Couples Therapy and Enrichment Techniques

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CHAPTER 5
Couple and Marriage Enrichment and Therapy

Chapter Overview

Approximately 90% of people in the United States will couple and eventually marry at least
once by age 45
Approximately 50% of all marriages fail
Only 3% of married couples seek marital therapy
Over 40% of clients seeking psychotherapy cite marital distress and the reason for seeking
services

Types of couple and marriage treatments

A process by which a therapist works with two individuals who are in a primary and intimate
relationship
couple therapy is when a therapist works with two individuals to improve their
relationship as a dyad
marriage therapy is when a therapist works with a couple that is legally married to help
them improve their relationship
more complicated than couples therapy due to legal considerations
premarital counseling is when a therapist works with a couple to enhance their
relationship before they get married
viewed as preventive
focus is on communication skills, conflict resolution skills, finances, and parenting
ideal time is 4 to 12 weeks before the wedding date

Preventive approaches to working with couples

Universal prevention
focuses on preventing problems in the general population (e.g., a media campaign on
family togetherness)
Selective prevention
focuses on making interventions with at-risk groups to prevent problems (e.g., parenting
classes for parents whose children are having difficulty in school)
Indicated prevention
focuses on minimizing the harmful impact of serious problems in the early stages of their
development (e.g., working with couples to prevent marital difficulties from resulting in
abuse or physical harm to their children)

Major theorists for prevention

David and Vera Mace
marriage enrichment (i.e., strengthening marriages before they are in crisis)
first marriage enrichment retreat in 1962
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founded the Association for Couples in Marriage Enrichment (ACME) in 1973
authored 33 books on marriage enrichment
Marriage education
more cognitive than marriage enrichment (which is more experiential)
use or lectures, visual aids, books, handouts, and interactive discussions
goal is to help couples learn about how relationships work and the rationale behind the
strategies for improvement
bibliotherapy is an important learning strategy
'Smart Marriage' conferences are popular events for marriage education
Marriage enrichment
a systematic effort to improve the functioning of marital couples
focus on married couples interacting with other married couples, learning from each other
involves self-help and couple-help
structured exercises
sharing information and experiences
confronting areas of conflict
giving and receiving feedback (e.g., communication, finances, problem solving, and
having children)
Father Gabriel Calvo
founded Marriage Encounter Program in 1962
team couple leads husbands and wives during a weekend of exercises and sharing of
emotions and thoughts
effective communication skills taught
David and Vera Mace
founded the ACME and it's marriage enrichment programs
husband and wife team lead a structured weekend experience and also provides long term
support
five stages in the ACME process
1. security and community building
2. developing an awareness of the couple's relationship
3. developing knowledge and skills to help improve the relationship
4. planning for growth
5. celebrating and closure
Bernard G. Guerney, Jr.
Relationship Enhancement (RE)
skills building approach
empathic expression
discussion/negotiation
problem/conflict resolution
facilitation (partner coaching)
self-change
other change
generalization
maintenance
use of coaching, modeling, and positive reinforcement
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useful with distressed and nondistressed couples
solid research base
David Olson
PREPARE/ENRICH inventories
PREPARE is used with engaged couples
ENRICH is used with married couples
identifies strengths and growth opportunity areas for couples
five areas of focus
1. communication
2. conflict resolution
3. family-of-origin issues
4. financial planning/budgeting
5. goal setting
strong supportive research
effective with African American as well as European American couples
Training in Marriage Enrichment (TIME) and Prevention and Relationship Enhancement
Program (PREP)
TIME is for married couples and can be a weekend or 10-week long program
organized developmentally and sequentially
begins with accepting responsibility and ends with resolving an actual problem
PREP is a 12-week long program focusing on communication and problem solving skills
and enhancing commitment to the relationship
research supports long lasting benefits from these programs
Other programs
Couples Communication Program (CC)
Great Start
SANCTUS
Practical Application of Intimate Relationship Skills (PAIRS)

Marriage and Couple Therapy

Research support for reducing conflict, increasing marital satisfaction
Conjoint therapy more effective than individual treatment
Major theorists
Susan Johnson
developed emotionally focused therapy in the mid-1980s
an alternative to behaviorally focused approaches at the time

Therapeutic Approaches for Working With Couples

Psychoeducational approaches combined with marriage therapy can make marriages stronger
Crisis oriented approaches are less effective in the long term than approaches with
developmental perspectives
Half of all couples treated eventually return to original levels of relationship discord
Primary reasons for seeking marital therapy
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lack of communication
financial stress
disagreements over priorities
infidelity
All approaches focus on improving marital quality (how the relationship is functioning and
how partners feel about and are influenced by the functioning)
Assessment is complex
"feelings expressed about marriage are greatly affected by the events of the moment and
can change considerably over short periods of time . . . Additionally, individuals in
distressed relationships sometimes do not report themselves distressed" (Lebow, 2005, p.
38)
Common factors among all approaches
establishment of a therapeutic alliance with the couple
goal oriented in deescalating negative reciprocity
building of positive interactions
monitoring treatment progress
successful termination

Behavioral Couple Therapy (BCT)

Premises of the theory
based on the exchange/negotiation model of adult intimacy
combines problem solving and communication skills with behavioral contracting
Treatment techniques
focuses on negotiating pleasant behaviors and teaching problem solving and
communication skills
techniques include positive reinforcement, shaping, modeling
contingency contracts describe the terms for behaviors and reinforcers, one action being
contingent on another
operant interpersonal approach based on the assumptions of exchange theory and quid pro
quo that successful relationships are rewarding
'caring days' is a creative technique in which couples act as if they care about their
spouses, regardless of the other's actions
'positive risk,' is a unilateral action that is not dependent on another for success
Process and outcome
behavioral analysis to assess the marital distress
positive reciprocity to increase rewarding and valued behaviors
communication skills training to increase use of "I" statements, develop behavioral labels,
and provide positive feedback
problem solving to develop conflict resolution and negotiation skills
Unique aspects of behavioral couple therapy
well researched
works best with young couples without a long history of marriage
more effective than individual treatment with alcoholics and, with this population,
reduces social costs, domestic violence, and problems of the couple's children
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Comparison with other theories
a specific and precise skills-based approach
more linear than systemic
Offshoots of behavioral couple therapy
integrative behavioral couple therapy (IBCT)
promotes acceptance as well as change
helps identify areas of the relationship unlikely to change and coming to terms with
those problems
reframing of hard emotions (e.g., hostility) to softer emotions (e.g., sadness)
results are less blaming and more soft emotions, increased empathy and emotional
closeness, and long lasting change
cognitive-behavioral couple therapy (CBCT)
empirically supported, highly effective, short term in nature
used psychodynamic, cognitive, behavioral, and humanistic constructs
first introduced by Albert Ellis and his Rational Emotive Therapy (called Rational
Emotive Behavior Therapy today)
ABC procedure (A is the event, B is the thought produced by the event, C is the
emotion produced)
four choices regarding what individuals and couples thought
positive
negative
neutral
mixed
forms of cognition that cause marital distress
selective perceptions about the events occurring in couple interactions
distorted attributions about causes of positive and negative relationship events
inaccurate expectations or predictions about events that may occur in the
relationship
inappropriate or inaccurate assumptions or general beliefs about the characteristics
of people and their intimate relationships
extreme or unrealistic standards to which individuals hold relationships and their
members
other cognitive behavior methods include
cognitive distraction (thinking of something other than negative aspects)
self-control strategies (how to use rational coping statements)
relapse prevention (learning self-control strategies to prevent relapse)
psychoeducational methods (reading books, attending workshops, listening to
audiovisual materials)

Emotionally Focused Therapy

A systemic approach based on integration of experiential and structural family therapy
Focus on dual perspectives of intrapsychic processes (processing of emotional experiences)
and interpersonal processes (patterns and cycles of partner interactions)
Approach is rooted in attachment theory
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secure attachment is related to higher self-esteem, internal locus of control, extroversion,
openness to experience
insecure attachment often stems from family-of-origin issues and is expressed in the form
of put-downs, belligerence, lecturing, stonewalling, and anger
Interventions include both experiential and structural techniques
Goal is to soften intense emotions to help build attachment and connectedness
focuses on disclosure of feelings
therapist may interrupt arguments and disagreements and reflect with each member as a
means of defusing hostility
members explore the perceptions behind partners' emotional responses and
catharsis is encouraged along with self-awareness
techniques from Gestalt and psychodrama approaches may also be used
Role of the therapist
provides a safe environment for release of both positive and negative emotions
encourages emotional expression while protecting the couple as individuals and partners
Process and outcome
three stage interaction process with nine steps
1. cycle de-escalation (steps 1-4)
designed to uncover negative or hard feelings
2. restructuring interactional positions (steps 5-7)
explore intrapsychic processing of attachment related affect
work to create new interactive patterns
externalize the problem into a relationship problem rather than an individual
problem
3. consolidation/integration (steps 8-9)
review accomplishments
reinforce secure bonding interactions
restructure interactions more positively
Unique aspects of Emotionally Focused Therapy
strong empirical base
process research oriented
timing of positive/negative interaction important change element
appropriate for couples from all backgrounds
wide application
post-traumatic stress disorder
moderately distressed couples
families with a bulimic child
couples suffering from trauma
couples with depression and chronic illnesses
older couples
gay couples
new focus on forgiveness and reconciliation, attachment injuries, and relationship
traumas
70% recovery rate for distressed couples
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90% overall recovery rate for all couples
stronger emphasis on emotion and the concept of self than most theories
strong emphasis on empirical validation
demonstrates efficacy apart from its originators

Divorce Therapy

All marriages have some conflict
25% of couples seeking divorce report seeking professional help
Those couples who do seek help wait an average of 6 years following onset of a serious
problem before actually seeking help
Reasons for divorce are many, including marital stress and dissatisfaction, and physical
assault
Therapists must assess whether or not their efforts will be toward salvaging a relationship or
assisting with its dissolution
Two common ways of dissolving relationships is through divorce therapy or mediation
Divorce therapy helps couples separate from each other physically, psychologically, and/or
legally
Goals include
accepting the end of the marriage
achieving a functional postdivorce relationship with an ex-spouse
achieving a reasonable emotional adjustment and finding emotional support
coping with religious or spiritual angst
realizing the part one played in the dissolving of the marriage
helping the children from the marriage (if there are any) adjust to the loss
using the crisis of the divorce as opportunity to learn about oneself and to grow\
negotiating a reasonably equitable legal settlement
developing healthy habits
Techniques
reading
reflecting
participation in structured exercises
listening for feelings
shifting you statements to I statements
setting aside specific time to discuss problem issues
learning to fully attend to ones partner during conflict without interrupting
avoiding dumping of past unresolved issues or behaviors
refraining from physical actions and/or advice giving
postponing resolution, if needed, until the couple can reenergize and think through issues

Family Mediation

Process of helping couples and families settle disputes or dissolve their marriages in a
nonadversarial way
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A viable alternative to court action
Family/couple mediators are specially trained to function as impartial and neutral third parties
to facilitate negotiation between disputing parties
Objective is to help the disputing parties make informed and mutually agreed upon decisions
that resolve their differences in a practical and fair manner
Steps include
obtain a brief history
gather data about assets, incomes, liabilities, and goals
prioritize important issues
When compared to divorce proceedings, mediation is quicker, less costly, less hostile and
stressful, and more productive
Part of the mediation process is teaching disputing parties how to bargain and come to a fair
agreement
Mediation is conducted within external deadlines and concludes with a negotiated written
contract
For more information
Academy of Family Mediators
Association of Family and Conciliation Courts
National Institute for Dispute Resolution
Society for Professionals in Dispute Resolution

CHAPTER 6
Psychodynamic and Bowen Family Therapies

Chapter Overview

Both therapies began developing in the 1950s
Nathan Ackerman the founder of psychodynamic therapy
Murray Bowen the founder of Bowen family therapy
Similarities
based on psychoanalysis
belief that changes occur best in the context of family history and development
conscious and unconscious processes are the focus of interventions
the past is active in the present
initial life experiences are relevant
intrapersonal and interpersonal processes are intertwined
change is gradual and requires a long term investment of time and resources (20 40
sessions)

Psychodynamic Family Therapy

Major theorists
Nathan Ackerman
began with an interest in families and their influence on mental health and illness
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treated whole families and conducted staff home visits at the Menninger Clinic
established the Family Institute in 1960 (later called the Ackerman Institute for the
Family)
cofounder of Family Process, the first journal in family therapy
new concepts included
tickling of defenses (i.e., provoking family members to open up and say what
was on their mind)
complementarity
focus on strengths
interlocking pathology
Ivan Boszormenyi-Nagy
James Framo
Theodore Lidz
Norman Paul
Donald Williamson
Robin Skynner
Lyman Wynne
Premises of the Theory
human nature is based on drives (e.g., sexuality and aggression)
mental conflict arises when children learn, and mislearn, that expressing basic impulses
leads to punishment
conflict is signaled by unpleasant affect such as depression or anxiety
unconscious processes, called interlocking pathologies, take place among family
members that keep them together
more recent focus is object relations theory
an object is something that is loved, usually a person
object relations means relations between persons involved in ardent emotional
attachments
humans have a basic motivation to seek objects, starting at birth
children often internalize (interject) good and bad characteristics of these objects
within themselves
interjections form the basis for how individuals interact and evaluate their
interpersonal relationships
evaluating relationships can result in splitting (viewing object representations as
either all good or all bad)
results in projection of good and bad qualities onto persons within ones environment
splitting helps people control their anxiety and even their objects, by making them
predictable
splitting distorts reality
object relations theory helps explain reasons for marital choice and family interaction
patterns
transference (the projection onto a therapist of feelings, attitudes, or desires)
used to understand dominant feelings within a family and identify which emotions are
being directed toward what people
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helps with the expression of pent-up emotions (i.e., catharsis)
dream and daydream analysis
helps identify and analyze what needs within the family are not being met and that
may need attention
confrontation
pointing out behavioral contradictions or conflicts with expressed wishes
focusing on strengths
concentrating on strengths helps change the familys focus
life history
identifies past and present interactional patterns
affirms value and acceptance of all family members
promotes trust in the therapist
provides insight for family members
complementarity
the degree of harmony in the meshing of family roles
teacher
good enough mother (e.g., nurturing, encouraging)
catalyst (e.g., activates, challenges, confronts, interprets, integrates family processes)
emphasis on family as well as individual interactions
Process and outcome
therapists interpretation of events
insight by family members
interpretations best offered at the preconscious level
insights translated into new and more productive ways of behaving and interacting
differentiation (i.e., balance of rational and emotional selves and separation of self and
others in a nonaxious way)
if differentiation is not possible, crisis resolution (reduction in symptoms) is utilized,
focusing more on supporting defenses and clarifying communication
Unique aspects of Psychodynamic Family Therapy
focus on the importance of the unconscious in influencing human behavior
raises awareness of intrapersonal and interpersonal connections, such as invisible
loyalties
examines basic defense mechanisms and their influence on family interactions
emphasizes the historical origins of dysfunctions and the treatment of persons and
families so affected
explains how persons form attachments and how family members function as a result
linear, not circular
requires long-term commitment of time and money
requires higher than average intellectual ability
requires abstract thinking skills
lacks empirical research

Bowen Family Therapy
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Among the first systemically based approaches for working with families
Also known as transgenerational family therapy due to its historical focus
Major theorists
Murray Bowen
the originator of this approach
started working with families at the Menninger Clinic
studied mother-patient symbiosis
studied dynamics of families with schizophrenic children
initiated the founding of AFTA
Michael Kerr
Edwin Friedman
theory and therapy cannot be separated
patterns passed down from previous generations must be examined and changed to avoid
repetition in current families
risk for problems associated with family members who are emotionally overinvolved (i.e.,
fused) with each other or emotionally cut off (psychologically or physically) from each
other
low anxiety results in few problems for people or families
eight basic concepts of Bowen Family Therapy
1. differentiation
a level of maturity reached by individuals who can distinguish themselves from
their families of origin and separate their rational and emotional selves.
differentiation is the opposite of fusion.
continuum from autonomy (an ability to think through a situation clearly) to
undifferentiated, also called fusion or undifferentiated family ego mass (emotional
dependency on ones family members)
2. emotional system
emotional reactivity
emotional cutoff
fusion with others
ability to take an I-position
3. multigenerational transmission process
patterns and strategies of coping with stress that are passed on from generation to
generation
selection of marital partners at ones own level of differentiation
4. nuclear family emotional system
low levels of anxiety produce stress, illness, and chronic dysfunction
high levels of anxiety produce rapid emotional equilibrium after the stress passes
5. family projection process
tendency to produce offspring at the same level of differentiation as the couple
poorly differentiated spouses keep emotional distance from one another
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when anxiety gets too great, result may be marital conflict, physical or emotional
illness in one spouse, projection of the problem to the children, or a combination
of these
6. triangles
the basic building block of any emotional system
the smallest stable relationship system
some triangles are healthy, others are not
triangles are a frequent way of dealing with anxiety in which tension between two
persons is projected onto another object
detriangulation helps people separate their feelings from their intellect, reducing
anxiety
multigenerational genograms (a type of family tree) helps people detriangulate
homework assignments to visit their families and ask questions also help reduce
anxiety
7. sibling position
people can develop fixed personality characteristics based on their functional birth
order
8. societal regression
the deterioration or decline of a society struggling against too many toxic forces
(e.g., overpopulation and economic decline) countering the tendency to achieve
differentiation
focus is on the process of differentiation
genograms
a visual representation of a persons family tree
minimum of three generations
tracks relationship changes
repetitive patterns
coincidences
impact of change and life cycle transitions (e.g., off schedule events)
trends
shifts from emotional reactivity to clear cognitions
www.genopro.com
going home again
clients/family members instructed to return home to get to know their family of origin
better
individuals may need to practice staying calm before returning home
detriangulation
the process of being in contact and emotionally separate
two levels
resolving anxiety over family situations and not projecting feelings onto others
separating ones self from becoming a focus when tension or anxiety arises in the
family, avoiding scapegoating or blaming
person-to-person relationships
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helping two family members relate to each other about each other without talking
about others or about impersonal issues
differentiation of self
the degree to which a person is able to distinguish between the subjective feeling
process and the more objective intellectual (thinking) process
may involve all the previous techniques as well as confrontation between family
members and the therapist
asking questions
a main tool of Bowenian therapists
helps people to understand the reactions of those in their families better
differentiation of the therapist is crucial
objectivity and neutrality are important therapist characteristics
coaching
teaching
having family members talk through the therapist to reduce emotional reactivity
setting an example of a reasonable, neutral, self-controlled adult
helping clients look for clues to identify where family pressures have been expressed
and how the family has adapted
assist with drawing genograms
interpret multigenerational patterns of fusion and cut offs
Process and outcome
family members will understand intergenerational patterns and gain insight into historical
experiences that influence current interactions
family members increase levels of differentiation
primary unit of treatment is the individual or couple; whole families usually not seen
best outcome is when spouses work together as a team
Unique aspects of the Bowen Family Therapy approach
focus on family history and avoiding replication of past negative patterns of interaction
use of the genogram
therapy and theory are consistent and inseparable
systemic in nature
controlled focus
cognitive orientation
effective with individuals or client families
well established
strong emphasis on theory and practice
criticism that it is not gender sensitive
some research support
historical focus may encourage families to examine their history rather than the present
insight promoted before action
effective with clients and families experiencing severe dysfunction or low differentiation
the theory underlying the approach is its own paradigm
requires a large investment of time and money due to its long term structure
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the number of people who can benefit from this type of therapy is limited

CHAPTER 7
Experiential Family Therapy

Chapter Overview

Emerged out of the humanistic-existential psychology movement of the 1960s
Most popular in the early days of family therapy
Emphasis is on immediate, here and now, intrapsychic experience
Emphasis on affect (i.e., emotions) and awareness and expression of feelings

Major Theorists

Virginia Satir
social worker and teacher
one of the original members of the Mental Research Institute in Palo Alto, CA
known for a nurturing, warm, and genuine style
published Conjoint Family Therapy in 1964
strong and charismatic leader in the field
originator of family communications theory
utilized group family therapy
Satirs model of family therapy is now called communication/validation family therapy
Carl Whitaker
psychiatrist
pioneering work with schizophrenics
utilized co-therapists to increase effectiveness
coauthored The Family Crucible with Augustus Napier
difficult to separate the therapist from the therapy
intuitive, spontaneous, and unstructured
major contribution was working with families in an uninhibited and emotional way
challenged people to gain control of their lives, examine their own view of reality, and
live more fully in the present
Whitakers approach is called symbolic-experiential family therapy
experience, not education . . . changes families


Individuals are not aware of or suppress their emotions
Results in a climate of emotional deadness where people avoid each other
Emphasis on expression of feelings and increased sensitivity
Focus is on the present
Concentration on increasing self-awareness by actively experiencing the here and now
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Attachment theory is a major component of the experiential approach

Treatment Techniques

The effectiveness of this approach depends on the personhood of the therapist
Two groups of experiential family therapists
few techniques and a strong emphasis on use of self, spontaneity, and creativity (e.g.,
Whitaker)
use of highly structured activities congruent with the personality of the therapist (e.g.,
Satir and the majority of experiential therapists)
Therapists who use few techniques: Carl Whitaker
seven active interventions
1. redefine symptoms as efforts for growth
helps families see previously unproductive behaviors as meaningful
2. model fantasy alternatives to real-life stress
change may be fostered by going outside the realm of the expected or
conventional
3. separate interpersonal stress and intra personal stress
important to distinguish between them because there are often different ways of
resolving them
4. add practical bits of intervention
concrete and practical information may assist in making needed changes
5. augment the despair of a family member
enlarging or magnifying a family members feelings to increase understanding by
other family members
6. promote affective confrontation
directing family members to examine their feelings before exploring their
behaviors
7. treat children like children and not like peers
play with children and treat them in an age appropriate manner
Therapists who use structured techniques: Virginia Satir
techniques are used to increase family members awareness and alter their
relationships
modeling of effective communication using I messages
replaces unclear and nonspecific messages with clear and direct personal positions
promotes leveling or congruent communication
4 communication roles that do not contribute to congruency
1. blamer is one who attempts to place the focus on others and not take
responsibility for what is happening
2. placater is one who avoids conflict at the cost of his or her integrity
3. distracter is one who says and makes irrelevant statements that direct attention
away from the issues being discussed
4. computer (or rational analyzer) is one who interacts only on cognitive or
intellectual level and acts in a super-reasonable way
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sculpting
family members are placed into positions during the therapy session symbolizing
the actual relationships as seen by one or more members
sculpting consists of 4 steps
1. setting the scene
therapist helps the sculptor identify a scene to explore
2. choosing role players
individuals are chosen to portray family members
3. creating a sculpture
sculptor places each person in a specific metaphorical position spatially
4. processing the sculpture
sculptor and other participants derole and debrief about experiences and
insights gained from the exercise
choreography
family members are asked to symbolically enact a pattern or relational sequence
similar to a silent movie
reenact 2 to 3 times to increase depth of experience
discuss what occurred and what family members would like to change
humor
can be a risky intervention
if successful, humor will reduce tension and promote insight
if unsuccessful, humor may alienate some or all family members
humor can be used to point out the absurdity of rigid positions or to relabel a
situation to make it seem less serious
touch
putting ones arms around another, patting a person on the shoulder, shaking
hands
respect personal boundaries of clients
represents care and concern but can be overdone or used inappropriately
props
materials used to represent behaviors or to illustrate the impact of actions
may be metaphorical or literal
ropes, blindfolds
family reconstruction
helps families discover dysfunctional patterns in their lives stemming from their
families of origin
reveals sources of old learning
develops a more realistic picture of who their parents are as persons
paves the way for family members to discover their own personhood
begins with a star or explorer who maps out his or her family of origin in
visual ways
a guide (usually the therapist) helps develop a chronology of significant family
events
3 entry points or tools for a family reconstruction
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1. family map a visual representation of the structure of three generations of
the stars family
2. family life fact chronology a listing of all the demographics and significant
events
3. wheel or circle of influence a visual representation of those who have been
important to the star and who have had an impact, positively or negatively on
him or her
star completes the exercise by working with a group of at least 10 people and
enacting important family scenes
Other experiential techniques
play therapy
interventions that use play media as the basis for communicating and working with
children
in child-centered play therapy, the therapist accepts the child with unconditional
positive regard and allows the child complete freedom of expression
in experiential family therapy, play therapy is usually done within the context of a
family session
filial therapy
an approach in which trained play therapists train parents to be therapeutic agents
with their own children
techniques include didactic instruction, demonstration play sessions, at-home
laboratory play sessions, and supervision
goal is to positively impact the parent-child relationship
strong research support
family drawings
joint family scribble
each member makes a brief scribble, followed by the whole family incorporating
their scribbles into a unified picture
promotes awareness of what it is to work both individually and together
conjoint family drawing
each family member draws a picture as you see yourself as a family
each family member shares his or her drawing and perceptions that emerge are
discussed
symbolic drawing of family life space
therapist draws a large circle and instructs family members to include within the
circle everything that represents the family and to place outside the circle
everything those people and institutions that are not part of the family
family is instructed to symbolically arrange themselves, through drawing,
according to how they relate to each other
family is asked to discuss what was drawn and why, as well as to share each
members perspective on family dynamics and interactions
puppet interviews
one of the family members is asked to make up a story using puppets
acting out stories with puppets can help children feel safe enough to talk about
what is happening in real life
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a variety of puppets is desirable
works well with young children, shy children, or selectively mute children
in actual practice, this technique is limited
therapist is an active participant
co-therapists increase effectiveness by allowing greater utilization of intuition
in Whitakers model, the therapist at times engages in spontaneous and absurd activities
designed to raise emotion, anxiety, and insight and to break down rational defenses
in Satirs model, the therapist is a facilitator and resource person who helps families
understand themselves and others better and promotes clear communication
more structured experiential family therapists use props or other objects
in general, experiential family therapists
establish a warm, accepting, caring, respectful, hopeful environment with an
orientation toward change and improvement
verbalize presuppositions of hope the family has
help family members clarify goals and to use their natural abilities
promote growth through stimulating experiences that provide opportunities for
existential encounter
behave as real, authentic people
do not encourage projection or act as blank screens for families
not only must have a commitment to the approach but must also be active risk-takers
to be effective
Process and outcome
family members should become more aware of their own needs and feelings and share
these impressions with others
more capable of autonomy and intimacy
treatment is designed to promote individual growth without an overriding concern for the
needs of the whole family
some experiential family therapists insist on the whole family, preferably three
generations, attending sessions
according to Whitaker, therapy consists of three stages
engagement is when the therapists become personally involved with their families
through the sharing of feelings, fantasies, and personal stories
involvement is when therapists concentrate on helping the families try new ways of
relating through the use of playfulness, humor, and confrontation
disentanglement occurs after families have made constructive changes and rules and
roles have been modified
according to Satir, therapy consists of three stages
making contact (e.g., shaking hands, attending) to raise self-worth
chaos and disorder is when people are engaged in tasks, taking risks, sharing hurt and
pain
integration and closure occurs as issues in stage two are worked on and family
members are assisted to understand themselves and issues more thoroughly
the family is terminated when
transactions can be completed
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family members can see themselves as others do
there is clear communication
family members can share openly and honestly and take responsibility for outcomes
primary goal of therapy is growth, sensitivity, the sharing of feelings, and congruence
between inner experiences and outward behaviors
family must win the battle for initiative, becoming actively involved and responsible for
making changes
therapist must win the battle for structure by setting up the conditions under which the
therapy will proceed
Unique aspects of experiential family therapy
training programs set up for communication/validation family therapy (Avanta Network)
and filial therapy (National Institute of Relationship Enhancement)
this approach is difficult to research but there is some evidence of the efficacy of Satirs
approach and for filial therapy
focus on immediate experiences
treatment tends to be of short duration and more direct than historical based approaches
emphasizes people as well as structures within the change process
approach depends on sensitive and charismatic therapists
families are encouraged to participate physically in activities
focus on the present rather than on the past may keep therapists form dealing with
historical patterns that need changing
individual growth and intrapersonal change is emphasized rather than family growth and
interpersonal change
emphasis on the here and now without offering assistance about preparing themselves for
the future

CHAPTER 8
Behavioral and Cognitive-Behavioral Family Therapies

Chapter Overview

One of the oldest approaches in the helping professions
Began with a primary focus on behavior but has expanded to include cognitions
Behavioral Family Therapy began with parent-child problems and is based on social learning
theory
Currently embraces a more interactional style of explaining and treating family behavior
problems
Functional Family Therapy is a systemic type of behavioral family therapy
Cognitive-Behavioral Family Therapy began in the 1970s and acknowledged the important
role of cognitive factors (e.g., thoughts, beliefs) in causing and/or maintaining maladaptive
behaviors

20
Major Theorists

B. F. Skinner
first to use the term behavior therapy
originated the concept of operant conditioning (i.e., people learn through rewards and
punishments to respond behaviorally in certain ways)
Gerald Patterson
primary theorist to apply behavior theory to family problems in the 1960s
primary rewards (e.g., candy, point systems, time-out, and contingent attention) used with
parent-child problems
developed family observational codes to assess dysfunctional behavior
authored programmed workbooks for parents to help parents, children, and families
modify behaviors
played a critical role in influencing other behaviorists to work from a systemic
perspective with families
Neil Jacobson
strong research foundation, especially blending academic and clinical outcome research
research in 1995 revealed that 20% of male batterers have lower heart rates during times
of physical assault
developed the concept of acceptance or loving your partner as a complete person and
not focusing on differences, as a strategy to promote change
prolific writer and workshop presenter


All behavior is learned and people act according to how they have been previously reinforced
Behavior is maintained by its consequences and will continue unless more rewarding
consequences result from new behaviors
Maladaptive behaviors, not underlying causes, should be the targets of change
Primary concern is with changing present behavior, not dealing with historical developments
Assessment is ongoing throughout treatment
It is not necessary to treat the entire family
Behaviorists concentrate on teaching functional and appropriate new skills
Behavior therapy is not considered completely systemic but does have an emphasis on family
rules and patterned communication processes
Social exchange theory (the rewards and costs of relationships) is viewed by some as the
basis for a behavioral economy
Cognitive-behavioral theory holds that the relationship-related cognitions individuals hold,
shape couple and family relationships
Health-promoting, relationship-related cognitions promote growth
Negative relationship-related cognitions lead to distress and conflict
Resistant in family members may be based on irrational beliefs

Types of behavioral and cognitive-behavioral family therapies
21

Therapies
more forms of treatment than any other approach, with the exception of strategic family
therapy
Behavior Parent Training
also referred to as parent-skills training
goal is to change parents responses to a child or children, both through thoughts and
actions
linear in nature
initial task is to identify and define a specific problem behavior, and its antecedents
and consequences
parents are trained in social learning theory
didactic instruction and written materials utilized to change behaviors and thoughts
techniques include role playing, modeling, behavioral rehearsal, and prompting
problem behavior is charted throughout treatment
therapist rewards successful efforts through encouragement and praise
psychoeducational approaches are particularly effective for at-risk parenting behaviors
Functional Family Therapy
all behavior is adaptive and serves a function
behaviors helps families achieve one of three interpersonal states
1. contact/closeness (merging)
2. distance/independence (separating)
3. combination of 1 and 2 (midpointing)
therapy is a three stage process
1. assessment
focuses on the function of the behavioral sequence
2. change
clarifying relationship dynamics
interrelating thoughts, feelings, and behaviors
interpreting functions of behaviors
relabeling behavior to reduce blame
discussing how change impacts the entire family
shifting treatment from the individual to the whole family
3. maintenance
educating the family
skills training for dealing with future difficulties, specifically communication,
team building, and behavioral management (e.g., contracting)
Behavioral treatment of sexual dysfunctions
Masters and Johnson pioneered cognitive-behavioral approaches to working with couples
in the treatment of sexual dysfunction in the late 1960s
Four phases of sexual responsiveness
1. excitement
2. plateau
3. orgasm
4. resolution
22
learning and behavioral techniques important tools in treating sexual dysfunctions
squeeze technique for treating premature ejaculation
teasing technique for treating performance anxiety
primary treatment is the conjoint therapy using a dual-sex therapy team
extensive sexual histories are taken
approach is systemic in orientation
Helen Singer Kaplan combined behavioral treatments with psychoanalytic techniques
couple sexual dysfunctions can stem from intrapsychic conflict, interpersonal couple
conflict, and anxiety
Joseph LoPiccolo and associates report success with behavioral sex therapy techniques
including
reduction of performance anxiety
sex education including the use of sexual techniques
skill training in communications
attitude change methodologies
Cognitive-Behavioral Family Therapy
similar to cognitive-behavioral therapy but broader and more extensive
cognitive treatment focus
modifying personal or collective core beliefs (i.e., schema)
teaching families to think for themselves and to think differently when it is helpful
behavioral treatment focus
expressive and listening skills used in communication
problem solving skills
negotiation and behavior change skills
positive reinforcement
extinction
shaping
desensitization
contingency contracts
cognitive/behavior modifications
General behavioral and cognitive-behavioral approaches
education
attending lectures, reading books together, viewing videos as a group, having group
discussion based on learning
communication and problem-solving strategies
instruction, modeling, positive reinforcement
operant conditioning
mostly used in parent-child issues
teaches parents to use time-out and shaping procedures
contracting
used with families expressing severe levels of hostility
contracts build in rewards for behaving in a certain manner
Specific behavioral and cognitive-behavioral techniques
classical conditioning
23
a neutral stimulus is paired up with another event to elicit certain emotions through
association
a person is associated with a gratifying behavior, such as a kind word or pat on the
back
coaching
therapist helps families make appropriate responses by giving them verbal
instructions and a chance to practice
contingency contracting
a written schedule or contract describing terms for trading or exchanging behaviors
and reinforcers between two or more individuals
extinction
process of withdrawing previous reinforcers to return behavior to its original level
replacement behavior is positively reinforced
positive reinforcement
a material or social action that increases desired behaviors
for a reinforcer to be positive, the person must be willing to work for it
quid pro quo
something for something
often the basis for behavioral marital contracts
reciprocity
the likelihood that two people will reinforce each other at approximately equitable
rates over time
marriage is often viewed as based on this principle
shaping
the process of learning in small, gradual steps
also referred to as successive approximation
systematic desensitization
dysfunctional anxiety is reduced or eliminated through pairing it with incompatible
behavior, such as muscular or mental relaxation
gradual procedure
time-out
removal of persons from an environment in which they have been reinforced for
certain actions
isolation for a limited amount of time results in the cessation of the targeted action
best accompanied by a retraining program where rewards are given if the undesirable
behavior does not occur for an agreed-upon time period
job card grounding
used with adolescents and pre-adolescents
an age appropriate type of time-out
small household jobs are listed on index cards
when problem behavior occurs, the adolescent is given one of the jobs to complete
and is grounded until the job is complete
grounding
used with adolescents where the person is removed from stimuli, thus limiting
reinforcement from the environment
24
usually means the adolescent is required to attend school, perform household chores,
and stay in his or her room unless eating meals, doing chores, or attending school
adolescents are not permitted to use the phone, watch television, use the computer
(except for school work), have visitors, etc. until the job is completed or time has
been served
charting
clients are asked to keep an accurate record of the problem behavior in order to
establish a baseline (data on problem behavior before interventions are made)
from baseline data, interventions can be made to reduce the problem behavior
Premack principle
family members use high probability behavior (preferred behaviors) to reinforce low
probability behavior (non-preferred behaviors)
family must first do less pleasant tasks before they are allowed to engage in
pleasurable activities
disputing irrational thoughts
uses the ABC format
through disputing irrational thoughts, the couple or family will develop more rational
thoughts and behaviors
used when a family member unproductively obsesses about an event or person
therapist has person engage in ruminating on a certain thought and interrupts the
rumination by shouting stop
instruction is given for the person to interrupt the thought process internally
neutral or healthy thoughts replace the nonproductive or unhealthy thoughts
self-instructional training
focus on people instructing themselves in changing negative self-talk
self-statements help recall desirable behaviors or interrupt automatic behaviors
modeling and role playing
have family members act as if they were different
new behaviors are practiced and modeled
therapist gives feedback and correction as appropriate
shame attack
a family member experiences something he or she has dreaded and learn they are
no worse off for having engaged in the activity (e.g., asking for something and not
getting it)
family members can use stress inoculation to break down potentially stressful
events into manageable units and then to link all the parts together
therapist is the expert, teacher, collaborator, and coach
assists the family to identify dysfunctional behaviors and thoughts and works to set up
behavior and cognitive-behavioral management programs
engages in modeling, giving corrective feedback, and teaching how to assess behavior
and cognitive changes
Anatomy of Intervention Model (AIM)
1. introduction
2. assessment
25
3. motivation
4. behavior change
5. termination
therapist must be able to exhibit relationship skills such as warmth, humor, nonblaming,
and self-disclosure
cognitive-behavioral therapists spend more time discussing issues with family members
than do behavior therapists
therapists must have persistence, patience, knowledge of learning theory, and specificity
in working with family members
Process and outcome
family members learn to identify, modify, change, or increase certain maladaptive
behaviors and/or thoughts to increase functioning
behavioral family therapy focuses on parenting skills, positive family interactions,
improving sexual behaviors
cognitive-behavioral family therapy is effective with family stress, adult sexual
dysfunctions
blending of behavioral and cognitive-behavioral family therapies is common in practice
Unique aspects of behavioral and cognitive-behavioral approaches
emphases
use of learning theory
strong research orientation
approach has continued to evolve, expand, and incorporate new ideas
treatment is short term
focus is not on pathology (i.e., medical model)
ahistorical approach
assessment does not include looking for biological or chemical causes of behavior or
cognition
less systemic than other approaches
linear orientation may limit the introduction of a more complete family change process
no focus on the affective domain
lack of spontaneity and dependence on techniques may result in losing rapport with
families
by not considering historical data, family patterns and dynamics may be misunderstood
family action is stressed over insight which may lead to change without understanding
integration of concepts and methods from other approaches may make cognitive-
behavioral strategies appropriate as an adjunct to treatment when another approach is
used

26
CHAPTER 9
Structural Family Therapy

Chapter Overview

Based on the experiences of Salvador Minuchin at the Wiltwyck School
Active and often aggressive family members resulted in the development of dramatic and
active interventions for effectiveness
Continues to be a popular family therapy approach
Symptoms are best understood in the context of family interaction patterns
Changes in organization or structure must take place before symptoms can be relieved

Major Theorists

Salvador Minuchin
psychiatrist
wrote Families of the Slums based on his work at the Wiltwyck School
became the Director of the Philadelphia Child Guidance Clinic in 1965
developed a training program for paraprofessionals providing services to the poor
developed treatment techniques for psychosomatic families, particularly with anorectics
wrote Families and Family Therapy, a clearly written and influential book
prolific writer and workshop presenter
pragmatic
every family has a structure that organizes the ways in which family members interact
family structure is revealed only when the family is in action
emphasis on the whole family and its subunits
coalitions are alliances between specific family members against a third
stable coalitions are fixed and inflexible unions that become a dominant part of the
familys everyday functioning
detouring coalitions occur when the pair holds a third family member responsible for
their difficulties or conflicts with one another, thus decreasing stress on themselves or
their relationship
the family is the unit of treatment
subsystems are smaller units of the system as a whole and exist to carry out the tasks of
the family
spousal subsystem is composed of the marriage partners and works best when there is
complementarity of functions
parental subsystem is made up of those responsible for the care, protection, and
socialization of the children and works best in a cohesive and collaborative manner
parental subsystems change as children grow
cross-generational alliances contain members of two different generations and may
involve collusion to obtain certain objectives or needs, such as love or power
sibling subsystem contains members of the same generation
27
boundaries are the physical and psychological factors that separate people from one
another and organize them
clear boundaries are rules and habits that enhance clear communication and
relationships
rigid boundaries are inflexible and keep people separated from each other, making it
difficult to relate in intimate ways, and may result in emotional detachment from
other family members
diffuse boundaries do not have enough separation among family members and
encourage dependence
a parentified child is one who is given responsibilities and privileges that exceed what
would be developmentally consistent with his or her age
therapists must be careful to not mistake normal family development and growing pains
for pathological patterns
alignments are ways that family members join together or oppose one another in
carrying out family activities
roles are prescribed and repetitive behaviors involving a set of reciprocal activities with
other family members or significant others; behaviors family members expect from each
other and themselves
rules are implicit or explicit guidelines that determine behaviors of family members and
may be adhered to irregardless of changes in the family
power is the ability to get something done and is related to authority and responsibility
dysfunctional sets are the repetitive family reactions to stress, repeated without
modification
two general types of techniques, those used in establishing a therapeutic alliance and
those focused on the change process
joining
therapist makes contact with the family, expressing interest in each member
therapist takes a leadership role in initiating the treatment process
important to join with powerful as well as angry family members
four techniques of joining
1. tracking is when the therapist follows the content of the family, uses open ended
questions, is nonjudgmental, and give objective feedback
2. mimesis is when the therapist adjusts the manner or content of his or her
communications to become more like the family
3. confirmation of a family member occurs when the therapist uses an affective
word to reflect an expressed or unexpressed feeling of a family member; also may
involve a nonjudgmental description of the behavior of a family member
4. accommodation is how a therapist joins the family by making personal
adjustments in order to achieve a therapeutic alliance
Disequilibrium techniques
techniques aimed at changing a system by creating a different interactional sequence and
producing a different perspective of reality
28
reframing is used to change a perception by explaining a situation from a different
context; helpful in helping negative situations to be viewed more favorably and to
promote movement
punctuation involves the therapist selectively describing or highlighting a transaction as
a means of changing the perception of everyone involved
unbalancing is a procedure in which the therapist temporarily supports an individual or
subsystem against the rest of the family, forcing the rest of the family to respond
differently and expand their roles and functions
enactment brings the action into the therapy room by asking family members to show
the therapist how they interact during problematic behavioral sequences; redirects
communication among family members instead of between the family and the therapist
working with spontaneous interaction focuses attention on a particular behavior, allowing
the therapist to point out the dynamics and sequences and to focus on process not content
boundary making helps the family define, redefine, or change the boundaries within the
family
intensity involves the use of strong affect, repeated interventions, or prolonged pressure
to change maladaptive behaviors
restructuring is the process of altering existing hierarchical and interactive patterns to
increase family functioning and symptom reduction; accomplished through enactment,
unbalancing, directives, and boundary making
shaping competence is when the therapist reinforces family members for doing things
right or making their own appropriate decisions
diagnosing is a proactive method to describe and/or map out the systemic
interrelationships of all family members; usually done early in the therapeutic process
adding cognitive constructions supplements action oriented techniques by using words,
such as advice or information, to help families help themselves.
pragmatic fictions are pronouncements that help families change
paradox is a technique in which a confusing message is sent to the family designed to
frustrate or confuse them and provide them motivation to search for alternatives
observer
expert
active and directive
requires high energy and precise timing
therapist role changes over the course of therapy
first phase therapist joins the family and takes a leadership position
second phase therapist maps out the underlying family structure
final phase therapist helps transform the family structure
assumes responsibility for setting up and directing therapeutic activities and interventions
therapist is never a player in the family interactions, but works to change the family
structure without becoming a part of it
Process and outcome
process of change is gradual but steady
successful treatment results in symptom resolution and structural change
action is emphasized over insight
29
homework is given for activities outside the sessions to practice new behaviors
family members learn to relate to one another in more functional and productive ways
dated and outgrown rules are replaced
parents are placed in charge of children
differentiation among distinct subsystems occurs
goal is structural change
Unique aspects of structural family therapy
a versatile approach applicable in many situations, especially with juvenile delinquents,
alcoholics, anorexics, low SES families, minority and cross-cultural populations
sensitive to the effect of culture on families
strong emphasis on terminology and ease of application
structural family therapy helped family therapy become accepted in the medical and
psychiatric communities
strong emphasis on symptom removal and family reorganization
pragmatic focus on problem-solving
active therapist involvement in bringing about change
structural family therapy is a well developed, action-oriented and pragmatic approach
as well articulated and illustrated as any other family therapy
criticized for being too simple and lacking complexity
criticized for being sexist and reinforcing sexual stereotypes
focus on the present with no emphasis on past patterns or family history
sometimes difficult to distinguish from strategic family therapy
focus on process, not content
therapist takes a great deal of responsibility for initiating change
short time frames for treatment
may limit family empowerment because the therapist is active and in control of the
process

CHAPTER 10
Strategic and Systemic Families Therapies

Chapter Overview

Influenced by the work of Milton Erickson
Treatment goal is change
Insight and history are not part of treatment
Three major variations
Mental Research Institute
Family Therapy Institute of Washington, DC
Milan Systems Group

Strategic Family Therapy

Goal is to change behavior by manipulating it and not to instill insight
30
Milton Eriksons approach had three major facets
accepting and emphasizing the positive
using indirect and ambiguously worded directives
encouraging or directing routine behaviors so that resistance is exhibited through change
rather than through normal and continuous actions
Major theorists
Jay Haley
masters in communication
worked with and influenced by Gregory Bateson, Milton Erikson, and Salvador Minuchin
adapted Eriksons individual approach to work with families
first editor of Family Process
established the Family Therapy Institute of Washington, DC with Cloe Madanes in 1974
prolific writer, trainer, supervisor, and workshop presenter
influential books include Problem Solving Therapy in 1976 and Leaving Home in 1980
short term treatment
family rules are the overt and covert rules families use to govern themselves
family homeostasis is the tendency for families to stay in the same patterns of
functioning unless challenged to change
quid pro quo refers to the responsiveness of family members to treat each other in the
way they are treated; something for something
redundancy principle is the fact that a family interacts within a limited range of
repetitive behavioral sequences
punctuation refers to a belief that people in a transaction believe that what they say is
caused by what others say
symmetrical relationships and complementary relationships highlight the fact that
relationships within a family are both symmetrical (among equals) and complementary
(among unequals)
circular causality is the idea that one event does not cause another but that events are
interconnected and factors behind behavior are multiple
techniques are very innovative
not helpful to tell families what they are doing wrong
behavior change must precede changes in feelings and perceptions
interventions are tailored to fit each family
reframing is the use of language to bring about a cognitive shift and thus alter the
perception of the situation
directives are instructions from the family therapist for the family to behave differently
nonverbal messages (e.g., silence, voice tone, posture)
direct and indirect suggestions (e.g., go fast or you may not want to change too
quickly)
assigned behaviors (e.g., when you think you wont sleep, force yourself to stay up all
night)
directives increase the influence of the therapist in the change process
paradox is a controversial and powerful technique and has several variations
31
prescribing the symptom is giving the family permission to do something they are
already doing in order to decrease resistance
restraining is when the therapist tells the family they are not capable of changing
prescribing is instructing the family to enact a problem behavior in front of the
therapist
redefining is attributing positive connotations to problem behaviors
ordeals help clients to give up symptoms that are more troublesome to maintain than
they are worth
the ordeal is a constructive or neutral behavior that must be performed before
engaging in the undesirable behavior
the goal is for the client to give up the symptomatic behavior in order to avoid
performing the constructive behavior
pretend is when family members are asked to pretend to engage in problem behavior,
helping them to change through experiencing control of previously involuntary action
positioning involves the therapist accepting and exaggerating what the family is saying
to help the family see the absurdity of what they are doing
active, flexible and creative
therapist is responsible for planning strategies to resolve problems
symptom focused and behaviorally oriented
first task is to define a presenting problem in such a way that it can be solved
problem is defined as one the family has control over and that involves a power struggle
essential to make changes within the first three sessions
each case is handled uniquely
extensive use of homework
Process and outcome
goal is to resolve, remove, or ameliorate the problem the family agreed to work on
families learn how to address other problems in a constructive manner
four common procedures for successful outcomes
defining a problem clearly and concisely
investigating all solutions that have been previously tried
defining a clear and concrete change to be achieved
formulating and implementing a strategy for change
emphasis on process rather than content
focus on breaking up vicious cycles of interaction and replacing them with virtuous
cycle that highlight alternative ways of acting
Unique aspects of strategic family therapy
flexible approach that works well with a variety of client families
effective in cases of enmeshment, eating disorders, and substance abuse
the entire system does not have to be involved in treatment
emphasis on innovation and creativity
works well in combination with other therapies, including behavioral, and structural
approaches
concentrates on one problem and helps focus family resources quickly and efficiently
32
criticized for being too cookbookish and mechanical
existence of schizophrenia is not acknowledged by Jay Haley
strategic family therapy requires considerable training and skills to implement some of its
methods
short term nature may not adequately address the seriousness or extent of problems
lack of collaborative input from client families
therapist takes the blame if treatment does not produce the desired results

Systemic (Milan) Family Therapy

Major theorists
Mara Selvini Palazzoli
trained as a psychoanalyst
specialized in eating disorders but frustrated with results
pioneer in applying psychoanalytic ideas to working with families
blended psychoanalytical approach with approaches of Bateson, Haley, and Watzlawick
formed the Center for the Study of the Family in Milan, Italy in 1971
formed a new group to work with schizophrenics and anorectics in 1982
developed the concept of games, which occur when children and parents stabilize
around disturbed behaviors in an attempt to benefit from them
Palazzoli died in 1999
based on a systemic (circular) view of problem maintenance and a strategic (planned)
orientation to change
focus on the consequences of family communication patterns and conflict between
competing hierarchies
neutrality is essential to keep the therapist from being drawn into family coalitions and
disputes and gives the therapist time for assessing family dynamics
long brief therapy refers to the length of time between sessions (usually a month) and
the duration of treatment (up to a year)
hypothesizing involves a meeting of the treatment team before the family arrives to
formulate and discuss what could be creating a symptom; it is a way of preparing for
treating the family
positive connotation is a type of reframing in which family members behavior is
labeled as benevolent and motivated by good intentions; used to decrease resistance and
establish rapport
circular questioning frames questions so that every question addresses differences in
perception by family members; intent is to highlight information, differences, and circular
processes
invariant prescriptions are a specific type of ritual given to parents of psychotic or
anorexic children to break up power struggles
requires parents to unite so that children cannot manipulate them
parents tell their children they have a secret but dont reveal the secret
parents record the childrens reactions to the parents having a secret
33
parents then go out together for varying periods of time but dont tell children where
they are going or for how long
this mysterious behavior allies parents in a new way
constructive changes in the family and the parents are preserved
variant prescriptions are given for the same goals as invariant prescriptions
tailored to each family and considers unique aspects of each family
rituals are assigned to break up dysfunctional rules and serve to dramatize positive
aspects of problem situations
a type of prescription that directs the family to change their behavior under certain
circumstances
directive should state a specific time the ritual is to be carried out, what is to be done,
who is to do it, and how it is to be done
both and expert and a co-creator of the evolving family system
neutral and nonblaming stance
gives directives
does not try and overtly change families but uses a paradoxical approach to argue against
change
extensive use of circular questions and other indirect interventions
stresses the positive connotations of behavior
defines troublesome symptoms as ultimately in the service of family harmony
Process and outcome
short treatment period
family dynamics are changed
one member (the scapegoat) stops being the focus of the familys problems
nonproductive interactions and games change
old epistemology is replaced with more productive and appropriate behaviors
process of growth continues beyond therapy
vicious cycles are replaced with virtuous cycles of interaction
Unique aspects of systemic therapy
flexibility and application for a variety of client families
therapists work in teams, either present with the family or behind a one-way mirror;
expensive but effective
Greek chorus is a special type of reflecting team in which observers may debate the
merits of what the therapist is doing and families are helped to acknowledge and feel their
ambivalence
concentrates on one problem over a short period of time
European bias toward non-intervention refers to a high respect for peoples individual
boundaries; this view is not universally shared, especially outside of Europe
controversial view about schizophrenia by Palazzoli who states that schizophrenia
always begins as a childs attempt to take sides in the stalemated relationship between . . .
parents
like strategic family therapy, interventions are tailored to the specifics of each family

34
CHAPTER 11
Solution-Focused and Narrative Family Therapies

Chapter Overview

The most recent theoretical developments in the field of family therapy
Solution-focused family therapy concentrates on finding solutions rather than dealing with
problems
Narrative family therapy focuses on helping people solve difficulties by depersonalizing them
and rewriting their own family stories

Solution-Focused Family Therapy

Major theorists
Steve deShazer
began his career at the Mental Research Institute
established the Brief Family Therapy Center in the late 1970s
an ecosystemic approach that uses a team approach whenever possible
team members are called consultants
died in 2005
Bill OHanlon
trained as a family therapist
studied with Milton Erikson
influenced by Erikson, he shifted attention from problems to solutions
approach now called possibility therapy
pragmatic approach
based on social constructionism
treatment includes social, historic, and cultural contexts
reality is not objective but a reflection of observation and experience
language influences the way people see the world
there is no absolute truth; all meaning is constructed
dysfunctional families get stuck in repetitive, unproductive attempts to solve their
problems
solution-focused family therapy breaks up repetitive nonproductive behavior patterns and
sets up situations with a more positive view and active participation in doing something
different
causal factors are not important
identifying problems from nonproblems is important
exceptions to problem behavior are emphasized
all families have resources and strengths to resolve complaints
treatment is short term
history is not emphasized
all families want to change
only a small amount of change is necessary
35
treatment is collaborative with clients
primary technique is to co-create a problem with a family that they want to solve
set up a hypothetical solution by asking the miracle question (If a miracle happened
tonight and you woke up tomorrow and the problem was solved, what would you do
differently?)
miracle questions require family members to suspend present time frames and enter a
different reality
exceptions are times when family members are temporarily free from their problem
scaling questions are used to identify concrete, behavioral levels and to assess for
movement toward treatment goals (On a scale of one to ten, how far do you think you
have come in solving your problem?)
scaling questions are also used to challenge family members to think about what is
needed to get to the next level
emphasis on second-order (qualitative) change or a basic change in organization and
structure
compliments are written messages praising families for their strengths and are always
used as lead-ins to giving family tasks or assignments
clues are interventions that mirror the usual behavior of a family and are intended to
alert a family that some behavior is likely to continue
skeleton keys are procedures that have worked before and that have a universal
application that can help families unlock a variety of problems
five interventions with universal application
1. Between now and the next time we meet, I want you to observe, so that you can tell
me next time, what happens in your (life, marriage, family, or relationship) that you
want to continue to happen.
2. Do something different. This encourages families to explore a range of possibilities
3. Pay attention to what you do when you overcome the temptation or urge to . . .
perform the symptom or some behavior associated with he complaint. This helps
families understand that symptoms are under their control
4. A lot of people in your situation would have . . . This helps families realize there
are more options than those they are currently exercising
5. Write, read, and burn your thoughts. This creates an opportunity to write about past
times and then read and burn the writings the next day
determine how active a client family will be in the change process
visitor not involved in the problem, not motivated to make changes, not part of the
solution; best approach is to respect them, try and establish rapport, and hope theyll
become customers eventually
complainant complain about situations, can describe problems even though they are
not invested in solving them; best approach is to assign them activities where they can
focus on exceptions, respect them, do not push them, hope they can become
customers
customers can not only describe a problem and their involvement in the problem,
but are invested in solving it; best approach is to engage the person in solution
36
oriented conversations and co-create assignments to reproduce behaviors that are
exceptions to the problem
therapist helps clients access resources and strengths
therapist uses pre-suppositional questions to lead families to believe that a solution will
be achieved (e.g., What good thing happened since our last session? and How did you
make that happen?)
several keys may fit the lock (or problem) well enough to open the door to change is
used to illustrate the belief that solutions do not need to be as complex as the presenting
problem
the treatment team is used to map or sketch out the course of successful intervention that
will be a proper solution fit for the family and provide multiple perspectives about the
problem
therapist assists the family in defining clear, specific goals and to create desired behaviors
(i.e., solutions)
clients are encouraged to make small changes rapidly
clients are encouraged to focus on changes in behavior and perceptions and the
mobilization of family strengths and resources
gender solution-focused genograms can help identify gender role messages that may be
negatively influencing their present behaviors
Process and outcome
focus is on seeking solutions and accessing internal resources and strengths
the concept of pathology is not a part of treatment
client families are viewed as cooperative and wanting to change
families are frequently commended for a members behavior
change is inevitable
future oriented
finding exceptions to problem behaviors is important
asking of optimistic questions presupposes that change can happen
reinforcement of small but specific movement
treatment ends when the agreed upon outcome has been reached
Unique aspects of solution-focused family therapy
solution-focused therapies focus on and are directed by the familys theory (i.e., their
story)
therapists assist the family in defining their situations clearly, precisely, and with
possibilities
the past is not emphasized, except when it call attention to the present
the focus is on change rather than on achieving a clinical understanding
emphasis is on empowering families and unlocking their resources and strengths
emphasis on achievable goals, such as small changes in behavior
change is inevitable and clients want to change
unlike Bowen or psychoanalytic theory, virtually no attention is paid to history
like strategic and systemic family therapy, solution-focused family therapy is brief
regarding the situation focused on and the time of treatment
like behavioral family therapy, treatment ends when a behavioral goal has been reached
37
like systemic family therapy, a team is used to help the family help it self
like MRI strategic therapy, solution-focused therapy works to help client families change
thoughts and actions to increase life satisfaction, although solution-focused therapists
trust the family and use family resources more than MRI strategic therapists
solution-focused therapy is an effective adjunct to conventional medical treatment for
migraine and holds promise for other headache symptoms

Narrative Family Therapy

Major theorists
Michael White
began working as a family therapist in Australia in the 1970s
influenced by the work of Gregory Bateson, Edward Bruner, and Michael Foucault,
and of feminist theory
narratives are lived experiences that may be overshadowed by problem-saturated
stories
comparison and evaluation is also a source of life problems
peoples problems viewed as related to the stories they have about themselves rather
than systemic in nature
problem stories are related to oppressive cultural practices
one description of reality is no better than any other
non-systemic
consistent with postmodernism and social constructionism
there are no universal principles or truths
based on narrative reasoning (i.e., stories, sub-stories, meaningfulness, and liveliness)
rather than logico-scientific reasoning (i.e., empiricism and logic)
emphasis is on empowering client families to develop unique and alternative stories about
themselves that will lead to novel options and strategies for living
reauthoring is a way for families to highlight different stories than those that have been
dominant
externalization of problems is used to solve them in that the problem becomes a separate
entity that the whole family needs to solve as a team
externalization of the problem results in:
decrease in unproductive conflict between persons
decrease in the sense of failure an unresolved problem has on persons
increase of cooperation among family members to problem solve and dialogue with
each other
opening up of possibilities for action
freeing of persons to be more effective and less stress in approaching problems
influence of the problem on the person
used to increase the persons awareness and objectivity (e.g., How has the problem
influenced you and your life and your relationships?)
influence of the person on the problem
38
increases awareness of their response to a problem
helps them realize their strengths or potential in facing such a situation
breaks a fixed perception or behavior pattern and creates possibilities for solving the
problem in new ways
raising dilemmas
helping client families to examine possible aspects of a problem before the need
arises
predicting setbacks
setbacks are best dealt with when they are planned for or anticipated
using questions
challenging families to examine the nature of the difficulties they bring to therapy and
the resources available to handle their problems
exception questions identify instances when a situation reported to be a problem was
not true; most begin with when or what
significance questions are designed to reveal the meanings, significance, and
importance of the exceptions
letters
writing letters to families after therapy sessions can extend the dialogue and remind
families what happened in the session; David Epston uses letters as case notes
celebrations and certificates
celebrations
used to bring closure to therapy
tangible affirmations of defeat of a problem
marks a new beginning
should be festive
certificates
should be tailored for the family and their situation
should be printed and affixed with a logo (e.g., apathy
collaborator and non-expert
utilizes basic relationship skills
does not view symptoms as serving any function
problems viewed as oppressive to families
questioner who works to find unique outcome or exceptions when families experience
problems
examines the meaning of situations for families
therapist assists families to separate themselves from old, problem saturated stories and
construct new ones in which they, not their problems, are in control (i.e., reauthoring)
therapist searches for unique outcomes or times when client families acted free of their
problems, even if they werent aware of doing so
Process and outcome
three phases
deconstructing the dominant cultural narrative
client family challenged to examine exceptions
externalizing the problem
39
asked to change their behaviors and collectively address problem
reauthoring the story
reconstruct their story so that problems are less dominant and significant
narrative family therapy has been applied to couple relationships, substance abuse,
adolescent sexual offenders, schizophrenia, post-traumatic stress disorder, AIDS,
anorexia/bulimia, and grief
Unique aspects of narrative family therapy
emphasis on reauthoring of life stories
deconstruction of taken for granted realities and practices
externalizing family problems to increase cooperation among members
searching for exceptions rather than problems
planning for setbacks and the raising of dilemmas as a way of anticipating and planning
for future problems
sending letters to client families about their progress
celebrations and certificates issued when goals are achieved
based on postmodern, social constructionist points of view
the most intellectual and cerebral of any family therapy approaches
no normative patterns for families to strive for; each family determines their own life
story and culture
strong emphasis on the use of language
little attention paid to family history, which is similar to solution-focused, strategic,
systemic, and behavioral therapies
originated outside the United States, as did systemic family therapy
focus on collaborative therapeutic relationships, which is similar to solution-focused and
systemic family approaches
not a systems oriented approach
no acknowledgement of the functionalist elements of both family systems and
psychoanalytic models

CHAPTER 12
Working with Single-Parent Families

Chapter Overview

Single parent families are headed by a mother or father, a sole parent, responsible for taking
care of herself or himself and a child or children (Walsh, 1991)
Single parent families are created as a result of
divorce
death
abandonment,
unwed pregnancy
adoption
uncontrollable circumstances (e.g., receiving a military assignment to a combat zone)
40
Numbers of single parent families have increased sharply, with over 1/3 of US families
headed by a single parent
Historically single parent families were created by death or desertion of a spouse
In the 1950s, families created by divorce started to exceed those created by death
In the 1970s, the decision of many unmarried women to bear and raise children by
themselves also increased

Types of Single Parent Families

Single parenthood as a result of divorce
two subunits are formed (except in some cases of joint custody)
custodial parent, with whom the child resides and his or her interactions with the ex-
spouse and child(ren)
stressors include rebuilding financial resources and social networks
benefits include a renewed sense of confidence in oneself
noncustodial parent, and his or her relationships with the ex-spouse and child(ren)
stressors include finding ways to stay involved with ones children as a parent
rebuilding of social networks
benefits include devising creative problem-solving methods
gaining renewed self-confidence
both parents have the same rights, unless a court order specifies differently
Single parenthood as a result of death
reestablishing ones life and restructuring of the family are major tasks
three stages
mourning stage helps with release of positive and negative feelings and emotions;
death ends a life, not a relationship
readjustment stage learning to do new tasks, dropping old tasks, reassigning duties
to other family members
renewal and accomplishment stage focus on finding and engaging in new growth
opportunities
Single parenthood by choice
characterized by choice and intentionality
actions include
conceiving a child out of wedlock
carrying a child to term after accidentally becoming pregnant out of wedlock
adopting a child as a single adult
parent has time to prepare before the child arrives
clear from the beginning that there will usually be no outside support
Single parenthood as a result of temporary circumstances
change that is usually the result of uncontrollable circumstances (e.g., job change,
deployment in the military)
usually involves one parent making an immediate move while the other parent remains
behind
sudden and seriousness of the change increases stress levels

41
Dynamics Associated with the Formation of Single Parent Families

Dynamics of single parent families formed through divorce
only 70% of marriages last through the first ten years
top three reasons for divorce are social, personal, and relationship issues
social issues
new technologies
more alternatives
less stability
greater opportunities for frustration, fulfillment, and alienation
changing of womens roles
weakening of alliance of men and their work
increased acceptance of options, transitions, and a new openness to mores and laws
divorce is more acceptable today
personal issues
people marry at different levels of psychological maturity
people marry with different expectations
personality conflicts may doom marriages
some marriages may be best served when the relationship is dissolved
interpersonal issues
marriages dissolve when couples perceive the costs as exceeding the benefits
couples frequently do not seek help or seek it too late
common issues following divorce or separation
resolution of the loss of the marriage
acceptance of new roles and responsibilities
renegotiation and redefinement of relationships with family and friends
establishment of a satisfactory arrangement with ones ex-spouse
enormous decrease in income
society disapproves and stigmatizes those who divorce
Dynamics of single parent families formed through death
important to appropriately grieve
family members should talk to one another and with others
releasing feelings assists family members to see the deceased person as mortal instead of
superhuman
Dynamics of single parent families formed through choice
a large and rapidly growing segment of the population
cuts across racial, social, and economic divisions
three major factors influencing this trend
historical tradition
in maternally oriented subcultures, many children have been raised by single
parent mothers and are inclined to avoid marriage and follow the same patterns
they grew up in
racism, ignorance, and socioeconomic crises contribute to this pattern
such patterns or cycles can be difficult to break
change and acceptance by society
42
stigmas and taboos have been broken down
traditional norms and patterns have eroded
choice
includes women who are well educated and older
dramatization in books, movies, and television
more women over the age of 25 are choosing to have children outside of marriage
it is more socially acceptable for single women to adopt babies
women who adopt can pick the time when they wish to become a parent
women who adopt tend to be affluent, not encumbered by a marital relationship,
and can provide more nurturance and time to the child(ren)
Dynamics of single parent families formed through temporary circumstances
the parent left in charge may be overloaded with extra duties and responsibilities with no
additional resources
the parent must prioritize tasks and decide what can be postponed and/or dropped
can be a period of disorganization and stress
the time period for functioning in this way is time-limited

Single Parent Mothers and Fathers

Families of single parent mothers
historically, 85% to 90% of children in single parent families live with their mother
full time paid employment increases self-esteem, daily affect, and arousal as well as
levels of health
because womens wages tend to be lower than mens wages, fewer economic resources
are available
although child support is often part of a divorce settlement, nearly 70% of fathers become
delinquent within a few years of child support
violence and abuse are associated with mother-only homes at the poverty level
time pressures such as work duties and school obligations result in self-sacrifice (e.g.,
sleep and rest)
as a group, identity development is difficult due to issues low-esteem and little work
experience or education
lack of knowledge of medical and psychological services contributes to low functioning
Families of single-parent fathers
historically, 10% to 15% of children in single parent families live with their father
single parent families headed by fathers are growing fast numerically
fathers as single parents usually have access to more than twice the financial resources of
women
increased flexibility in what they do with their children
ability to hire caretakers and take needed breaks from parenting
single parent fathers can choose when to be close to their children and be good role
models
quality time alone, however, seldom bring closeness to a relationship; a combination of
qualitative and quantitative time works best
most single parent fathers feel comfortable and competent as single parents
43
time pressures may lead to exhaustion at the end of the day, with no relief from others
social and parental fatigue is a common

Effects of Divorce or Death on Children in Single Parent Households

50% of children under age 18 will spend some time growing up in a single parent household
Adjustment of children is strongly correlated with pre divorce/death levels of family
functioning, experiences surrounding the formation of the single parent household, and
available resources to the children afterward
Children who lose a parent by divorce
adjustment is best when parents maintain parenting roles, put differences aside, and allow
children to continue relationships with both parents
without strong parental subsystem functioning, children may experience mental and
emotional anguish, acting out behaviors, poor academic achievement, and psychological
problems
in 15 year longitudinal studies, preschoolers were most distressed at the time of divorce
and most adjusted at the time of follow up; adolescents were most affected, both at the
time and at follow up
adjusting to divorce is a continuum, not a discrete event
children disrupted by divorce are less likely to do well educationally and less prone to
form strong adult attachment bonds
kids who are helped to feel socially, emotionally, economically secure are less likely to
end up as cardboard kids (i.e., children who appear fine on the surface, but who may
lack depth, or the ability to be authentic with themselves or others)
suggestions for helping kids through the divorce process include
having both parents tell the children about the divorce with care and concern
giving children advanced warning before a parent moves out
ensuring that children do not feel they are being divorced from either parent
explaining divorce to children in words they understand
giving children space of their own body physically and psychologically
helping children look forward to the visit of a non-custodial parent (which includes
realizing that children often wish their parents would reconcile)
continued contact with non-custodial parent is important
children do best who perceive their fathers as accepting, supportive, and trustworthy and
sense that their fathers will be there for them and provide for them financially
Children who lose a parent by death
children who experience death within the family may become anxious, hope for a
reunion, blame themselves or others, become overly active
important to give children accurate information and support of the surviving parent
three stages of bereavement include protest, despair, and detachment
for adolescents, grief response is influenced by their adjustment prior to the parents death
and their religious beliefs

Strengths and Challenges Connected with Single Parent Families

44
Strengths of single parent families
tendency to be more democratic than most family types
informal style of relating
the needs of all parties are usually considered in decision making
limited resources may result in role flexibility in household tasks regarding which
members perform which tasks
children often learn how to take responsibility for their actions at an early age
children learn essential skills, such as find a bargain or saving money, faster than most
children
increase in creativity in locating and utilizing needed materials for their overall well-
being
survival skills are developed through being frugal as well as innovative
Challenges of single parent families
defining and refining boundaries and roles
problem areas include boundary disputes between former spouses, absent spouses,
and between children and their custodial parent or joint custody parents
boundary issues with former spouses may focus on everything from visitation to
sexuality
democratic nature of single parent families may blur parent and child roles, resulting in
chaotic and confusing interactions
children more than twice as likely to have emotional and behavior problems than
children in intact families
role flexibility may add stress and work resulting in fatigue and burnout
academic difficulties are common for the first 18 months after a divorce
children of divorced parents are less educated than others their age and are less likely
to graduate from high school than those from intact families
difficulty establishing a clear and strong identity and relating to the opposite gender
children of divorce leave home earlier than others
children of divorce are far more likely to cohabit before they marry
children of divorce more likely to divorce
children of divorce may not experience life to the fullest
children of divorce may come to resent growing up so fast and may consciously or
unconsciously display less maturity
single parent families are financially less well off than other family forms
six times more likely to be poor than are nuclear families
frequently lack child support
50% of children living in single parent families live below the poverty line
emotional issues
common emotions are helplessness, hopelessness, frustration, despair, guilt,
depression, and ambivalence
unresolved issues with a significant other
lack of ready access to the needed person
over time, feelings may increase and stress intensify
unresolved emotions keep the person hooked emotionally to historical times and
situations
45
usually takes 2 or more years for a single parent family to resolve their emotions and
to form into a functional unit

Approaches for Treating Single Parent Families

Prevention approaches
premarital counseling results in couples who are more likely to seek marriage therapy
more often, had lower levels of stress, and benefited more from marriage therapy than
couple without premarital counseling
programs that help a spouse after a traumatic separation may be extremely beneficial
Family therapy approaches
structural family therapy
deals with common concerns of single parent families such as structure, boundaries,
and power
puts parents in charge of children
strategic family therapy
focuses on immediate problem solving in connection with a particular problem
interventions are direct but often more subtle, such as reframing, use of paradox, and
prescribing symptoms
reframing may be helpful in changing cognitions to make situations more manageable
solution-focused therapy
effective in focusing on new aspects of their lives, finding exceptions to difficult
situations, and doing something different
emphasis on making small changes helps during the initial stages of single parent
family formation
Bowen family therapy
helps resolve the past and examine historical family patterns
genograms help single parent families notice and deal with the absent person or
persons that have influenced them, positively or negatively
experiential family therapy
Satirs approach is particularly useful in helping single parent families metaphorically
enact troublesome and unresolved situations
feelings that emerge from activities such as sculpting or choreography can be worked
through and resolved
narrative family therapy
externalizing the problem may help family members pull together to deal with
emotions such as anger, fear, and anxiety as a team
future stories can also be therapeutic and provide hope and direction
Many children in single parent families have already formed opinions about mental health
treatment, ranging from prejudice to negative expectations

Other Approaches for Treating Single Parent Families

Non-theory strategies can also be helpful
helping family members communicate clearly and frequently
46
weekly family conference to talk about concerns, resolve problems and plan for the future
linking family members to needed sources of social support (e.g., Parents Without
Partners)
assisting families with resolving financial matters so the can best utilize their resources
educational methods such as reading books and newsletters

Role of the Therapist

Single parent families, as with all families, are socially, psychologically, and economically
unique
Biases and personal prejudices about single parent families
therapists must examine and set aside their own biases and personal prejudices about
single parent families
therapists must resolve their own personal problems (e.g., a divorce) that might involve
the issue of a single parent family
family therapists must deal directly with people, hierarchies, and circumstances of these
families, not myths and stereotypes
family therapists must assist single parent families in giving up negative stereotypes of
themselves
Emotional volatility
assist clients to distinguish between emotional divorce issues and legal divorce issues
assist clients to set aside emotional issues at times in order to make mature and
reasonable legal decisions
Accessing inner resources
assist families to tap into their inner resources and strengths
encourage families to utilize support groups

Process and Outcome

Single parent families benefit from family therapy in four major ways
1. more confidence and competence in themselves. Family members:
rely more on themselves and extended networks of family and friends
function better with greater efficiency
better knowledge of agencies or support networks
experience fewer behavior problems and less stress
increase their relationship skills, especially between parents and children
2. clear and functional boundaries
new hierarchies, free of intergenerational enmeshment
parentified childs role is no longer necessary and can be given up
interactions between the new single parent family and others
3. ability to make informed decisions about remarriage
ability to examine the pros and cons of remarriage options
single parents can make better decisions
children can work through their feelings before instead of after the marriage
4. utilization of resources
47
more use of community resources
better use of their own resources
financial and personal management improvement
reduction of negative feelings from past experiences

CHAPTER 13
Working with Remarried Families

Chapter Overview

Terms for remarried families include
stepfamilies
reconstituted families
recoupled families
merged families
patched families
blended families
Two adults and step-, adoptive, or foster children
Remarried families have become the norm in American society
High divorce rates (approx. 50%) have contributed to a large remarriage trend because 3 out
or 4 divorced people eventually remarry

Forming Remarried Families

Most commonly formed when a person whose previous marriage has ended in death, divorce,
or abandonment marries a previously married person or someone who has never married
Common concerns of remarried families
establishing a remarried family is a complex process
complex kinship networks
ill-defined goals
new patterns of interaction
Carter & McGoldrick developmental stage model
Dealing with the death of a parent
before the twentieth century
one of every two adults died before age 50
less than a third of all marriages lasted more than ten years
50% of children lost a parent before reaching maturity
blending of families and use of kinship networks were common responses
death was real and rituals helped with mourning and moving on with life
currently
death is covered up or denied in many families
death occurs in hospitals away from family members
funeral services may have closed caskets
those who have died are described in vague terms (e.g., departed, passed on)
result may be incomplete grief
48
in remarried families, family members may have difficulty accepting a new member
who is seen as replacing a deceased family member
no established guidelines for couples and their offspring to follow in coming together
Dealing with the divorce of a couple
common reasons include affairs and conflicting role expectations
predictors include a husbands unwillingness to be influenced by his wife and a wife who
starts quarrels harshly and with hostility
two thirds of divorces occur in the first ten years of marriage
most vulnerable times for divorce are during the first seven years and after 16 to 24 years
of marriage
the birth of a child can also produce distress and disruptions
most people who divorce eventually remarry
ethnic groups experience the consequences of divorce differently
African-Americans couples are more likely to separate and stay separated longer
before obtaining a divorce and less likely to remarry once separated
a greater percentage of African-American children (75%) will experience divorce than
will European-American children (40%)
contact between nonresidential parents and their children declines over the years
boys are negatively impacted without contact with non-residential fathers, becoming less
competent and having more behavioral problems than children in other types of family
arrangements
Making healthy adjustments in remarried families
transitions for children in remarried families
liabilities include
losing the closeness of a previous parent relationship
losing ones ordinal position from a previous family experience
moving into a new house and/or neighborhood
having to relate to stepsiblings and a stepparent
benefits include
increased closeness with biological parents as well as their stepparent
increased positive attention from known and new relatives and relations
identifying common interests among new stepsiblings and developing lasting
relationships
establishing a new identity that is more congruent with who they wish to become
Transitions for parents and stepparents in remarried families
uncertainty is common
no accepted social roles for stepparents
established routines may be difficult to modify or break
previously unmarried parent may have difficulty making a place for themselves within the
new family system; may alienate others in the process
expectation that new family will act like the old family
previously married spouses may have unpleasant memories or experiences with an ex-
spouse that are unresolved
the nature of the relationship between ex-spouses is a significant predictor of intimacy in
the remarried spouses
49
children do best having parents who form an ongoing parental alliance

Dynamics Associated With Remarried Families

Remarried families are born out of loss and hope
Remarried family members often carry a positive fantasy with them about what family life
can be like
Before a remarriage can develop, prior experiences with a former family must be resolved
Without mourning and resolving prior issues, it is difficult to emotionally join a new family
Structural characteristics of remarried families include
a biological parent elsewhere
a relationship in the family between an adult (parent) and at least one child that predates
the present family structure
at least one child who is a member of more than one household
a parent who is not legally related to at last one child
a couple that begins other than simply as a dyad
a complex extended family network
The structure of most remarried initially is a weak couple subsystem, a tightly bonded parent-
child alliance, and potential interference
Remarried families are binuclear, that is, two interrelated family households that comprise
one family system
Remarried families have quasi kin who are part of an extended kin network of remarried
spouses families

Issues Within Remarried Families

Prominent issues center around
resolving the past
alleviating fears and concerns about stepfamily life
establishing or reestablishing trust
fostering a realistic attitude
becoming emotionally/psychologically attached to others
Finding time to establish the couple relationship
younger children (below the age of 9) bond more easily with stepparents but are more
physically demanding on parents than older children
adolescent identity development issues may complicate the bonding process
Romantic and negative feelings must be sorted out in a timely and appropriate way
partners may not have thought through feelings they bring into the relationship until after
it is formed
expectations may not be realized
unresolved mourning issues may not be adaptable or open to changes
Integrating new members into a cohesive family unit
stepfamilies are less cohesive, more problematic, and more stressful than first marriage
families
50
stepparent/child and sibling relationships are less warm and intimate than first marriage
families
interpersonal connectedness and rapport requires much work
stepfather/stepdaughter interactions, especially with preadolescent children, can be
especially troublesome
2 to 5 years may be needed to form in-depth relationships with stepchildren and to
establish the primary parent role
Visher and Visher have identified eight tasks for stepfamily identity development

Strengths and Challenges of Remarried Families

Strengths of remarried families
life experience
common interests or opportunities unavailable in the original family of origin
survival of critical incidents from which they have learned about themselves and
others
assists in understanding environments in different and potentially healthy ways
can increase empathy and influence individual and family resilience
kin and quasi-kin networks
help reduce couple and family isolation and frustration
may provide moral support, guidance, or physical comfort
creativity and innovativeness
remarried family members can offer new ideas, perceptions, and possibilities for
resolution of issues
appreciation and respect for differences
ability to appreciate and respect differences in people and ways of living
mothering and fathering can take many different forms
new habits from stepsiblings may be helpful
making the most of situations
coping successfully with difficult situations strengthens remarried families
insights gained can be taught to other families
Challenges of remarried families
loss of an important member
non-custodial parents may be physically absent but retain a strong impact on the
remaining family members
all members of the family may be affected by one individuals unresolved personal
issues related to loss
establishment of a hierarchy
children can lose status regarding their ordinal position in the family
loss of place and power are exacerbated if the children involved dont like their new
stepsiblings or stepparent
until relationship issues are worked out, families may be vulnerable to disruption and
volatile emotional and/or physical outbreaks
boundary difficulties
the structure of a stepfamily is less clear than biological families
51
boundary ambiguity may result in loyalty conflicts and feelings of guilt about
belonging to two households
boundary issues include
membership (Who are the real members of the family?)
space (What space is mine? Where do I really belong?)
authority (Who is really in charge? Of discipline? Of money? Of decisions?
etc.)
time (Who gets how much of my time and how much do I get of theirs?)
boundary problems can create chaos and members are unsure of who and what is
involved in making their lives adaptable
boundary issues are best dealt with in straightforward fashion, including sexuality
issues between unrelated siblings or parents and siblings
boundary issues can and should be discussed and negotiated by family members
resolving feelings
feelings and emotions need to be resolved but are often suppressed, denied, or
projected onto others
economic problems
as a group, remarried families are less affluent than all other family types except
single parent families
lack of money adds stress to the family
unique expenses of child support and/or the cost of maintaining two residences add to
financial difficulty
blending finances can be difficult but are best achieved through:
re-evaluating insurance needs
updating financial documents
creating and sticking to a budget
rethinking asset allocations
developing a will or a living will

Approaches for Treating Remarried Families

Guidance in retaining old loyalties
remarried family members need not give up old loyalties in order to form new ties
families benefit from learning to be inclusive rather than exclusive
therapists draw instructional diagrams of how the family is operating and challenge the
family to participate in cooperative interactive events
Focus on parental involvement
stepparents need to balance their involvement so there is a balance among all family
members
stepparents should spend time before and after their wedding discussing the impact of
past relationships on new relationships
family therapists can help stepparents overcome unresolved issues and learn to contribute
to the well-being of all family members.
Provide education
52
education can help remarried families understand differences between stepfamily and
non-stepfamily systems and provide guidelines for handling typical situations
books and pamphlets can be effective for all ages
Assist in the creation of family traditions and rituals
help families develop new traditions and rituals
rituals may be beneficial to:
the forming of relationships
the resolution of ambiguous boundaries
the healing of loss
the settling of hierarchy and power struggles
the creating of beliefs
the beginnings of changes
Structural family therapy
effective approach because of strong focus on setting up clear hierarchies and establishing
clear boundaries
open systems are encouraged to insure permeable boundaries with current and former
spouses and their families
facilitates co-parenting relationships and prevents children from having inappropriate
power
Experiential family therapy
Virginia Satirs methods may be particularly appropriate
sculpting and choreography can help family members see closeness and distance of
relationships as well as dysfunctional patterns
Transgenerational work
use of a three generation genogram helps family identify patterns that can inform and
assist in forming the new family unit
the past can be used to plan for a productive future and avoid previous mistakes

Role of the Therapist

Therapists must be active, take charge of emotional sessions, and be flexible and resourceful
in the use of different therapeutic modalities
Decrease confusion, fear, and depression of children who are the focal points of child
custody, visitation, or child support disputes
Be well informed about legal processes as well as psychological ones
Knowledge of family jurisprudence can help all family members make better decisions
Work with family members to arrange predictable and mutually satisfactory arrangements
between former parents and their child or children
Help stepparents work together to be effective parents
Encourage family members to relinquish personal myths they have carried into the new
family relationship
Help family members learn effective communication skills
Provide information about structured programs and reading lists for both adults and children
53
Provide a forum within the therapeutic setting for mourning the loss of the previous
relationships and developing new relationships in the reconstituted family

Process and Outcome

Better understanding of themselves as systems and subsystems
Support for the new parent and sibling subunits, stressing the importance of learning to work,
play, and make mistakes together
Development of age and stage appropriate cohesion
Parents present a unified front regarding acceptable and unacceptable behaviors
Increase tolerance for one another and family life events
Decreased projection and distortions
Eliminating the romanticizing or idealizing of those who are now outside the formal structure
of the family
Helping each member find their place in the new family
Family environment becomes cohesive, safe, and open to novel ideas
Fostering of new traditions, celebrations, and rituals
Development of a healthy self-concept of themselves as a family
Development of internal strength to deal with external pressures and stereotypes

CHAPTER 14
Working with Culturally Diverse Families

Chapter Overview

Multiculturalism is a term used to refer to the cultural groups within a region or nation
Although American society has been diverse since its beginnings, little focus was placed on
multiculturalism until the 1970s and 1980s
assumption that conceptual, theoretical, and methodological frameworks already
developed would be appropriate for everyone, regardless of color or background
until the 1980s, the non-white population was relatively small in the United States
today, non-white racial and ethnic groups are growing rapidly and intercultural couples
are becoming more common
1 in 15 marriages in the United States in 2005 were mixed race or ethnicity, a 65%
increase from 1990
Interethnic, interfaith, and interracial couples experience challenges both inside and outside
the couple and family
Family therapists must be open to diversity and culturally competent to be effective
Cultural competency is sensitivity to factors such as race, gender, ethnicity, socioeconomic
status, and sexual orientation and the ability to respond appropriately in a therapeutic manner
to persons with a different cultural background than their own
Therapists who are not culturally competent risk undervaluing, misunderstanding, and/or
pathologizing client behaviors
54
Although cultural groups share similarities, stereotyping groups according to cultures should
be avoided; within group differences are greater than outside differences in cultures

What Is A Culture?

Culture is the customary beliefs, social forms, and material traits of a racial, religious, or
social group
culture include diverse groups of people who may differ in regard to race, religion, or
social status but who identify themselves collectively in a certain way
cultures operate on many levels, inclusive or exclusive, specific or general
cultural values define behaviors and therefore establish norms for attitudes and behaviors
within families
Racial group is a family, tribe, people, or nation belonging to the same stock
race is primarily a biological term
Ethnic groups are large groups of people classed according to common racial, national, tribal,
linguistic, or cultural origin or background
ethnicity influences the kinds of messages that people learn, such as patterns for intimacy
ethnic family customs influence a groups fit within an overall culture, just as race does

Dynamics Associated with Culturally Diverse Families

The ways in which families from different cultural backgrounds view and respond to life
events differs from other families
Jewish families often marry within the group, encourage children, value education, and
use guilt to shape behavior
Italian families place importance on expressiveness, personal connectedness, enjoyment
of food and good times, and traditional sex roles
certain events in the family life cycle represent greater crises for one culture than another
Irish families view death as the most significant life cycle transition and will go to great
lengths to not miss a wake or a funeral
Puerto Rican families stress interdependence in their culture and therefore experience
death as an especially profound threat to the familys future and often experience extreme
anxiety
Culturally diverse families often experience overt as well as covert criticisms of their patterns
of family interaction that may not be universally accepted
women who are treated as inferior by certain families may be taken to task by others
majority culture may ignore or disdain important civic or religious holidays in particular
cultural groups
Physical appearance (e.g., skin color, physical features, dress) may lead to subtle and blatant
prejudice and discrimination
families are faced with the task of nurturing and protecting each other in ways unknown
to majority culture families
Access to mental health services may be difficult
55
location, formality, advertising of services, clinic operation hours, language used, and
lack of culturally diverse practitioners may limit access and utilization of services by
culturally diverse families
Economic factors such as exclusion from certain jobs and limited employment opportunities
result in many culturally diverse families living in poverty

Issues Within Culturally Diverse Families

Family therapists may be at an initial disadvantage in working with culturally diverse families
because the field of marriage and family therapy reflects a dominant European American bias
Sensitivity, experience, acceptance, ingenuity, specificity, and intervention are factors that
often determine successful treatment
Sensitivity
sensitivity and respect for beliefs and world view of the client/family is crucial
culturally encapsulated counselors tend to treat everyone the same and make mistakes in
so doing
Experience
family therapists can benefit from having life experiences that include cultural diversity
cultural backgrounds of culturally diverse families are often influenced by a familys
experience with the larger society
Acceptance
therapists who cannot openly accept culturally diverse families, they may exhibit overt or
covert prejudice that negatively impacts the therapeutic process
social, behavioral, and economic differences need to be examined to determine whether
the therapist and family are a good match
Ho (1987) has developed a model for examining therapists values
Ingenuity
effective family therapists utilize natural help-giving networks that exist in most cultural
settings
therapists act as consultants to agencies and persons who can best work with certain
families
Specificity
because each family is unique, family therapists must assess the strengths and weaknesses
of each family and design and implement specific procedures for each
therapy models should be selected and/or modified to address the needs of specific
families
intervention
therapists serve as systematic change agents by intervening on behalf of families in
unhealthy and intolerant systems
some systems involve passive insensitivity to diversity (i.e., the plight of people outside
ones culture is simply ignored) while others involve active and intentional insensitivity
to diversity (i.e., fostering active discrimination that is easier to identify)
advocating for culturally diverse families requires courage, persistence, and time

Approaches for Treating Culturally Diverse Families
56

Culturally diverse families have some commonalities, including the importance of extended
family and kinship ties
Gay and lesbian families
1 out of every 10 cases in marriage and family therapy involves lesbians or gay men
gay and lesbian couples are more likely to seek professional mental health services than
heterosexual couples
gay and lesbian couples are intergenerational
gay and lesbian life cycle issues are crucial to understand if these families are to be
understood
there is much within group variation among gay and lesbian families
gay and lesbian families have mixed levels of satisfaction in their relationships
many gay and lesbian couples and families suffer from a lack of affirming role models
gay and lesbian couples and families face discrimination from society in general
Therapeutic treatment of gay and lesbian families
therapists need to begin by examining their own values and feelings regarding this
population
therapists need to be aware of internal and external issues associated with being a gay or
lesbian couple or family, including cultural and societal homophobia and local, state, and
national laws affecting gays and lesbians
extended families may need to be involved in treatment due to the difficulty many
families have in accepting the lifestyle and sexual orientation of their kin
treatment planning can be complex due to the variety of gay and lesbian lifestyles and
subcultures
a challenge is assisting families to relate positively to themselves, their partners, and
society
commitment ambiguity can occur where one partner is not sure about his or her place in
the relationship
African American Families
African Americans are currently the third largest minority group in the United States
because of continuous racism, poverty, and discrimination, the family unit has been an
essential institution for survival
families are known to be strong in the areas of kinship bonds
religious orientation and spirituality are strengths
cooperation, strong motivation to achieve, caring parenting, and work orientation are
positive characteristics of African Americans
African Americans are adaptable in their family roles, meaning they are less likely to
stereotype each other into roles based on gender
male-female relationships tend to be more problematic, conflictual, and destructive
mistrust, insecurity, unemployment, socialization, and rage (conscious and unconscious
legacies of slavery and a changing society) influence African American roles
despite a belief in the institution of marriage, fewer African Americans marry today than
at any time in history
out of wedlock births account for two out of three first births to African American women
under age 35
57
since the 1970s, African Americans have had increasing opportunities for financial and
social upward mobility, employment and education, and housing and social options
African Americans who remain in poverty tend to be poorer and less educated, and to
have less opportunity to advance
unemployment has risen for African Americans because of the elimination of many
working-class jobs
single parenting, high unemployment, and living in or near the poverty level has resulted
in a loosening of family ties
Therapeutic treatment of African American families
although utilization rates for individual therapy are high, they are low for family therapy
traditionally, African American families have relied upon extended family networks
men, in particular, have been reluctant to share intimate thoughts and feelings because of
socialization patterns that have taught them not to share pain and frustration
problem-focused and multigenerational approaches may be of benefit with this population
(e.g., structural, Bowenian, and strategic family therapies)
psychoeducation, especially with single parent African American women, can also be
effective
trust issues must be resolved between non African American family therapists and
African American families
it is helpful to frame family therapy as a form of social support that they can benefit from
clear understanding of multigenerational family systems, especially the importance of
respect for elderly family members
therapists must assure families that they can learn how to handle many of their own
problems, increase their confidence and competence levels, and learn to advocate on their
own behalf
social and institutional issues may need to be challenged when they act as barriers to
improvement
presentation of positive role models can also make a difference
Asian American Families
Asian Americans trace their cultural heritage to countries such as China, Japan, Vietnam,
Cambodia, India, Korea, the Philippines, and the Pacific islands
as many as 32 different Asian ethnic groups have been identified in the U.S.
shared cultural values include
respect and reverence for the elderly
extended family support
family loyalty
high value on education
strong emphasis on self-discipline, order, social etiquette, and hierarchy
Confucian philosophies and ethics heavily influence family life
specific and proper relationships and roles including father/son, husband/wife,
elder/younger siblings
feelings of obligation and shame are prevalent (e.g., if a family member behaves
improperly, the whole family loses face)
Buddhist values stress
harmonious living
58
compassion
respect for life
moderation of behavior
self-discipline
patience
modesty
friendliness
geographically and emotionally, families are moving further apart
substance abuse is increasing among some Asian American populations
weakening of the patriarchical family system with less complete obedience from children
and more democratic family decision making
Therapeutic treatment of Asian American Families
levels of acculturation must be assessed
first-generation families may need assistance in interrelating to other families and
societal institutions as well as problems of social isolation, adjustment difficulties,
and language barriers
role of the therapist with first-generation families may be primarily educational and
avocational rather than remedial
established families may need help in resolving intrafamily difficulties such as
intergenerational conflicts, role confusion, and couple relationships
an acculturation gap (i.e., different rates of acculturation) between immigrant parents and
U.S. raised children often result in misunderstandings, miscommunications, and conflict
best practices include problem or solution focused treatment approaches and an emphasis
on family empowerment
because most Asian American families are reluctant to initiate family therapy, therapists
can be most effective by doing the following:
orient them and educate them to the value of therapy
establish rapport quickly through the use of compassion and self-disclosure
emphasize specific techniques families can use to improve relationships and resolve
problems
racism may disrupt internal family dynamics as well as outside relationships
therapists can assist by addressing societal changes and assessing family skills and
values for dealing with prejudice and discrimination
therapists must create a safe and nurturing environment where family members are
respected and, without fear, explore relevant problems and concerns
general guidelines for working with Asian American families
assess support available to the family
assess past history of immigration,
establish professional credibility
be problem focused/present focused
be directive in guiding the therapy process
provide positive reframes that encourage the family

Hispanic/Latino American Families

59
Hispanic or Latino refers to people who were born in any of the Spanish-speaking countries
of the Americas (Latin America), Puerto Rico, or from the U.S. who trace their ancestry to
either Latin America or to Hispanic people from U.S. territories that were once Spanish or
Mexican
Hispanic/Latino population is the nations largest minority and is growing rapidly
Most Hispanic/Latino American families trace their ancestry to Mexico, Cuba, or Puerto Rico
Most wish to be in the mainstream of society in the United States
Most do not support traditional roles for women
Family oriented and child centered
Parents tend to take complementary roles in disciplining (i.e., fathers) and nurturing (i.e.,
mothers) of their children
Challenges for Hispanic/Latino families
higher unemployment rate than non-Hispanic/Latinos
live below the poverty line at twice the rate of non-Hispanic/Latinos
lag behind non-Hispanic/Latinos in earning high school diplomas and college degrees
Strengths and assets of Hispanic/Latino families
collectivistic culture which views accomplishments as being dependent on the outcomes
of others
cultural values of
dignidad (dignity)
orgullo (pride and self-reliance)
confianza (trust and intimacy)
respecto (respect)
simpatia (smooth, pleasant relationships)
personalismo (individualized self-worth)
machismo (male self-respect and responsibility)
Therapeutic treatment of Hispanic/Latino families
develop a basic knowledge about cultural traditions (e.g., traditional rituals, religious
festivities, Quinceanos, engagements, weddings, and funerals)
Hispanic/Latino individuals prefer to get to know someone as a person rather than
assessing others based on external factors (e.g., occupation, socioeconomic status)
Hispanic/Latinos tend to be physically expressive (e.g., gesturing while they talk)
specific therapeutic considerations
stress related to economic and working conditions can contribute to intrafamily
difficulties; therapists can advocate and be a resource in this area
assess for different levels of acculturation and how the pressure to acculturate may
contribute to family turmoil, especially as it relates to family loyalty
language factors, especially bilingualism, must be explored
outside resources, such as the Catholic church, may be helpful in providing social,
economic, and emotional support
therapist must reinforce the father as being the central figure of the family
therapist must initially accept the role of women as self-sacrificing and victims of
other family members and redirect this behavior to assist in getting others to therapy
Hispanic/Latinos expect therapy to be brief, reflecting their experience with
physicians
60
family therapists should be active and directive, using short-term therapies such as
behavioral family therapy and structural family therapy

Native American Indian Families

Extremely diverse group belonging to 557 federally recognized and several hundred state-
recognized nations
Culture is built around
harmony
acceptance
cooperation
sharing
respect for nature and family, including extended family
Break up or dysfunctionality of the family and extended family is a major problem for Native
Americans
historically, between 25% and 55% of all Native American children have been separated
from their families of origin and placed in non-Native American foster homes, adoption
homes, boarding homes, or other institutions
family breakups have resulted in identity confusion and trauma about relationships to
others
More Native American Indians now living in urban areas than on reservations
cultural connectedness is important to Native Americans
urban life is stressful and contributes to poor mental health
isolation from their roots presents multiple difficulties in terms of functionality
Substance abuse, particularly alcoholism, is a major problem for Native American Indian
families
in some family groups, drinking is encouraged as a form of socialization
alcohol related problems include suicide, higher death and disorder rates, cirrhosis of the
liver, and fetal alcohol syndrome
Therapeutic treatment of Native American families
outsiders do not gain entrance into the family easily
indirect forms of questioning and open-ended questions work best
therapists should know and utilize sacred symbols that can be used metaphorically as
models for relationships
admission by therapists that they may make mistakes in treatment because of cultural
ignorance is helpful in establishing rapport
home-based therapy works well by offering essential services to families who would not
otherwise receive them
combining Structural family therapy and traditional healing modalities, both of which
utilize spontaneity, joining, an complementarity, can be effective
many Native American languages have a visual emphasis (e.g., the verb to learn is a
combination of the verbs to see and to remember
concrete and active behavior, rather than insight is stressed in Native American healing
61
therapeutic approaches that are directive but open ended, such as strategic orientations are
effective

Arab American Families

Over three quarters of the Arab American population are immigrants
Arab Americans mostly come from Asia, Africa, and the Middle East
Arab Americans are the largest cohort of Muslims in the United States
Arab culture is high context rather than low context as found in North American society
emphasis on social stability and collectivity
slower pace of social change
Family is the most significant element in most Arab American subcultures
family connections are the source of influence, power, position, and security
patriarchal family structure; husbands are the undisputed head of the household
husbands are subordinate to their own fathers who in turn, defer to the head of the clan
Therapeutic treatment of Arab Americans
sharp delineation of gender roles
patriarchal authority patterns
conservative sexual standards
emphasis on self-sacrifice for the greater good of the family
emphasis on honor and shame (i.e., outside help is sought only as a last resort)
negative fallout, tension, and distrust from September 11, 2001
clinical recommendations
awareness of the unique cultural context
sensitivity to issues of family leadership and authority
awareness of the strong influence of the family in decision making
sensitivity to the large role of culture
strengths-based approaches are most effective
therapist should be active and balance the role so as not to be seen as a rescuer or a
threat
initial interventions should focus on exploring identity, blending Arab and American
identities, and replacing either/or decision making
genograms can be helpful to assess couple/family strengths, both past and present
although difficult, focusing on couple dynamics can help each spouse find needed support
helping Arab Americans access religious and other groups can provide support and a
sense of community

European Americans

Sometimes referred to under the category of White due to their skin color
White skin is assumed to grant an individual membership into a privileged group
Most people equate White with White Anglo-Saxon Protestant (WASP) ideals
As with other groups, European Americans are a diverse group, coming originally from
countries such as Italy, France, Germany, Ireland, Sweden, Hungary, Ireland, and Greece
62
some groups of European Americans (e.g., Italians, Slavics, and Irish immigrant groups)
have experienced racist treatment from other European American groups
WASP values such as rugged individualism, mastery over nature, competitiveness, and
Christianity, are not representative of all European Americans
similarities between European American groups include middle-class African American
and middle-class European Americans being more alike than middle-class European
Americans and middle-class Russian-born Americans
Therapeutic treatment of European Americans
no one approach fits best
WASPS may prefer Bowen or Narrative therapy due to their focus on individuals and a
strong cognitive orientation

Guidelines for Selecting Treatment Approaches in Working with Culturally Diverse Families

Two main approaches
culture-specific model
emphasis on values, beliefs, and orientation of different ethnic cultural groups
basis for most counselor education multicultural courses
focus on memorizing variations among groups may result in information overload and
emphasizing stereotyping rather than uniqueness among groups
universal perspective model
a generalist approach
assumption that developed counseling models can be successfully adapted to different
cultural groups
focuses on identifying similarities in human processes, regardless of ethnicity or
cultural background
may be too general to be of any real use to therapists
General guidelines in selecting interventions
1. assess whether the familys difficulties are internal or external
for internal problems, standard approaches may be employed
for external problems, culture specific approaches may be best
2. determine the familys degree of acculturation
Americanized families may respond to a broader range of interventions than
families of new immigrants or only second generation
3. explore the familys knowledge of family therapy and their commitment to problem
resolution
for families with little knowledge of mental health services or with time pressures,
educational and/or direct, brief-theory driven approaches (e.g., behavioral, solution-
focused, or structural) are recommended
for other families, culture specific approaches are recommended
4. identify what the family has tried before and what they prefer
preference is an important element for establishing rapport and treatment
effectiveness
intellectual and emotional exploration of biases and values is essential
63
some majority culture therapists may minimize the impact of societal or cultural
expectations on minority families
culturally skilled family therapists have the following characteristics
aware and sensitive to their own cultural heritage and to valuing and respecting
differences
comfortable with differences between themselves and their clients
sensitive to circumstances that may indicate the need to refer a family to another
therapist (e.g., personal biases)
knowledgeable of personal racist attitudes, beliefs, and feelings
family therapists blend different styles of family therapy with the unique cultural or ethnic
values of the family
family therapists should remain concurrently culturally sensitive and open to themselves
and the family
provide support, when and where appropriate, for the expression of thoughts and
emotions
assist families to acknowledge and celebrate their heritage and marker events, especially
those associated with specific life cycle stages
assist families to be aware of, accept, and adjust to family life stages
four major investments therapists must make (ESCAPE)
E engagement with families and process
S-C sensitivity to culture
A-P awareness of family potential
E knowledge of the environment
Process and outcome
initial phase
establish rapport
define roles clearly and early
office furnishings and decorations can enhance development of rapport
respect the family hierarchy, talking to the person of highest status first, then to others
establish a structure or rules for therapy to reduce anxiety and provide direction
middle phase
set mutually agreed upon focus and goals
focus on achieving consensus
be patient
encourage the family members to be as specific as possible
stress family values
use reframing
utilize the assistance of others, such as extended family, family friends, church, or
support community
identify internal family strengths and resources to help promote change without
violating cultural heritage
final phase
evaluate with the family what has been achieved and what still needs to be addressed
highlight the familys ability to work in harmony to accomplish tasks
64
highlight changes so that new ways of interacting can be generalized to other
situations in the future

CHAPTER 15
Working with Substance-Related Disorders, Domestic Violence,
Child Abuse, and Infidelity

Chapter Overview

Substance-Related Disorders and Families

Disorders related to the taking of a drug of abuse (including alcohol, to the side effects of
medication, and to toxin exposure
Almost 60% of the worlds production of illegal drugs as well as a substantial percentage of
legal alcohol products are consumed in the US
1 in 11 Americans suffers from severe addictive problems
One third of all American families are affected by alcohol problems
Illicit drug use is highest among Native Americans, lowest among Asian Americans
Two types of general alcohol use disorders
alcohol abuse a problem pattern where the drinking interferes with work, school, or
home life in addition to problems with the law and society
alcohol dependency the person is unable to control the drinking even after trying
Substance abuse related disorders are considered to be family based
Families play a role in the development and maintenance of substance abuse
Pseudo-individuation may result in which young people in families of addicts lack basic
coping skills and fail to achieve real identify

Manifestation of Substance-Related Disorders

Couple and family manifestations
unhealthy or dysfunctional methods of responding to substance abuse are usually tried
first, such as
shielding the substance-related abuser from the negative consequences of his or her
actions; minimizes the seriousness of the abusers actions
denial of the existence of the disorder; family fails to acknowledge the problem and
may blame problem on external circumstances
negative feelings such as fear, anger, shame, or guilt result in relating to the world and
each other in a despondent or anxious manner
unhealthy roles may be assumed that help the family to survive
enabler a spouse or other family member on whom the abuser is most dependent
and who allows the problem to continue and become worse
family hero an adult or oldest child who functions to provide self-worth for the
family
65
scapegoat often a child who attempts to distract the family away from the abuser
by acting out and being blamed for the familys problems
lost child usually a child who suffers from rejection and loneliness and offers a
substance abuser family relief
family clown often the youngest member who functions to provide the family
with humor, thus reducing tension
deterioration of the couple or family itself by behaviors such as drinking or taking
drugs together; not common but does occur
focus on the substance abuser occurs when the family spends the majority of their
time focused on the substance abuser (e.g., begging, pleading, blaming, shaming)
misuse of family resources can occur when the rest of the family suffers due to a lack
of money and effort to purchase family necessities
Individual manifestations
children may be confused about their self-identity and self-worth, resulting in controlling
behavior in relationships to gain security
children in alcoholic environments are twice as likely to develop social and emotional
problems (e.g., low academic achievement and law violations)
lower levels of attachment and bonding to others may make intimate relationships, such
as marriage, more difficult
focus of energy and time on resolving issues related to the family of origin (e.g.,
numbness, confusion, guilt, denial, compulsive behavior)
inability to form long-lasting and intimate relationships

Engaging Substance-Related Disorder Families in Treatment

Family based treatments are among the most effective approaches for substance abuse
treatment
Despite being a preferred method of treatment for families with substance abusing members,
few family therapists report treating such families
Getting families to agree to come to treatment is a difficult challenge
Concerned significant others (CSO) can help engage families in treatment
old method was to surprise the substance abuser at a meeting known as the intervention
in which CSOs would confront the abuser about the problems they have caused
modern approach is for CSOs to meet with therapists to learn behavioral skills designed
to influence the substance abuser, with the goal to get the abuser into treatment
an effective approach with high success rates reported (64%)
Shift in focus to first forming a therapeutic system, diagnosing potential obstacles to
engaging the family including involving the family system and issues involving the
therapeutic system
Engaging the identified patient (IP)
usually an extremely powerful member of the family whose development has been
arrested and who is resistant to therapy
therapist should make contact with the IP immediately and seek to explore the IPs
goals
Engaging disengaged family members
66
often the father or another family member who is allegedly unwilling to enter family
therapy
direct contact can help convince such a family member that they have much to contribute
to the therapeutic process
Engaging fearful or suspicious family members
reframe the therapeutic process to achieve family agreement on the specific nature of
what will be worked on, thereby increasing their feeling of being more in control

Approaches for Treating Substance-Related Disorders

Families after engagement
many families have a high degree of resistance to therapy
relapse is common (up to 90% having at least one relapse in a four year follow up period)
using systems and supports in the community can reduce resistance and decrease relapse
community reinforcement approach (CRA) is highly effective and one of the top five
treatments for substance abuse
physical, emotional, social, and vocational issues influence each other and must be
addressed in therapy
environmental influences or the physical aspects of a familys life are important to
initially address (e.g., stopping the abusive behavior, getting the abuser dry)
multisystemic framework of family therapy is an approach based on social ecology or
interconnected systems; recognizes that problem behaviors derive from many sources of
influence and occur in the context of multiple systems
after the substance abusing behavior has stopped, work begins on interactional and
activity changes both within and outside the family system
with adolescent IPs, it is important to clarify the drug consumption
experimenting easier and more straightforward approaches work best
dependence and addiction require professional intervention
other issues that must be addressed
feelings
defense mechanisms
work by individuals within families
taking responsibility for behaviors
Structural-Strategic family therapy
one of the first approaches to recognize substance abuse as a family systems problem
begins with stopping the abusing behavior (e.g., detox, support groups)
techniques include
family mapping
searching for family strengths
use of praise
respecting and working within cultural traditions
Bowen family therapy
works well for codependency
67
codependency describes a dynamic in a family involving an overresponsible family
member (usually a spouse) and an underresponsible family member (the substance
abuser)
Bowen approach works to increase differentiation and create a healthy balance of
individuality and togetherness
family members learn to distinguish between subjective feelings and objective thoughts
family members increase flexibility, adaptability, and independence
techniques include
genograms
I position statements
reconnection of emotional cutoffs
Behavioral family therapy
works well, particularly for alcohol abuse
written behavioral contracts are effective in making specific behaviors explicit and
measurable and providing alternative behaviors
written agreements tend to decrease the nonabusers anxiety and need to control the
alcoholic and his or her drinking
Adlerian therapy
based on the premise that family members are discouraged
goal is to increase the social interest of family members
problem is shifted from a disease focused to a socially focused
group work can be helpful in raising self-esteem and increasing parenting and social skills
Systematic Training for Effective Parenting (STEP) helps parents understand family
relations better and improve communication with children
Multifamily therapy
treating several families at one time
cost effective and high success rate
family members may experience their own dynamics in other families easier than in the
context of their own family
women may benefit greatly from this approach and remain in therapy longer than other
approaches
Use of community resources and prevention
often essential to supplement other treatment
family members gain information, insight, coping skills, and support
examples include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Al-
Anon
prevention approaches
keep persons or families from engaging in substance abusing behaviors
make other activities with positive outcomes available and central to their lives (e.g.,
art, athletics, meaningful work, community activities)
for teen alcohol abuse
give kids accurate information about alcohol use
present information through a teen-respected source
help kids say yes to life, not just no to drugs
parent networking
68
set strict rules about drinking with kids
continue pressure to take back communities
primary prevention efforts require substantial community support and resources to be
effective
secondary and tertiary prevention efforts work to prevent relapses, increase understanding
of family dynamics, and provide support

Domestic Violence and Families

Aggression that takes place in intimate relationships, usually between adults
An attempt by one to control the thoughts, beliefs, or behaviors of an intimate partner or to
punish the partner for resisting ones control
Approximately one-third of all married couples experience physical aggression
Referred to as
spousal abuse
partner abuse
marital violence
Includes physical, sexual, psychological, and economic abuse
Common forms are grabbing, slapping, pushing, and throwing things at one another
The worst form of domestic violence is battering - severe physical assault or risk of serious
injury
Gottman identified two types of batterers
1. violent only within the relationship and so afraid of abandonment that he monitors his
partners independence and is jealous of her every move, especially moves toward
independence, such as getting a job
2. violent with just about everyone, exhibiting belligerent, provocative and angry
behavior
well documented association between alcohol intoxication and battering (60% to 70%
rate of alcohol abuse among men who batter)
Assessment of domestic violence
assessment is difficult due to legal barriers (e.g., court orders that mandate separation of
family members) and psychological barriers (e.g., stigma surrounding domestic violence)
violent families tend to go to great lengths to keep the abuse a family secret
violent families often minimize the amount of violence and its impact on the family
assessing the power imbalance within the family helps individuals transition from violent
to nonviolent behaviors and assists in learning the difference of each
open assessment shifts the focus from blame to how the violence has impacted the
entire family and the dynamics associated with emotional expression, family finances,
sexuality, and social connections

Approaches for Treating Domestic Violence

Two major positions about responsibility and domestic violence influence treatment options
1. both parties are equally responsible for the violence (conjoint or couples therapy)
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2. the perpetrator is unilaterally responsible for the violence (intimate justice theory and
education)
Conjoint or couples therapy
involves seeing the couple together
requires an assessment of safety issues
the mans participation must be voluntary
special agreements must be established, that is, material on domestic violence will not
be disclosed by the woman or the therapist until the woman is ready
an optimal therapeutic stance must be achieved, that is a context of self-protection
that recognizes the emotionally disturbing, dehumanizing, and intimidating nature of
domestic violence
conjoint or couples therapy may work if the following additional criteria are met
a history of only minor and infrequent psychological violence or abuse
no risk factors for lethality, such as prior use or threat of weapons
the man admits and takes responsibility for the abusive behavior and demonstrates an
ongoing commitment to contain his explosive feelings without blaming others or
acting them out
the couple talks about their wishes and the current relational dynamics
agreement is reached about new ways to behave and relate
Intimate justice
incorporates the ethical context of domestic violence in intimate relationships
encourages therapists to confront, challenge, explore, and educate clients about abuse of
power in emotional systems
closely related to solution-focused approaches
emphasis on empowerment and disempowerment, internalized beliefs about how partners
should be treated, and abuses of power in ones family of origin
effective with couples who voluntarily enter therapy
Educational treatment
commonly based on intimate justice theory and cognitive behavior theory
Duluth model
a cognitive-behavioral model
people learn violent behaviors because they are reinforced in cultural and societal
circles
people can unlearn these behaviors and learn new ones using cognitive-behavioral
means, such as education
long term social and educational programs (i.e., at least a year) are more effective than
short term
perpetrators must be held accountable for their actions

Child Abuse and Neglect in Families

Child abuse is maltreatment of a child due to acts of commission
physical, sexual, and psychological abuse
Child neglect is maltreatment of a child due to acts of omission
neglect and abandonment
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Abusive families are usually chaotic and have relationship deficits
Effects of child abuse include
aggression
delinquency
suicide
distrust of others
poor school performance
later substance abuse
cognitive, academic, and psychological impairment
Childhood abuse can influence adult behavior (e.g., decreased life satisfaction, depression,
low self-esteem)
Childhood sexual abuse (CSA) includes
unwanted touching (i.e., fondling)
making sexual remarks
voyeurism
intercourse
oral sex
pornography
CSA is significantly underreported, especially for boys
Most abuse of boys is done by perpetrators outside the family
Most abuse of girls is predominantly intrafamilial
Psychological abuse or emotional neglect is more constant in nature and more damaging
throughout life

Approaches for Treating Child Abuse and Neglect

Treatment is complex and involves legal, developmental, and psychological issues
All states require mental health professionals to report child abuse and neglect
Before treatment can begin, legal issues must be resolved
Child abuse may not be treated until adulthood when other complications overlay the original
problems
Therapists should not take the focus off the abuser, which may lead to a belief that the
therapist is excusing the abusive acts
Focus on assisting the abuser to delay impulsive acts and the entire family to recognize and
use alternatives other than violence
Motivation for change is highest right after an abusive act when the family is in crisis and the
abuser usually feels badly about their behavior
Bowen family therapy can be effective in bridging historic issues from childhood and current
adult behaviors associated with the history
Behavioral approaches can be effective in modifying behavior triggered by memories of the
abuse
Group meetings attended by mothers and children in addition to family/network meetings
alone can increase self-esteem and outcome

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Infidelity

Unfaithfulness in marriage
having an affair
extramarital relationships
cheating
sexual intercourse
oral sex
kissing
fondling
emotional connections that are beyond friendships
friendships
internet relationships
pornography use
Infidelity is common in American society
Approximately 25% of men and 10% of women have affairs sometime during marriage
Risk factors include
race (African Americans)
gender (males)
age (younger couples)
employment (working outside the home)
infrequent church attendance
low marital satisfaction
Approaches for treating infidelity
assess for cultural context as culture may define how a couple view unfaithfulness
infidelity is one of the most damaging problems couples face and one of the most difficult
to treat
three recovery stages
1. an emotional roller coaster of emotions
2. a moratorium
3. trust building
stages may be sequential but the recovery process is uneven and includes regressive
moments
Should the act of infidelity be revealed in therapy and how much should be told?
one model of therapy requires no disclosure and respects self-determinism; most
prevalent outside the United States
second model of therapy requires the noninvolved spouse be made aware of the affair
if it has not been previously disclosed before therapy begins; if an affair is kept secret,
it cannot be treated
behavioral couple therapy is effective in cases of infidelity
cognitive-behavioral approaches can emphasize forgiveness and letting go of
resentment, bitterness, and the need for vengeance
therapist must instill hope to the couple that they can make it
it is common for many couples to separate and divorce rather than trying to continue their
lives together
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CHAPTER 16
Ethical, Legal, and Professional Issues in Family Therapy

Chapter Overview

In family therapy, there is a link between selecting treatment approaches and professional
issues, such as ethical and legal factors
Knowledge of ethical, legal, and professional issues can prevent clinical or personal actions
that result in harm to families

Overview of Ethics in Family Therapy

Ethics are moral principles from which individuals and social groups, such as families,
determine rules for right conduct
Relationship ethics refer to ethics in a family that are based on the principles of equitability
and caring.
equitability everyone is entitled to have his or her interests and welfare considered in a
way that is fair from a multilateral perspective
caring moral development and principles are centered in the social context of
relationships and interdependency
Early family therapy models stressed neutrality, rarely discussed ethical principles with
clients, and believed theory and practice were value free
Modern practitioners understand that all therapeutic decisions are related to values and
cannot be ethically neutral
Family therapists may face more ethical conflicts than other types of therapists due to the
complexity of relationships and of meeting the needs of multiple individuals within the
system

Ethics and Values

Values are a ranking of an ordered set of choices from the most to the least preferable
Values have four domains
personal
family
political/social
ultimate
Effective family therapists closely examine their own values first
ethical genograms help determine how ones family of origin made tough ethical
decisions
examine the values of client families from a systemic view (i.e., how family members
values affect the family as a whole) and negotiate with the family if values are far apart
explore values associated with theories, processes, and outcomes selected
using therapy as a means to promote personal values is unethical
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denying the role of values in selecting treatment approaches and outcomes can lead to
clinical errors and possible harm to clients

How Do Values Influence Ethical Practice?

All ethical decision making has, as its core, the values, beliefs, and preferences of
individuals and groups
All values that deal with social rights and obligations inevitably surface in ethical
decisions (Doherty & Boss, 1991)
Action oriented research focuses on finding solutions to problems such as abuse
Family therapists are ethically bound to be honest and open with client families, clearly
informing them of biases and values that impact clinical practices and outcomes

Guidelines for Making Ethical Decisions

Family therapists must be aware of professional guidelines for making ethical decisions
Five primary models and resources
1. Codes of ethics guidelines developed by professional associations (e.g., AAMFT,
IAMFC) to address issues confronting family therapists including:
confidentiality
responsibility to clients
professional competence
integrity
assessment
financial arrangements
research and publications
supervision
public statements
common ethical concerns include
treating the entire family
being current on new family therapy developments
seeing one family member with the others present
sharing values with clients
few specific behavioral guidelines on what to do and how
dual or multiple relationships can be problematic
determining the best course of action from simply reading the code of ethics may be
difficult for both beginning and experienced family therapists
2. Educational resources
case histories relating to ethical dilemmas
Users Guide to the AAMFT Code of Ethics (AAMFT, 2001)
The Family Journal
ethical decision making process
1. generate a continuum of alternative actions for the good of the family and to
meet professional responsibilities
2. evaluate and weigh the consequences of each
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3. make a tentative decision and consult with colleagues/supervisors
4. implement the decision
5. document the process
3. Professional consultation
consultation is the use of experts in an area to enhance ones own knowledge and
abilities
internal consultation talking with an expert where one works about an ethical
matter
outside consultation conversations with a professional outside ones agency or
setting
process consultation conferring with an expert about the ethics or methods one
is using with a family
outcome consultation focuses on the ethics of what the therapist and/or family
hopes to accomplish
formal consultation input received from an expert through an appointment or
structured meeting
informal consultation talking with an expert in the hallways at a professional
therapy conference or some less structured way of interacting
4. Interaction with colleagues and supervisors
provides opportunities for sharing of expertise and wisdom
colleagues may be more accessible than consultants/ed. materials
cost is inexpensive or free
direct supervision by noncolleagues is effective and recommended
family therapy supervision is different from individual therapy supervision
focus on interpersonal as well as intrapersonal issues
videotapes used to critique work
one-way mirrors for live observation and/or supervision
bug-in-the-ear supervision allows live communication with the therapist
during sessions
5. Meta-ethical principles
high level principles that guide ethical decision making
autonomy the right of individuals to make decisions and choices
nonmaleficence the avoidance of doing possible harm to a client through
ones actions
beneficence doing good and promoting the welfare of the client
fidelity being trustworthy, loyal, and keeping ones promises
justice treating people equally

Common Ethical Concerns

6. Confidentiality is the ethical and legal duty to fulfill a contract or promise to clients
that the information revealed during therapy will be protected from unauthorized
disclosure
Confidentiality issues should be conveyed to all family members in a written professional
self-disclosure statement
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Confidentiality has limitations, including:
if clients may inflict harm on themselves or others
when the mental or physical health of a client(s) is called into question
when child or elder abuse or neglect is suspected
when clients give the therapist written permission to share information (e.g., with
another professional)
privileged communication is a clients legal right that confidences originating in a
therapeutic relationship will be safeguarded
avoid talking about cases in public
cell phones, e-mails, and faxes may not be secure
office personnel must understand and abide by confidentiality requirements
client information stored on computers should be password protected
computers should be oriented so that unauthorized persons cannot view the screen
client notes and records must be kept securely locked
Gender issues
gender of therapist and family members influence what issues are addressed in treatment
gender sensitive issues may include
the balance of power between a husband and wife both financially and physically
the rules and roles played by members of different genders and how these are
rewarded
what a shift in a familys way of operating will mean to the functionality of the family
as a while
avoid implementing changes in gender-prescribed behaviors solely based on therapist
values or beliefs
failure to address emotional abuse or intimidation that is lethal to the life and functioning
of the family is irresponsible
Sex between a therapist and a family member
sexual relations between a therapist and client are forbidden in the code of ethics of all
family therapy associations
if sexual behavior between a therapist and client is discovered, the person receiving the
news should confront the accused professional with the evidence and file a written report
to the appropriate association ethics and/or licensure/certification board
ethics and licensure boards have the authority to investigate, receive testimony, make a
decision, and determine appropriate consequences
Theoretical techniques
some theoretical approaches are controversial and should be used with discretion
conscious deceit
paradox
neutrality when violence is occurring
Multicultural therapy issues
multicultural competence is necessary to insure therapists dont impose their values on
families
three potentially serious ethical errors in working with minority culture families
1. overemphasize similarities
2. overemphasize differences
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3. make assumptions that either similarities or difference must be emphasized
culturally relevant perspective identifies what is culturally significant from the familys
perspective rather than from a prescribed cultural perspective that may not be relevant to
a family
Use of the Internet for on-line therapy
useful to communicate with clients locally and around the world
clients can e-mail questions to a counselor and receive an e-mail response within 24 to 72
hours for a predetermined fee
hearing impaired clients or clients in remote areas can benefit from Internet based
counseling
introverted clients may benefit from web based counseling
communication with families or family members in between sessions for guidance, to
lower anxiety, or clarify issues
ethical issues include:
security issues
possible breaches of confidentiality
inability of therapists to either protect clients or warn others of potential danger
inability of therapists to read nonverbal responses and clues
potential for client misunderstanding of written communications
client vulnerability due to incompetent therapists
few existing guidelines for ethical practice (e.g., ACES, NBCC)

Addressing Unethical Behavior

When unethical behavior is observed, the behavior should first be discussed directly with the
person observed to have acted unethically
If the problem is not resolved at this level, the family therapist should be reported to the
appropriate national association (e.g., AAMFT, IAMFC) or licensure/certification board
regulating the practice of family therapy
If allegations about a family therapist are made through a client, options include:
check with an attorney or ethics case manager
encourage your client to file an ethics complaint with her or his professional association
or licensure/certification board
file a complaint yourself
do nothing, if your professional code doesnt require you to report
In addressing ethical violations, it can be traumatic for a client to come forward against a
therapist

Legal Issues in Family Therapy

Ethical issues often overlap with legal issues
Important legal terms
legal law or the state of being lawful
law a body of rules recognized by a state or community as binding on its members
liability an obligation and responsibility one person has to another
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civil liability results from lawsuit by a client against a therapist for professional
malpractice (negligence) or gross negligence
criminal liability results from the commission of a crime by the therapist, such as
failing to report child abuse, engaging in sexual relations with a client, or insurance
fraud
administrative liability results when the therapists license to practice is threatened
by an investigation from a board which has the power to suspend or revoke the license
Differences between legal and therapeutic systems
legal systems are concerned with gathering evidence based on facts
therapy is more interested in processes and making changes

attorneys spend more time gathering information and concentrating on content than
therapists do

legal systems rely on adversity
therapeutic systems rely on cooperation

attorneys focus on winning cases for their clients, often discrediting or disproving
evidence that contradicts their cases
family therapists affirm family members and work towards equitable resolution of family
issues

in the legal system, each family member is represented by a different legal counselor
family therapists work with the whole family to resolve internal disputes

AAMFT provides its members one free consultation per quarter with legal counsel to
discuss legal and ethical practice issues

Types of law
common law law that is derived from tradition and usage; accepting customs passed
down from antiquity
statutory law laws passed by legislative bodies and signed by an authorized source; only
valid in the jurisdiction in which they are passed
administrative (regulatory) law specialized regulations passed by authorized
government agencies that pertain to certain specialty areas
case law (court decisions) law that is decided by decisions of courts at all levels from
state to federal
civil law acts offensive to individuals; most applicable to family therapists
criminal law acts offensive to society in general

family therapists must be aware of their duties and responsibilities in all areas of law and
ethics

Legal Situations That Involve Family Therapists

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Expert witness
family therapists may be asked to testify in court about probable causes and
recommendations in regard to family members
essential to remain objective, establish credibility, speak from authority, and be specific
courts are adversarial, with one side seeking to affirm the testimony of the expert witness
and the other side working to discredit the expert witnesss testimony
Child custody evaluator
family therapists may be asked to determine what is in the best interest of a child when
making child custody arrangements
child custody evaluators represent the child and the court, not the parents
duties may include home visits, testing, and conversations with the child
requires a background and experience in child development, family systems, parenting
skills, psychometrics, counseling, and witness testimony
Reporter of abuse
when reporting abuse, family therapists are breaking confidentiality
abuse reporting is mandated in all states
Child Abuse Prevention and Treatment Act of 1974 established mandated reporting for
the greater good of society
it is recommended that family therapists advise the family when they are obligated to
report abuse and to explain the reporting process
Court-ordered witness
family therapists may be asked to testify in court on behalf of or against a family or
family member
if subpoenaed, it is recommended that family therapists immediately seek the advice of an
attorney to avoid pressures to take sides and to avoid penalty or perjury situations

Issues of Law in Family Therapy

Malpractice failure to fulfill the requisite standard of care because of omission (what
should have been done, but was not done) or commission (doing something that should not
have been done)
negligence must be proven for a malpractice suit to be brought forward
common malpractice issues include:
advertising most states place legal limits on practice titles and only professionals
who have met specified criteria may call themselves licensed marriage and family
therapists
record keeping clinical records must be accurate, kept secure, and maintained for a
specified length of time
camera review of clinical records is when an impartial party, usually a judge,
reviews records and releases on pertinent parts of the clinical record
liability insurance is essential to protect therapists financially from legal claims that
they have mishandled family needs or members

Professional Identification as a Family Therapist

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Who are marriage and family therapists?
AAMFT research on MFTs in the United States in 2004
over 50,000 licensed MFTs
30,000 MFT trainees working toward licensure or completing coursework
two-thirds have masters degrees, one-third doctorates
half of the professionals work exclusively in private practice
one quarter work in institutional or organizational settings
one quarter work in both
two thirds work full time; 21% work part time
most clients are seen during normal business hours
73% also see clients in the evenings
one third see clients on weekends
mean salary in 2004 was $46,573, compared to the overall mean of $43,000 for the
general population
income varies greatly due to the diversity of settings, and other factors such as age and
experience
mean age is 54
60% of licensed MFTs are women
91% are white
Who seeks marriage and family therapy?
majority are women
ethnic distribution closely resembles the general population
80% white
9% black
10% Hispanic
4% Asian
1% Native American
10% other
children are overrepresented in MFT caseloads
average session length is 59 minutes
two thirds of clients were in therapy for less than one year
treatment approaches
33% use cognitive-behavioral approaches
10% use multi-systemic approaches
6% use psychodynamic approaches
5% use Bowen family therapy
5% use solution-focused therapy
most common presenting problems
mood disorders
couple relationship problems
family relationship problems
anxiety disorders
adjustment disorders
Organizations associated with family therapy
professional associations
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establish standards for the profession, including ethical codes
provide a means for address grievances involving practitioners or the profession in
general
provide a means for practitioners to communicate with one another through
conferences and publications
provide opportunities for continuing education to keep practitioners abreast of current
practices and issues
American Association for Marriage and Family Therapy
oldest and largest (23,000 members)
established in 1942
focus on accrediting educational programs (COAMFTE)
focus on advocating for MFT licensure at the state level
publishes professional literature and videotapes
Journal of Marital and Family Therapy
Family Therapy News
lobbies for MFTs, including recognition of MFTs as core mental health providers
American Family Therapy Association
founded by Murray Bowen in 1977
1,000 members
objectives are
advancing systemic theories and therapies
promoting research and professional education
disseminating information about family therapy
fostering the cooperation of all professionals concerned with the needs of families
promoting the science and practice of family therapy
membership categories include
charter
clinical-teacher
research
distinguished
foreign
annual conference to share ideas and develop common interests
Division 43 of the American Psychological Association: Family Psychology
established to enable psychologists who worked with families to maintain their
identity as psychologists
3,000 members
concerned with the science, practice, public interest, and education of psychologists
who work with families
annual conference
The Family Psychologist
Journal of Family Psychology
according to LAbate (1992), family psychologists differ from family therapists in
three areas
1. family psychology is interested in the whole functionality-dysfunctionality
continuum, while family therapy is mainly concerned with dysfunctionality
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2. family psychology focuses reductionistically on the relationship of the individual
within the family, while family therapy focuses holistically on the family as a
whole unit or system
3. family psychology stresses objective evaluation and primary and secondary
prevention approaches, while family therapy stresses the subjective understanding
of the family and sees therapy as one type of tertiary prevention
not everyone agrees with LAbate and there continues to be debate on the identify of
family psychology
International Association of Marriage and Family Counselors
a division of the American Counseling Association
4,000 members
regional and national conferences
established national training standards (CACREP)
The Family Journal: Counseling and Therapy for Couples and Families
IAMFC Newsletter
produces training videotapes and publishes books
established standard to credential MFTs
National Council on Family Relations
established in 1939
the oldest professional association dedicated to working with families
focus on education
focus on disseminating information on family history, family forms and functions,
and family life in a variety of settings
Journal of Marriage and the Family
Family Relations: Interdisciplinary Journal of Applies Family Studies
annual conference
Education of family therapists
professional identity is linked to ones education
educational programs and processes are regulated by accreditation bodies
Commission on Accreditation for Marriage and Family Therapy Education
(COAMFTE)
Council on Accreditation of Counseling and Related Educational Programs
(CACREP)
issues in the education programs in family therapy
professional in-fighting for recognition among accreditation boards and professional
groups
some professional groups refuse to recognize other similar groups
current programs tend to ignore controversial issues or issues that are hard to teach
(e.g., divorce, substance abuse, homelessness, teen pregnancies, extramarital affairs,
impact of HIV/AIDS on family life)
Issues in professional identification
practitioners have many choices for professional organizations and alignment
each professional association has unique aspects or foci
friction continues to exist among associations dedicated to family therapy

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CHAPTER 17
Research and Assessment in Family Therapy

Chapter Overview

Family therapy has incorporated research based procedures since the early days of the field
In the initial development of family therapy, research came first and therapy was secondary
Many practitioners later abandoned research and assessment due to ethical, moral, and legal
considerations as well as the complicated nature of family therapy research
There was a resurgence in research interest in the 1990s with increased incidence of
published research articles and increased sophistication and quality of research procedures
Family assessment focuses on dimensions of particular families and is based on theoretical
models of family function and dysfunction
formal or informal tests
behavioral observations
Family assessment is less well developed and more complex compared to individual
assessment

Importance of Research in Family Therapy

Accountability the ability to prove that family therapy is effective
Practicality the influence of research findings on clinical practice
Uniqueness research findings help establish both similarities and distinct differences with
other mental health counseling approaches

Research Findings in Family Therapy

In general, most individuals and families improve with couple and family therapy, especially
when compared with control groups
marriage and family interventions are more effective than no treatment with effects of
treatment maintained at follow-up
improvement rates are similar to improvement rates in individual therapy
deterioration rates are similar to deterioration rates in individual therapy
family therapy is as effective as individual therapy for some personal problems, such as
depression
family psychoeducation programs decrease relapse and rehospitalization rates among
patients whose families receive such services
different kinds of marriage and family interventions tend to produce similar results
brief therapy (20 sessions or less) is as effective as open-ended or long-term therapies
participation of fathers in family therapy is much more likely to bring positive results than
family therapy without him
co-therapists and co-therapy have not been shown to be more successful than sessions
conducted by one therapist
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persons receiving individual, marital, or family therapy reduce their health care use after
therapy (the offset effect); largest reductions associated with conjoint therapy
therapists with good relationship skills are more successful than those with poor skills
marriage therapy outcomes are greater than family therapy outcomes; attributable to more
difficult family therapy presenting problems
psychosomatic and substance abuse problems respond well to a modified version of
structural family therapy
the type of family, its background, and its interactional style do not relate to family
therapy success or failure
marriage and family treatments are moving more towards evidence based approaches
strong research by Jose Szapocznik and associates with Hispanic/Latino and African
American families
development of brief strategic family therapy
development of Structural Ecosystems Therapy (SET)
development of Strategic Family Systems Rating (SFSR)
development of one-person family therapy (OPFT)

Two Types of Family Therapy Research

Qualitative research
rooted in anthropology and sociology
emphasis on open-ended questions
use of extended interviews with small numbers of individuals/families
results are often written up in an autobiographical form
often used in theory building
visual and verbal data reporting rather than numerical data reporting
participatory evaluation research
differs from other approaches in the degree of participants involvement
engages and empowers participants
more democratic than other types of research
Quantitative research
rooted in physics, chemistry, and biology
most common form of research
emphasis on closed-ended questions
use of large sample sizes to gather information
data are gathered in a precise form, frequently using standardized instruments, and
reported in a statistical format
results are used to prove or disprove theories and assertions
findings often focus on interventions that made a difference in treatment

Difficulties in Family Therapy Research

Family relationships are complex (e.g., What within the family will be the focus of attention?
The IP, marriage, whole system, cross-generational relationhips, etc.)
Environmental factors can impact research findings (e.g., home setting or laboratory setting?)
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Time commitment, number of researchers needed, and expenses are great in family therapy
research
Ethical and regulatory standards (e.g., National Research Act, Belmont Report) require close
attention to rigorous ethical and procedural regulations
Research design
exploratory research a qualitative approach used when issues are still being defined
descriptive research the design is set up to describe specific variables
developmental research focuses on studying changes over time
experimental research classic research methodologies with hypotheses,
dependent/independent variables with at least one variable manipulated
correlational research measures the degree of association or relatedness between two
variables; usually conducted after the fact
Sampling
random sampling represents an entire group of families
random assignment sampling gives each family an equal chance of being selected;
increases generalizability of results
probability samples are drawn from a known population such that it is possible to
calculate the likelihood of each case being included
simple random sample every family has an equal chance of being selected
systematic random sample first family selected at random, then every nth family is
automatically included
stratified sample random samples are drawn from different strata or groups of a
population
nonprobability sample is used when representiveness of a whole population is not as
important and the information itself
convenience sample using local families known by the researcher
snowballing a sampling method in which participating families are asked to refer
other families
purposiveness involves choosing families because they are thought by the
researcher to be representative of the whole population
Instrumentation
self-report instruments
easy to distribute to large numbers of families inexpensively
scoring is objective
easy to establish external validity
information helps family members understand other members concerns
easier to self-disclose through paper and pencil rather than usual ineffective ways
questionable construct validity
direct observational assessment
characterized by the use of coders, raters, or judges
weaknesses include interrater reliability and other biases
can be expensive and time consuming
videotaped observations with multiple observer ratings can be cost effective

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Procedure
research procedures are not neutral but, instead, reflect the epistemology (e.g, world
view) of the investigator
outcome research measures the impact of changes
process research examines the how and why of therapeutic effectiveness
time consuming and labor intensive
reveals which treatments are effective under which conditions and with what types of
client situations
Theory
theory, research, and practice are interrelated in family therapy
research is generally based on questions rooted in theory and theoretical assumptions
Statistics
research results are usually reported statistically
statistics are used to report levels of change
descriptive statistics provide clinically relevant and readable statistics that are useful to
family therapists
Validity/Reliability
the extent to which a measuring instrument measures what it was intended to measure
content validity - the degree to which an instrument actually taps into representative
beliefs or behaviors that it is trying to measure
criterion validity the degree to which what is measured actually relates to life
experience
construct validity the degree to which a measured performance matches a
theoretical expectation
Reliability
the consistency or dependency of a measure
the degree to which the assessment measures differences between families
perfect reliability is expressed as a correlational coefficient of 1.0

The Importance of Assessing Families

Assessment procedures are methods used to measure characteristics of people, programs, or
objects
Assessment differs from testing
testing is usually a task in which people are asked to do their maximum best
assessment usually evaluates typical performances, behaviors, or qualities; it is broader
than any test measure
assessment assist therapists to better understand a familys structure, control,
emotions/needs, culture, and development
The Diagnostic and Statistical Manual (DSM) is based on the medical model and is
individually oriented
little attention has been given in the DSM to marital and family diagnostic categories
in the DSM, V codes are relational/interpersonal problems or conditions described is not
attributable to a mental disorder
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the Global Assessment of Relational Functioning Scale (GARF) is analogous to Axis V
of the DSM GAF (Global Assessment of Functioning)
V codes are not currently reimbursed by third party payers, such as insurance companies
Assessment information can help families better understand the dynamics within their
relationships, clarify goals, and gain a sense of perspective
Assessment information documents services, the reasons behind services, and provides
baseline and change data to increase accountability and professionalism

Dimensions of Assessing Families

Based on a systemic orientation
Utilizes the transactions between individuals rather than the characteristics of each given
individual
Behavior is analyzed regarding its power to influence other family members and the variables
of the ecosystem that have influenced it
Four elements of assessment (Fishman, 1988)
contemporary developmental pressures on the family
history
structure
process
Provides multiple perspectives of the family

Methods Used in Assessing Families

Informal assessment
observational data
assessment of a couples ability to create positive experiences in the relationship (Couples
Creativity Assessment Tasks)
Family Assessment Form
Formal assessment
more than 1,000 assessment instruments available for family therapists
assessment areas include intimacy, power, parenthood, and adjustment
despite the wealth of assessment instruments available, family therapists are reluctant to
use them
using assessment instruments removes family therapists from the cutting edge of
innovative practice
some therapists lack adequate training in family assessment
family therapists who do assessment tend to use individually oriented assessment
instruments

Family Therapy Scales

Family-of-Origin Scale
measures self-perceived healthiness in ones family of origin
test-retest reliability is .97
87
subscales include
clarity of expression
personal responsibility
respect for other family members
openness to others within and outside the family system
expression of feelings
emotional warmth
conflict resolution without undue stress
sensitivity to other family members
trust
effective with couples and families
Personal Authority in the Family System Questionnaire
describes an individuals current interaction with his or her family of origin
assesses relationships in three generation families
test-retest reliability is .55
internal consistency is .95
good construct and concurrent validity
subscales include
dependence/independence
intergenerational triangles
intergenerational intimidation
personal authority
intergenerational fusion/individuation
Family Adaptability and Cohesion Evaluation Scale III
based on the circumplex model of family functioning (i.e., adaptability and cohesion)
measures an insiders perspective on family functioning
acceptable reliability and validity
can be taken twice to determine ideal and perceived descriptions of a family
Family Inventory of Life Events and Changes
measures the impact of life stresses on family well-being
strong reliability and validity
subscales include
family life event score
family-couple life events score
family-couple discrepancy score
family adjustment score
family-couple readjustment score
Family Environment Scale
measures the social and environmental characteristics of a family
reportedly the mostly widely accepted measure of the family climate
adequate validity and reliability
Real Form and Ideal Form
subscales include
relationship (cohesion, expressiveness, conflict)
88
personal growth (independence, achievement orientation, active-recreational
orientation, intellectual-cultural orientation, moral-religious emphasis)
system maintenance (organization, control)
Family Assessment Device
based on the McMaster Model of Family Functioning
measures family functioning
well researched
seven dimensions of family functioning
problem solving
communication
roles
affective responsiveness
affective involvement
behavior control
general functioning
subscales overlap considerably so best way to read the results is to use the general
functioning subscale as a summary score
Family Strengths Scale
measures two areas of family functioning
family pride (loyalty, optimism, trust)
family accord (ability to accomplish certain tasks, to deal with problems, to get along
with one another)
designed to identify how happy families resemble one another
reliability is .83
Family Coping Strategies Scale
measures internal and external family coping strategies
internal strategies (reframing and passive appraisal)
external strategies (acquiring social support, seeking spiritual support, and mobilizing the
family to seek and accept help)
reliability is .60
Self-Report Family Inventory
measures five family domains
health/competence
conflict resolution
cohesion
leadership
emotional expressiveness
reliability is between .84 and .93
validity is .62 and better

Marital and Couple Therapy Scales

Locke-Wallace Marital Adjustment Test (MAT)
one of the oldest and most widely used tests of marital satisfaction
differentiates distressed from nondistressed couples
89
can be successfully modified for use with premarital couples
split-half reliability is .90
MAT is the standard by which other marriage adjustment inventories correlate their
results
PREPARE/ENRICH
developed for couples wanting increased awareness or nourishment of their relationships
designed to identify relationship strengths and weaknesses
PREPARE is designed for engaged couples
ENRICH is designed for already married couples
subscales include
personality issues
communication
conflict resolution
financial management
leisure activities
sexual relationship
children and marriage
family and friends
egalitarian roles
religious orientation
strong predictive use
in 3 year follow-up of the PREPARE, scores were better than 80% accurate in
predicting marital happiness versus separation/divorce
Bienvenu Marital Communication Inventory
measures the perceived quality of marital communication
used with marital and premarital counseling
split-half reliability is .93
Dyadic Adjustment Scale
a measure of marital satisfaction
reportedly the most commonly used self-report assessment of marital adjustment
reliability is .96
strong validity
subscales include
dyadic consensus
satisfaction
cohesion
affectional expression
Marital Coping Questionnaire
measures how frequently respondents engage in a set of coping efforts
the most reliable coping factors include
seeking advice
emotional discharge
positive comparison
negotiation
resignation
90
selective ignoring
Primary Communication Inventory
measures a couples verbal and nonverbal communication
one of the oldest and most frequently used marriage therapy indexes
distinguishes between satisfied and dissatisfied couples
validity is weak
Marital Satisfaction Inventory-Revised
measures both the nature and intensity of distress in distinct areas of marital partners
test-retest reliability of .89
one of the strongest marital satisfaction inventories available
includes two validity scales and a global distress scale
subscales include
time together
finances
sexual problems
role orientation
communication
family history
Marital Instability Inventory
assesses marital instability among intact couples
reliability and validity factors are high
two parts
cognitive (thoughts about the marriage)
behavior (actions based on thoughts about the marital relationship)
Dyadic Trust Scale
measures levels of trust between marital partners rather than trust in general
high internal consistency reliability (.93)
good face validity
weaknesses are that the initial sample was limited and norming sample participants were
all volunteers
Marital Problem-Solving Scale
measures problem-solving ability
strong internal consistency (.95)
high test-retest reliability (.86)
good validity
compares well with time consuming and expensive behavioral coding assessment
Couple Rating Scale
eight common problem areas are rated by each partner to assess current and desired level
of functioning for the self and other
subscales include
communication life
home life
work life
love life
sexual life
91
spiritual life
problem-solving life
dream for the future life

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