Jackson (1964) noted that people will punctuate
long series of events into short stimulus-response
sequences in order to make them easier to study
and understand. Punctuation, therefore, is an
intervention that allows therapists and clients to
organize events and discuss relationships in more
intuitive ways.
Rationale for the Intervention
Depending on the client context, the rationale for
using punctuation may vary. One way therapists
may use punctuation is to help clients slow down
and understand a circular communication process
by bringing attention to individual aspects of mutu-
ally influential interactions. When clients use punc-
tuation, it reveals power dynamics and says
something about the way clients assign responsi-
bility and blame (Rosenblatt 1994); a therapist can
use punctuation to make overt a hidden, previously
undetected or unexpressed power dynamic and
perhaps balance an out of balance system (i.e., the
therapist could suggest that B could have caused
A in contrast to the client’s claim that A caused B).
If clients can accept the possibility of a different
punctuation, it may help them empathize with the
other person in the relationship.
Description of the Intervention
During the assessment phase of treatment, thera-
pists use punctuation to help clients understand
how they communicate and interact with one
another (Colapinto 1991). It is a tool therapists
use to break apart complex interrelated sets of
factors into digestible, cause and effect talking
Punishment in Social Learning Theory
points. Punctuation can also be used as a form of
reframing when people in conflict blame one
another for an ongoing and self-perpetuating pat-
tern of interaction that may feel unresolvable. Often
clients are completely or partially unaware that they
make a significant contribution to the problem that
they blame the other for. In such circumstances,
punctuation is generally a brief sentence or two
that asks clients to look at a pattern of interaction
differently. When the therapist highlights a differ-
ent portion of an ongoing problematic pattern, cli-
ents become more aware of the mutually influential
nature of their relationship.
Case Example
Donelle (33) and Federico (32) presented for cou-
ple therapy with complaints of communication
issues and increasing interpersonal frustration. In
the first session, Federico was energized and highly
engaged, while Donelle was slow to speak and
seemingly sad and weary. Half way through the
first session, Federico, with tears filling his eyes,
complained, “Donelle doesn’t do anything – noth-
ing at all – to tell me she wants this to get better.”
Donelle’s only response was to slowly look down
with her hands in her lap and her shoulders
hunched, tears streaming down her cheeks. Her
body folded as if it were under a heavy weight. It
looked as if the only thing she could do was to wait
for Federico to keep talking. He asked, softly,
“Babe, can you please say something?” and gave
her no more than a second to respond before
looking at the therapist, saying, “See, she doesn’t
do anything.” Federico became more anxious as he
talked about how disengaged Donelle was and how
he felt overwhelmed by having to “do everything.”
The therapist understood that there was likely a
host of mutually influential factors that contrib-
uted to Federico’s distress, Donelle’s inaction, and
the couple’s relationship struggles. Federico’s
complaint seemed to come from a place of anx-
ious desperation rather than one of condescension
or criticism, and Donelle had the affect and body
language of someone suffering from depression.
Not wanting to further overwhelm the clients, the
therapist used punctuation to simplify and
2403
organize what was likely a complex and circular
couple communication pattern. “Let me see if
I understand. It looks like when Federico gets
desperate, he blames or begs and Donelle with-
draws.” Donelle looked at the therapist in agree-
ment. After a brief pause, Federico said humbly,
“What else can I do? I’m open to anything.”
Cross-References
▶ Bateson, Gregory
▶ Circular Causality in Family Systems Theory
▶ Jackson, Donald
▶ Linear Causality in Family Systems Theory
▶ Reframing in Couple and Family Therapy
▶ Strategic Family Therapy
▶ Structural Family Therapy
▶ Watzlawick, Paul
References
Bateson, G., & Jackson, D. D. (1964). Some varieties of
pathogenic organization. Disorders of Communication,
42, 270–290.
Colapinto, J. (1991). Structural family therapy. In A. S.
Gurman & D. P. Kniskern (Eds.), Handbook of family
therapy (Vol. 2, pp. 417–443). New York: Brunner/
Mazel.
Rosenblatt, P. C. (1994). Metaphors of family systems
theory: Toward new constructions. New York: P
Guildford.
Watzwalick, P., Bavelas, J. B., & Jackson, D. D. (1967).
Pragmatics of human communication. New York:
W. W. Norton & Company.
Punishment in Social Learning
Theory
Jinsook Song, Maxine Notice and Janet
Robertson
Antioch University New England, Keene, NH,
USA
Name of Strategy or Intervention
Punishment in Social Learning Theory
2404
Synonyms
Aversive stimuli
Introduction
Punishment in social learning theory is designed
to reduce and eliminate certain behaviors. Punish-
ment is not considered a behavior; instead, it has a
role of mediating the learning process (Bandura
1977; Skinner 1976). Bandura described punish-
ment as a stimulus or reinforcer in a learning
process. People can experience punishment in
two forms, positive and negative. Negative rein-
forcement and positive punishment are often con-
fused. Negative reinforcement is to take
something aversive away in order to increase a
response. Positive punishment is to add some-
thing aversive to modify behavior (Bandura
1977).
Theoretical Framework
Punishment is often discussed as a part of operant
conditioning in behavioral psychology attributed
to the work of B.F. Skinner (1976). Skinner stated
that behavior is strengthened by its consequences
or reinforcements.
Bandura added the cognitive approach – the
process of observational learning and the mediat-
ing process between stimulus and response – into
Skinner’s theory of operant conditioning. Social
learning theory focuses on learning that occurs
within the social context. People learn from one
another through direct experience, observation,
imitation, and modeling. In this learning process,
people employ self-reinforcement, external rein-
forcement, and vicarious reinforcement to
enhance behaviors (Bandura 1977). For example,
in vicarious reinforcement, people observe others’
behavior and its consequences (e.g., reward, rec-
ognition, or incarceration) and learn from the
observation and alter their own behavior. Rein-
forcement serves to increase desired behaviors.
On the other hand, punishment serves to decrease
unwanted behaviors or terminate them.
Punishment in Social Learning Theory
Rationale for the Strategy or
Intervention
Bandura’s social learning theory described that
individuals can learn through observations rather
than through only personal experiences as Skin-
ner’s work state. In social learning theory, punish-
ment can be experienced in external, self-produced,
and vicarious manners. External punishment – the
legal system of deterrence and exemplary
punishment – is designed to have a preventive
function for forbidden behaviors. Individuals
employ self-produced punishment such as self-
contempt when their behaviors do not match their
standards or values. In addition, individuals can
learn through vicarious punishment by observing
consequences that will enhance or inhibit certain
behaviors (Bandura 1977).
Observed punishments have effects on altering
the thoughts, feelings, and actions of others.
Therefore, vicarious punishment and its conse-
quences have functions of providing information
and motivation, creating an opportunity of emo-
tional learning, value setting, and influenceability
among observers (Bandura 1977).
Description of the Strategy
Educators, applied behavior analysts, behavior
therapists, residential staff, and parents use two
types of punishments as a tool to change an indi-
vidual’s behavior – positive and negative punish-
ments. Positive punishment is done by adding or
presenting aversive stimuli to have decrease
behaviors – naggings, scolding, spankings, or
extra chores. For example, a parent scolds a son
until he removes the trash. The son learns that the
parent’s scolding stops as he removes the trash.
He may do the same action before parent’s scold-
ing starts.
Negative punishment is done by taking some-
thing valuable to a person away – toys, privilege,
or fines (money is taken away). For example, a
teenager violated a curfew, and he lost his privi-
lege of going to a movie with his friends the
following weekend. The teen’s parents punished
him by taking away his privilege.
Punishment in Social Learning Theory
Punishment in social learning theory is gener-
ally considered aversive stimuli, or punishing
stimuli in the learning process, but in some
cases, punishment can produce rewarding effect.
For example, a teacher might scold a student
because of his disrupted behavior in class is a
positive punishment. However, the student con-
siders the teacher’s scold as a reward because he
gains attention from the teacher, and he may con-
tinue the undesired behavior in order to gain the
teacher’s attention.
Punishment works to improve desired behav-
iors on individuals, especially parents’ disciplin-
ary practice for their children. However, many
educators and therapists raised concern of harsh
punishment or corporal punishment impacting
children’s emotional and mental health in nega-
tive ways (Alampay et al. 2017; Rodriguez 2003).
Studies suggest that harsh punishment might be a
source of children’s anxiety, depression, aggres-
sion, and lower levels of moral internalization.
Family therapists often utilize social learning
theory for family interventions. Therapists would
monitor how punishment plays a role in the family
communication patterns, coping strategies, and
family rules and roles. Monitoring the use of
punishment can assist in developing a well-
balanced use of problem-solving strategies and
communication skills, as a tool to shape in the
behavior, cognition, and affect modification of
the family subsystem.
Case Example
In couple relationships, couples often use punish-
ment to modify their partners’ undesired behav-
iors. For example, a partner insisted and left a
party early because he saw his partner talking to
2405
other attractive people. He used punishment as a
teaching or communication tool that he didn’t
want his partner to show affection or attention to
others. A cognitive behavioral marital therapist
may teach alternative communication and
problem-solving strategies to assist the couple in
this scenario (Baucom and Epstein 1990).
Cross-References
▶ Applied Behavior Analysis in Family Therapy
▶ Behavioral Rehearsal in Couple and Family
Therapy
▶ Integrative Behavioral Couple Therapy
▶ Negative Reinforcement in Social Learning
Theory
▶ Parenting Skills Training in Couple and Family
Therapy
▶ Social Learning Theory
References
Alampay, L. P., Godwin, J., Lansford, J. E., Bombi, A. S.,
Bornstein, M. H., Chang, L., & ... Bacchini, D. (2017).
Severity and justness do not moderate the relation
between corporal punishment and negative child out-
comes: A multicultural and longitudinal study. Interna-
tional Journal of Behavioral Development, 41(4),
491–502. P
Bandura, A. (1977). Social learning theory, Prentice-Hall
series in social learning theory. Englewood Cliffs:
Prentice Hall.
Baucom, D. H., & Epstein, N. (1990). Cognitive behav-
ioral marital therapy. New York: Brunner, Mazel.
Rodriguez, C. M. (2003). Parental discipline and abuse
potential effects on child depression, anxiety, and attri-
butions. Journal of Marriage and Family, 65(4),
809–817.
Skinner, B. (1976). About behaviorism. New York: Vintage
Books.